Strategy for the practice of digestive and oncological surgery during the Covid-19 epidemic

We are today in an unprecedented situation that is putting all the world’s healthcare systems to the test. On 11 March 2020 the World Health Organization (WHO) declared that the epidemic of Covid-19 had become a pandemic. Everywhere in the world, public authorities are recommending strengthened preventive hygiene measures that call on the public’s civic responsibility.

Epidemiological peaks and the seriousness of the acute respiratory distress syndromes threaten to swamp our resuscitation and intensive care provision. Our governments are taking necessary measures to ‘flatten the curve’ and spread out over time the influx of cases requiring hospitalization. Meanwhile, they are taking measures to increase our conventional hospital and intensive care capacities. The French Health Minister Olivier Véran set in action an early plan at the national scale to ‘avert a stranglehold’.

On 12 March the government instructed ‘‘all hospitals to promptly de-schedule all non-urgent surgery requiring post-operative recovery and resuscitation or continuous monitoring, without adversely affecting patients’ lifechances. Special attention is required for patients in care for cancer. The purpose of this measure is both to free up beds in recovery and resuscitation wards, and to avoid exposing patients recently operated on to a harmful virus infection.’’

General strategy for visceral surgery during the Covid-19 epidemic

Digestive and parietal disorders are the reason for large numbers of surgical operations, accounting for 12% of surgical hospitalizations in 2015. The Covid-19 epidemic is still in its early stages in France, but the situation is already serious and has commanded mobilization at an unprecedented scale. The situation is straightforward for emergency cases (infection, ischaemia, obstruction, trauma), which must be dealt with promptly.

Health disorders that cannot be deferred for longer than one month must also be dealt with, if possible, by laparoscopy to minimize postoperative impact on respiratory function. In all cases, patients must be considered as possibly infected, and so cross-infection must be prevented. It is recommended not to carry out elective surgery for benign disorders, because such surgery can be performed without jeopardizing the result once the epidemic has subsided.

Precautions concerning laparoscopy (appendectomy, exploratory, etc.)LLaparoscopy has many advantages, essentially its favourable impact on respiratory function and length of hospital stay. However, caution is required when performing laparoscopy because of the risk of exposure and infection of the personnel present. The main risk arises from the presence of pathogens in the peritoneal cavity, which is favoured by dissection. The aerosol released into the room during surgery (leaks) or after the operation (exsufflation), can contaminate personnel and all the furniture and surfaces in the room via airborne particles.

Adaptation of the post-operative period

After every surgical intervention, the medical, paramedical and cleaning personnel must take the most stringent protection measures in line with national and local recommendations (French nosocomial infection control committees, CLIN). Like precautions must be taken for the recovery room or post-anaesthesia care unit (PACU). Post-operatively, patients will be admitted to a hospital ward adapted to their respiratory condition. Il is advisable for hospital wards to be sectioned off into individual rooms during the epidemic to forestall cross-infection with other patients or visiting relatives.

Adaptation of the consultation system: All non-essential consultations must be cancelled or deferred. They can best be replaced by distance consultations using telemedicine applications or the telephone. Reducing the number of consultations will reduce the risk of cross-infection. If a consultation is essential, it must be scheduled, and patients asked whether they feel any respiratory discomfort. Patients must be told to come alone or with only one other person to reduce the numbers of possible contacts.

Strategy for oncological digestive surgery practice during the Covid-19 epidemic

The Covid-19 epidemic is disrupting not only our daily lives but also how we manage patients, especially those with cancer. This new coronavirus is passed on mainly in breath droplets, but possibly also by contact and oro-faecally. The infection has an incubation time of 1—14 days. Asymptomatic infected patients may be contagious during the incubation period, and negative tests do not rule out infection. Cancer patients are fragile, often malnourished and with an immune system compromised by both the cancer and its treatment. There seems to be an increase in cases of severe ARDS in such patients.

Care for cancer patients has several common imperatives: combat malnutrition by favouring a balanced diet, providing nutritional supplements or by enteral tube feeding; avoid serious adverse effects on the immune system caused by aggressive treatments; avoid hospitalizations, visits, and hospital stays that favour contamination by the virus;prefer a therapeutic sequence that does not require strictly timed surgery that might not be feasible;

Specific features of care by cancer type

Two questions are essential in our thinking on care strategy: what are the known operating risks and the new added risks of respiratory infection? The latest research findings show that patients with tumours are more prone to infection by Covid-19 owing to their systemic immunodeficient status caused by the disease, oncological treatment (radiotherapy, chemotherapy) and surgery. Patients operated on or undergoing chemotherapy in the months preceding the infection had a serious form of infection in 75% of cases, representing a relative risk calculated by multivariate analysis of 5.34 (CI95% 1.80—16.18, P = 0.0026).

what would be the oncological impact of a long deferral (6—12 weeks) due to the epidemic? Time-to-surgery is often considered a measure of care quality. However, when waiting time is most often due to overloaded operating schedules, it has been shown that this time lapse can also be gainfully used to select the ‘‘best candidates’’ for surgery (true resectables) and prepare them for intervention (prehabilitation, management of anaemia if needed, preoperative nutrition). In the current situation, and given the risks incurred, it is essential to consider the oncological impact of deferral imposed by the exceptional demands made on care provision.

Specific features of care for colorectal cancers

Morbidity and mortality: In colorectal surgery, post-operative mortality and morbidity were estimated at respectively 3.4% and 35% in the French surgery association (AFC) trial . This prospective trial included 1421 patients, and mortality at 3 months was 6.3%. Four mortality risk factors, accessible before surgery, were isolated: the urgency of the surgery (relative risk 4.42), neurological antecedents (relative risk 3.85), weight loss above 10% of initial weight (relative risk 3.42) and age above 70 years (relative risk 2.16).

Oncological impact of deferral: This impact has not often been measured in colonic surgery. In advanced forms of rectal cancer, a neoadjuvant treatment is necessary, with a time lapse between the end of chemoradiotherapy and surgery of 8 weeks, extendable to 12 weeks with no harmful consequences (Greccar 6 trial) [8]. Hence is it not the patients at the start or in the middle of treatment who will be causing us problems, but the patients who have finished their treatment and whose surgery has already been scheduled.

Specific features of care for pancreatic cancers

Morbidity and mortality: Despite cumulated surgical, anaesthesiological and resuscitation efforts, and peri-operative optimization measures (improved rehabilitation, prehabilitation), morbidity and mortality for cephalic duodenopancreatectomies remain high. The latest review of data from the French medical information programme (PMSI) estimated the mortality rate at 8.2% [10]. Overall and severe complication rates were respectively 75% and 30% with, in order of frequency, specific complications (pancreatic fistula, haemorrhage) and infectious complications. After left splenopancreatectomy, although mortality rates were lower (3%), the rate of severe complications was about 25%.

Oncological impact of deferral: Two retrospective cohort studies of North American national register data  evaluated the impact of waiting time before pancreatectomy for cancer. Mirkin et al.  suggested that long-term survival was unaffected by waiting time. In the study published by Swords et al.  timeto-surgery was short (1—14 days) for 4.4%, medium (15—42 days) for 51.6%, and long (43—120 days) for 14% of patients. Mortality rates were lower for patients with medium waiting times (hazard ratio 0.94, CI95% 0.90—0.97) and long waiting times (hazard ratio 0.91, CI95% 0.86—0.96).

Specific features of care for oesogastric cancers

Morbidity and mortality: Surgery of œsogastric cancers carries a high risk of complications. Rates of major complications after upper polar oesophagectomy are high, at 36—64% in the MIRO trial, with rates of major respiratory complications of 18—30% [14]. After total gastrectomy, rates of major complications are lower, but still 10—15%, mostly respiratory and septic complications [15,16].

Oncological impact of deferral: Localized œsogastric cancers generally progress quite slowly (whatever the histological subtype). The average progression time from localized to locally evolved or metastatic is 34—44 months, based on Asian literature data. The doubling time of a locally advanced gastric cancer is 6.2 months. The epidemiology of oesogastric cancers in France and in Europe are different, so that these data need to be analysed with some clinical circumspection.

Specific features of care for liver tumours

Morbidity and mortality: The risks of post-operative complications must be estimated according to the status of the underlying liver tissue (cirrhosis, steatosis) and the surgical act planned (minor or major hepatectomy, liver segments/sectors concerned). Overall complication rates are 15% and 45% after minor and major hepatectomy respectively, and 4% and 20% for severe complications. On cirrhotic livers, the latest retrospective AFC study recorded overall and severe complication rates of 44% and 11% respectively.

Oncological impact of deferral: For hepatocellular carcinoma, the risk of tumour growth leading to non-resectability is low and is not life-threatening in the short term. An et al. retrospectively analysed the data of 175 patients with hepatocellular carcinoma withouttreatment. The median tumour volume doubling time was 85.7 days with an upper extremum of 851.2 days. Few similar data are available for intrahepatic cholangiocarcinoma.

 

Author: J.-J. Tuecha, A. Gangloff, F. Di Fiore, C. Brigand