key: cord-0944877-6cdy3wmq
authors: Maspero, M; Mazzola, M; Bertoglio, CL; Crippa, J; Morini, L; Magistro, C; De Martini, P; Gualtierotti, M; Lombardi, PM; Ferrari, G
title: Major cancer surgery during the coronavirus pandemic: experience from a tertiary referral center and COVID‐19 hub in Northern Italy
date: 2020-08-05
journal: Br J Surg
DOI: 10.1002/bjs.11892
sha: 277b39c3f07afa080be1088d08336a14b42facc9
doc_id: 944877
cord_uid: 6cdy3wmq

nan

provide resources for the emerging epidemic and in fear of exposing patients to in-hospital SARS-CoV-2 infections. Our Institution, one of the largest public hospitals in Lombardy (Italy), was designated as a COVID hub by the regional government, and has so far treated more than one thousand COVID-19 patients.

As smaller hospitals redirected cancer patients to designated Oncological hubs 1 , we kept performing major cancer surgery "in-house", for ours being a tertiary oncological referral center with a high specialization in minimally invasive procedures.

A dedicated pathway of care was designed based on three principles: multidisciplinary cooperation between clinical staff and health managers; systematic SARS-CoV-2 preoperative screening with RT-PCR on nasal swab; rigorous adherence to in-hospital COVID-19 regulations regarding clean pathways, use of personal protective equipment, and limitations of all unnecessary hospital accesses.

To evaluate the efficacy of our model, we compared outcomes of major cancer surgeries performed from February 24th 2020 to May 8th 2020 with the same time period in 2019.

The primary endpoint was waiting time, defined as the interval between the date of the first diagnostic investigation and surgery for newly diagnosed cancers, and as the interval between the date of the tumor board during which surgical indication was given and surgery for patients who received a neoadjuvant treatment ( Table 1) .

While overall surgical activity underwent a 84 per cent reduction in volume (from 502 procedures in 2019 to 73 in 2020), major cancer cases remained stable (44 vs 42).

Baseline characteistics of the patients were similar. Waiting time did not differ between the two cohorts (23 versus 22 days in 2019 and 2020, respectively). This was in contrast with a previous report from the COVID-SURGE-ITA group survey 2 , which showed an increase in time between tumor board and surgery.

Distribution of procedures according to anatomical district showed a trend toward less colorectal operations in 2020 compared to 2019, with an increase in gastroesophageal and pancreatic operations.

Several concerns have been raised on the use of laparoscopy during the COVID-19 pandemic 3 . The risk of SARS-CoV-2 transmission during laparoscopy has not been scientifically demonstrated 4,5 , while an increase in open procedures will have a detrimental effect on short-term outcomes. In our division, we continued performing laparoscopic operations, as all of our patients tested negative for SARS-CoV-2 before surgery.

Thirty-day surgical outcomes were similar between the two time periods. This was unsurprising as patients were operated on by the same surgical staff and cared for following the same standardized enhanced recovery protocol.

The potential need for postoperative ICU admission was a concern during the COVID-19 emergency. Scheduling major surgery in such situations requires collaboration between surgeons, anesthesiologists and healthcare managers. Our patients can rely on a dedicated high-care surgical ward with the presence of a multispeciality team; this also decreased the need for postoperative ICU admission.

A strict adherence to protocols was critical to patient safety. No patients developed a postoperative SARS-CoV-2 infection in our division.

Oncological surgical standards were equally maintained. The oncological pathway was not affected, as shown by the reduced interval from discharge to the first oncological follow up and to start adjuvant treatment.

Our study shows that major cancer surgery during the COVID-19 pandemic was not discontinued and was carried out with similar short-term outcomes as in standard conditions in our cohort of patients from a tertiary care center in Northern Italy. Multidisciplinary cooperation between the clinical staff and health managers played a critical role in ensuring a safe pathway of care. 

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