key: cord-0749003-31yms6t2 authors: Dolan, Daniel P.; Swanson, Scott J.; Lee, Daniel N.; Polhemus, Emily; Kucukak, Suden; Wiener, Daniel C.; Bueno, Raphael; Wee, Jon O.; White, Abby title: Esophagectomy for Esophageal Cancer Performed During the Early Phase of the COVID-19 Pandemic date: 2021-07-01 journal: Semin Thorac Cardiovasc Surg DOI: 10.1053/j.semtcvs.2021.06.022 sha: 0cb6439ede0f47ef52b713b9ccb63a3a89506e50 doc_id: 749003 cord_uid: 31yms6t2 Delay in time to esophagectomy for esophageal cancer has been shown to have worse peri-operative and long-term outcomes. We hypothesized that COVID-19 would cause a delay to surgery, with worse perioperative outcomes, compared to standard operations. All esophagectomies for esophageal cancer at a single institution from March-June 2020, COVID-19 group, and from 2019 were reviewed and peri-operative details were compared between groups. Ninety-six esophagectomies were performed in 2019 vs 37 during March-June 2020 (COVID-19 group). No differences between groups were found for preoperative comorbidities. Wait-time to surgery from final neoadjuvant treatment was similar, median 50 days in 2019 vs 53 days during COVID-19 p=0.601. There was no increased upstaging, from clinical stage to pathologic stage, 9.4% in 2019 vs 7.5% in COVID-19 p=0.841. Fewer overall complications occurred during COVID-19 vs 2019, 43.2% vs 64.6% p=0.031, but complications were similar by specific grades. Readmission rates were not statistically different during COVID-19 than 2019, 16.2% vs 10.4% p=0.38. No peri-operative mortalities or COVID-19 infections were seen in the COVID-19 group. Esophagectomy for esophageal cancer was not associated with worse outcomes during the COVID-19 pandemic with minimal risk of infection when careful COVID-19 guidelines are followed. Prioritization is recommended to ensure no delays to surgery. Esophagectomy for esophageal cancer can safely be performed during the COVID-19 pandemic. Perspective Statement: Delays in esophagectomy for esophageal cancer lead to worsened long-term outcomes. With the ongoing challenges of the COVID-19 pandemic we demonstrate that, with appropriate precautions, esophagectomies can proceed with similar short-term outcomes and minimal risk of COVID-19 infection. Prioritization of surgical care for these patients is recommended. Abstract: Delay in time to esophagectomy for esophageal cancer has been shown to have worse perioperative and long-term outcomes. We hypothesized that COVID-19 would cause a delay to surgery, with worse perioperative outcomes, compared to standard operations. All esophagectomies for esophageal cancer at a single institution from March-June 2020, COVID-19 group, and from 2019 were reviewed and peri-operative details were compared between groups. Ninety-six esophagectomies were performed in 2019 vs 37 during March-June 2020 (COVID-19 group). No differences between groups were found for preoperative comorbidities. Wait-time to surgery from final neoadjuvant treatment was similar, median 50 days in 2019 vs 53 days during COVID-19 p=0.601. There was no increased upstaging, from clinical stage to pathologic stage, 9.4% in 2019 vs 7.5% in COVID-19 p=0.841. Fewer overall complications occurred during COVID-19 vs 2019, 43.2% vs 64.6% p=0.031, but complications were similar by specific grades. Readmission rates were not statistically different during COVID-19 than 2019, 16.2% vs 10.4% p=0.38. No peri-operative mortalities or COVID-19 infections were seen in the COVID-19 group. Main Text: Coronavirus-19 has significantly affected healthcare globally. The safety of surgery and postoperative care for esophageal cancer patients who undergo esophagectomy during the pandemic is of particular concern due to the virus's multisystem effects that may impact the operation (1, 2) . During the coronavirus pandemic the screening, administration of chemotherapy, and surgical management of multiple cancers has been shown to be heavily impacted (3) . Due to the aggressive nature of esophageal cancer, delays in treatment are not advised and esophageal cancer patients have priority when resources are available (4). However, patients who undergo neoadjuvant chemoradiation therapy typically require a brief recovery period before proceeding to definitive surgery. The ideal duration between neoadjuvant therapy and surgery remains under debate both in terms of peri-operative outcomes and long-term survival and is of paramount importance during the ongoing pandemic (5, 6) . We hypothesized that esophagectomies performed during the COVID-19 pandemic would be delayed with more complications and worse peri-operative complications and mortality compared to one year before the pandemic. The Institutional Review Board (IRB) or equivalent ethics committee of the Brigham and Women's Hospital approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the IRB due to the retrospective nature of the study. Retrospective review of the charts of all patients who underwent esophagectomy for esophageal cancer at our institution from January 1, 2019, to December 31, 2019 (pre-COVID-19 group) and March 1, 2020 to June 30, 2020 (COVID-19 group) was performed. After June 30, 2020, the monthly rate of esophagectomies returned to pre-pandemic levels and differences were no longer expected to be observed. Esophagectomies performed for benign conditions were excluded. Demographic and comorbidity variables included were age, gender, body mass index Values were compared between groups using Chi-square test, Wilcoxon rank-sum test, As part of our institutional pandemic response, all surgical patients were required to have a negative COVID-19 test within 72 hours before surgery and were directed to self-quarantine from the time of their COVID test until day of surgery. Hospital staff completed daily symptom attestations before work and were required to wear masks while in the hospital. Visitors were restricted to one two-hour visit with a single visitor between 1-8PM daily. No visitors were allowed in the ICU. Esophagectomy patients were in the same ICU as COVID-19 patients at the start of the study prior to creation of COVID-19 ICUs. Every patient was tested every 3 days for COVID-19 during their inpatient stay and each patient had a private room. Thirty-seven esophagectomies were performed between March and June at our institution vs 96 in 2019. Four cases were done during mid-March to mid-April 2020 when the operating rooms were reserved only for emergency cases and the institution had the largest number of COVID-19 patients in the hospital. These cases were performed only after careful discussion with the patient, referring doctors, and operating room administrators. During this study, no patient was diagnosed with, or had COVID-19 symptoms during their hospitalization or by first follow-up. Age, gender, BMI, Barrett's esophagus, hypertension, pre-operative atrial fibrillation, history of other cancer, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, diabetes, and smoking history were similar between groups, Table 1 A summary of the key findings and their implications can be found in Figure 1 . Esophagectomy for esophageal cancer was not associated with worse outcomes during the COVID-19 pandemic with minimal risk of infection when careful COVID-19 guidelines were followed.. Our institution underwent an operating room shutdown in mid-March 2020 to mid-April 2020. Only emergencies and carefully considered cases were performed. As semielective operations were resumed there was a backlog of patients who were at risk significantly delayed surgery. Esophageal cancer cases were prioritized in the initial phase when the operating rooms were reopened due to their high-risk nature and to attempt to minimize the length of time from the completion of neoadjuvant therapy to surgery, if applicable. We found these efforts were successful. With institutional protocols put in place before guidelines were more common, none of our patients were infected with COVID-19 during their post-operative admission or by their first follow-up appointment. This allowed us to avoid many of the pulmonary complications and mortality that had been reported elsewhere (8) . Our institution did not set up full COVID-19-free surgical pathways (dedicated operating room, critical care, and inpatient wards) as noted in Glasbey et al. but dedicated critical care and inpatient wards were set up later in our study period (9) . In the early portion of the pandemic there was debate regarding the possible aerosolization of the virus during laparoscopy (10) (11) (12) . Larger tumor sizes were also seen during the pandemic, but conversion rate was similar to 2019. We do not believe these factors impacted Lastly, length of stay was shorter during the pandemic in part due to concerns for patients staying longer in the hospital but was accompanied by a higher readmission rate. The total readmission rate from March 2020 through February 2021 is 12.6% (12/95). Upon further review of the causes for readmission, none of the patients were readmitted for COVID-19 related issues. Examples include, delayed esophageal leak, failure to thrive, and dysphagia. The lessons we learned in this early experience dealing with a respiratory pandemic were myriad. Due to the progressive nature of esophageal cancer, significant efforts to ensure timely scheduling of operations after completion of neoadjuvant treatment is necessary. Next, staying current on the developing literature, guidelines, and reports of disease transmission to update pre-admission, and during hospitalization, COVID-19 testing strategies should be done. Additionally, hospital staff adherence to strict mask and symptom reporting policies to prevent potential iatrogenic COVID-19 transmission are mandatory. Clear discussions with patients on how to prevent getting COVID-19 before admission as well as restricting visitors is essential to further reduce transmission risk. Once patients are in the hospital, every effort to perform esophagectomies by minimally invasive methods and keep the conversion rate to a minimum help maintain transmission safety and reduce complications of esophagectomy. Since strict visitor restrictions are necessary to prevent infection from non-patient and non-hospital staff sources, the hospital should provide increased social support services and technology for patients to communicate with outside family and friends. After discharge, close 2 week follow-up by either in-person visit or tele-medicine is key to help monitor patients postoperatively, remind them of best practices for preventing COVID-19 infection, and attempt to reduce readmission. Later in the pandemic, our successful and safe results of the first few brave patients were able to be communicated to subsequent patients. This helped reassure them that coming to the hospital for their surgery was safe. Some limitations and possible biases may have been introduced. During resumption of semi-elective cases, patient selection bias may have occurred that may have not been captured in our data leading to decreased complication rates during COVID-19. The emphasis placed on rapid discharge to minimize COVID-19 exposure may have contributed to the higher, nonsignificant, readmission that was observed in the COVID-19 group. An additional limitation is the low number of patients operated on during he pandemic. We expect no difference in long-term outcomes for the COVID-19 group compared to previous patients since there was no increased rate of complications or upstaging on pathology. Continued observation is warranted as the pandemic progresses to ensure esophageal cancer patients who need to be evaluated and treated receive appropriate care (16) . During the ongoing COVID-19 pandemic, with appropriate case prioritization, preoperative testing, staff policies, and systemwide measures, esophagectomy for esophageal cancer was not associated with worse perioperative outcomes and minimal risk of infection with COVID-19 at our institution. Acknowledgements: None Dr. Dolan discusses the background, objectives, methods, and key findings of the study. COVID-19 and Multiorgan Response Coagulation dysfunction in COVID-19: The interplay between inflammation, viral infection and the coagulation system Impact of COVID-19 on Cancer Care: How the Pandemic Is Delaying Cancer Diagnosis and Treatment for American Seniors COVID-19 guidance for triage of operations for thoracic malignancies: A consensus statement from Thoracic Surgery Outcomes Research Network Does the timing of esophagectomy after chemoradiation affect outcome? Does timing of esophagectomy following neoadjuvant chemoradiation affect outcomes? A meta-analysis Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study Laparoscopy in the coronavirus disease 2019 (COVID-19) era The risk of COVID-19 transmission by laparoscopic smoke may be lower than for laparotomy: a narrative review COVID-19 may transmit through aerosol Changes in the number of US patients with newly identified cancer before and during the coronavirus disease 2019 (COVID-19) pandemic Management of anastomotic leaks following esophagectomy: when to intervene Effect of thoracic versus cervical anastomosis on anastomotic leak among patients who undergo esophagectomy after neoadjuvant chemoradiation No funding was provided for this study.IRB approval: Protocol number: 2014P000998; Approval date: 3/13/20. Patient written consent for the publication of the study data was waived by the IRB due to the retrospective nature of the study.