key: cord-316483-nrx8ovvq
authors: Mazzaferro, Vincenzo; Danelli, Piergiorgio; Torzilli, Guido; Busset, Michele Droz dit; Virdis, Matteo; Sposito, Carlo
title: A Combined Approach to Priorities of Surgical Oncology During the COVID-19 Epidemic
date: 2020-05-01
journal: Ann Surg
DOI: 10.1097/sla.0000000000004005
sha: 
doc_id: 316483
cord_uid: nrx8ovvq

nan

The number of people infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has exponentially increased worldwide 1 

(COVID-19) is officially a pandemic. On Feb 21 th , 2020, the first person-to-person transmission was reported in Italy and since then the infection chain has led to one of the largest COVID-19 outbreaks outside Asia to date. All started and spread in the Lombardy region, the most populated region in Italy (10.2 million of inhabitants), with an outbreak accounting for most of the Italian registered cases of COVID-19, thousands of hospitalized patients, 15% of whom required an admission in intensive care units 2 . Such a tsunami of acute patients punched the hospital system in a matter of 4 weeks, and forced the largest part of the region healthcare resources (3.2 beds/1000 inhabitants) to be reconverted into COVIDunits, with consequent dramatic imbalance between supply and demand for most non-urgent medical and surgical diseases 3, 4 . In particular, most patients with solid cancer awaiting surgical intervention had their surgery delayed indefinitely. The current regional model of prioritization in surgical oncology, based on the "first-come, first-served" principle and able Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

to guarantee an average waiting time of 40 days for elective gastrointestinal surgery in the pre-COVID era, had necessarily to be revised.

In such circumstances, the aim of the intervention we were asked to work on was twofold: a) guarantee a hospital-based system for surgical oncology interventions and b) design a unitbased priority system for cancer patients eligible to surgical intervention.

With respect to the first aim, the regional government selected a few hospitals able to remain relatively COVID-free, thanks to the implementation of restricted infectious triage protocols and intentional closure of emergency access. By means of a hub-and-spoke model the COVID-transformed hospitals with cancer patients in need of surgery could then refer to a full steam cancer-hub in which case discussion and possible interventions could be continued.

With respect to the second aim, we proposed a renowned system of priority for patients with gastro-intestinal malignancies (about one quarter of the surgical volume for oncological indications) 5 largely drawn from organ transplant allocation principles, namely from the longstanding area of surgery in which the imbalance between demand and supply is permanent 6, 7 . Here we share the framework that guided our work and the introduction of the model in the Lombardy region, in the hope that it could act as a positive influence for other regions possibly facing similar pandemic. The framework is outlined in Figure 1 borderline resectable pancreatic tumors, >T2N1 asymptomatic gastric adenocarcinoma, colorectal liver metastases etc.); 3) patients within TNM stage 1 or bearing biologically low aggressive cancers (i.e. neuroendocrine tumors, asymptomatic GISTs, pancreatic IPMNs). As for the previous category, green patients who progress during waiting time would be reclassified into the yellow class.

To each category a variable time frame for surgical intervention was arbitrarily assigned (see Figure 1 ). The entire framework was based on the following principles: Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

 As surgical intensive care units (SICU) play an essential role in determining the outcome of patients both in the surgical oncology scenario and for COVID19-related complications, allocation to surgery during the pandemic is prone to disfavour those who are more likely to require a prolonged SICU stay. To provide objective measures for decision-making we propose to consider the preoperative ASA (American Society of Anaesthesiologists) score and age cut-offs (in our region arbitrarily set at 80 years).

As presented in Figure 1 , red and orange patients who are ≥80 y.o. and/or with ASA score ≥3 are downgraded to next category, as well as yellow patients with similar preoperative risk.

 As definition of surgical complexity is an operator-dependent variable coupled with resource availability and hospital volumes, we felt that the risk of unfair discrimination would be in place if surgical burden was used as a universal priority variable. For instance, procedures related to pancreatic head, esophageal or retroperitoneal cancers are defined as complex in almost all cases.

In conclusion, an allocation scheme of priority for surgical oncology is proposed to face the dramatic restrictions in elective surgery resources during the COVID19 pandemic. We aimed at maintaining surgical indications while optimizing allocation and prioritization according to the survival benefit principle. The proposed framework has been adopted for patients with cancer of the gastrointestinal tract, but can be easily extended to most of other fields of surgical oncology. Only time will tell how it works.

Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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