In this study, we have shown how the recent COVID-19 outbreak affected our department of surgery and transplantation. Fewer surgeries were performed and these were only for cancer and for urgent liver or kidney transplantations. Notwithstanding, we have maintained our standard practice by enhancing selection of patients, meanwhile allowing for the re-allocation of the hospital resources.
SARS-CoV-2 virus infection has dramatically changed the world recently. More than two hundred countries all over the world had to undertake extraordinary measures to contain the epidemic and reduce possible side effects on healthcare and economy.1 Indeed, many eastern and western governments followed the example of China and are currently in lockdown, with few exceptions. A deep impact was expected on the healthcare systems all over the world: re-allocation of resources was urgently required in an effort to contain the devastating consequences of the pandemic. As a domino effect, patients with other medical conditions such as cardiovascular diseases, cancer and chronic conditions, suffered and are still suffering as a collateral damage.12
In response to the rapid increase of COVID-19 cases in our hospital, Institutional guidelines called for the re-arrangement of the hospital, shifting both infrastructures and personnel towards the containment of the infection and the management of SARS-CoV-2 positive patients. In this setting, our surgical department suffered the sudden closure of one daily OR and the significant reduction in the possibility to use ICU beds after surgery, as these were day by day used for the management of COVID-19 patients. As surgeons, we had to completely re-consider our roles and our surgical activity, reckoning with the limited resources. We had to face a healthcare emergency with uncertain future course and adapt accordingly. Surgeries for benign conditions were stopped and the waiting list for cancer was handled and reworked entirely. The most important limitation was the hampered access to the ICU as many patients require intensive monitoring after surgery for cancer, especially when major procedures are needed. Furthermore, we had to deal with the fact that transplantations normally require intensive care management in the postoperative. We were advised to limit the number of surgeries requiring ICU admission as much as possible, to avoid the saturation of resources and failure of the system. As an institutional policy, our transplant center remained opened and we decided to continue with our standard surgical oncology activity, improving selection of patients to limit the need for postoperative intensive care management. Notably, we have performed standard numbers of high-risk surgical procedures, selecting more surgically fit individuals. Furthermore, patients were less commonly having preoperative liver cirrhosis or neoadjuvant chemotherapy, significantly lowering intraoperative risks. All the transplantations performed were admitted to the ICU while only 3 oncologic patients required intensive care management after surgery: these latter were patients with significant comorbidities that were scheduled for high-risk surgeries (two pancreaticoduodenectomies for adenocarcinoma and one right hepatectomy for hepatocellular carcinoma). Our policy was pursued in an effort to prioritize patients by cancer prognosis. Indeed, malignancies requiring high risk surgical interventions (i.e. cholangiocarcinoma, liver metastasis, pancreatic adenocarcinoma, sarcoma) are generally those with the worst prognosis and more likely to suffer by a delay in treatment.20 A different approach would have been to rework the waiting list for cancer prioritizing less invasive procedures (i.e. colorectal resections) with no strict selection of candidates in order to cope with the limited resources.21 The main issue here, is that both strategies will generate a gap in cure that has to be considered in the near future when the COVID-19 crisis will be over. Surgical delay should not affect oncological prognosis, in order to minimize future repercussions of this international health crisis.20 The alternatives to surgery and their efficacy should be reviewed and discussed for each type of cancer and case by case, in an effort to minimize the waiting list and the loss of patients due to cancer progression.22 In some cases, systemic treatment could be prolonged or adapted, while in others the window of cure might be missed; sometimes surgery can be postponed while some other patients need surgical treatment to stay on their pathway. In this setting, multidisciplinary meetings should be reworked to consider patients with cancer in the COVID-19 era, in which resources and future are uncertain. Balancing the prognosis of cancer with the potential alternatives and the characteristics of patients might eventually lead to improve the treatment allocation exploiting resources and maintaining oncologic principles. 23
Patients with cancer are paying the price at different levels, not only because of the limited access to cure but also because of the delay in diagnosis.24 Indeed, the significant reduction of outpatient clinics and the limitation in imaging modalities and/or endoscopies, might hamper a rapid diagnosis and a prompt referral. As a further issue, it has already been shown that cancer patients are more susceptible to COVID-19 infections: 1% of COVID-19 patients in China had a history of cancer as compared to 0.29% among normal Chinese population. 2 These patients were also having more severe infections and most commonly required intubation and invasive ventilation. One lesson that we have learned in our hospital is that the diagnostic modalities for COVID-19 are important not only to contain the infection and avoid the spread of the disease, but also to ensure safe treatment of patients. Questionnaires are useless in our opinion, as we are at the point that this pandemic cannot be detected by recalling contacts or possible exposure to the infection. 25 Indeed, once we have shifted to nasopharyngeal swabs for all patients admitted to our department, we had our first SARS-CoV-2 positive surgical candidate. This patient, earlier tested negative to the questionnaire. On one hand this highlights the importance of swabs for all surgical candidates to contain the infection among patients and healthcare workers; on the other hand, it sheds the light on the need for further evidence concerning the management of positive COVID-19 patients with cancer. Indeed, our patient with cholangiocarcinoma was shifted to non-surgical treatment: our team was unprepared at that time as no recommendations were available and issues regarding potential complications and transmission were raised. Recently, Lei et al. have demonstrated that 34 positive asymptomatic COVID-19 patients undergoing surgery had a 20% mortality rate, and all developed atypical pneumonias. Furthermore, it is very important to stress that our decision, unfortunately altered the patient’s prognosis, and this highlights the impact of this pandemic on our healthcare system.
In our institution, we have recently standardized the use of PPE to limit the possible transmission of disease during surgery. It has been speculated that laparoscopy might increase transmission due to the aerosolized biological fluids.26, 27 In line with this, we are now using extra protection (double gloves, shield and filter mask) and filtered gas evacuation systems to avoid any possible transmission during minimally invasive procedures. However, as possible aerosolized fluids happen also as a result of cauterization during open surgery, the surgical community needs more evidence and guidelines concerning the proper use of equipment and resources to be used during surgery.28
This study has some limitations mainly being the retrospective analysis that might have introduced selection bias. In this setting, anesthesiologists could have decided subjectively whether the patient required ICU admission or not. Furthermore, as above-mentioned our hospital is a national referral for the infectious diseases and we have already faced previous emergencies;14, 15 therefore, the rapid adaptation that we have shown in this manuscript could be the result of experience and competences gained over years. As we write our hospital is at full capacity with 208 cases and 24 patients requiring mechanical ventilation in the ICU. Notwithstanding, our department is operating around 10 surgical oncology cases and 1 tranplantation per week ensuring assistance for patients.
Since the recent worldwide spread of the disease, many editorials, letters and expert opinions have been published on COVID-19 crisis and many have speculated that surgical activity have suffered the spread of this pandemic.9, 11, 20, 29-33 To the best of our knowledge, this is the first manuscript presenting numbers and statistical analysis highlighting the changes in surgical practice during COVID-19 outbreak. As we write, Italy is already in its fourth week of lockdown, and the emergency seems to have reached the peak. We will be probably moving towards more relaxed containment measures despite a total opening is unlikely. Meanwhile, countries worldwide are facing the ascending phase of this outbreak with a delay of days or even weeks. We believe it is important to share our anticipatory experience on how we have changed and adapted our surgical practice to face this crisis and optimized resources. Future evolution of this infection is uncertain: evidence, policies and recommendations may change on daily bases hopefully improving the quality of care and minimizing the side effects on more patients. We must be prepared to face the consequent need for care in the coming months. By then, a progressive inverse trend should be encouraged, reallocating resources to assist those who suffered the most by the outbreak, both re-enforcing diagnostic steps and treatment possibilities to counteract the delay we have so far accumulated.