This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. The disease caused by the SARS-CoV-2 coronavirus (COVID-19) has generated a worldwide pandemic with serious health consequences, and Spain has been one of the hardest hit countries by this crisis. Although surgeons are not front-line healthcare providers in the battle against this disease, the current situation has raised multiple concerns in the surgical community about how to proceed in different scenarios.
With the exponential increase in COVID-19 infections, the possibility that these patients will require surgery also increases, and we must therefore know how to act. Despite the current scarcity of scientific evidence, different surgical societies around the world have established the universal recommendation of using personal protective equipment (PPE) during the management of these patients. However, there is no consensus on ideal surgical approaches that would protect healthcare personnel. Thus, for example, the Spanish Association of Surgeons 1 recommends minimally invasive approaches to lessen the risk of infection of the members of the surgical team. Even so, the virus could potentially be present in pneumoperitoneum aerosols during laparoscopy, as is the case with other viruses. 2 Hence, if this approach is selected, the use of smoke filters in the cannulae of each of the ports is recommended. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) suggests individualizing the benefits of laparoscopy for each patient given the possibility of transmission through CO2. 3 In China 4 and Italy, 5 minimally invasive surgery is recommended because, in addition to reducing the exposure of surgeons to the body fluids of the patient, it can reduce the hospital stay of the patient and their family. They also suggest the use of assistance incisions to shorten surgical time. In contrast, transanal surgery is contraindicated due to the increased risk of aerosol exposure. 4 Another major concern is the delay in scheduled surgical activity in oncology patients. The Spanish Society of Medical Oncology (SEOM) estimates that 277 394 new cases of cancer will be diagnosed in Spain in 2020. 6 Furthermore, during the maximum health crisis due to COVID-19, around 46,000 new cases of cancer will be diagnosed, among which colorectal and breast carcinoma stand out, whose main therapeutic pillar is surgery. Most societies recommend postponing non-urgent interventions to avoid the use of beds in intensive care units (ICU) and protective material, which may be necessary for COVID-19 patients. In addition, one study 7 indicates that cancer patients, particularly those undergoing chemotherapy, are at higher risk of infection and severe coronavirus disease, although this may be controversial. Nevertheless, oncological disease may progress pending surgery, becoming unresectable or requiring urgent surgery (occlusion or perforation in colon cancer), which would increase the need for ICU care. Therefore, the American College of Surgeons 8 recommends individualizing each case and prioritizing certain cancer patients who require surgery.
The next ethical conflict we are faced with is selecting the best surgery that we can offer patients. Currently in Spain, the majority of patients undergoing scheduled surgery for colorectal carcinoma will not require a stoma. However, around 5% will present an anastomotic leak, 9 requiring reoperation and prolonged ICU stay. Therefore, during this health crisis we should consider modifying our surgical decisions and perhaps avoiding anastomosis in patients at risk. This would optimize hospital resources and reduce patient mortality.
Finally, given the economic crisis that lies around the corner and the accumulation of oncological patients pending surgery, it will be reasonable to consider reducing surgical spending and intervention times while always maintaining the oncological safety of our patients. Several studies have demonstrated the benefit of laparoscopy over open surgery in colon cancer. 10 However, in situations of locally advanced tumors, unspecialized hospitals or inexperienced surgeons, laparoscopic surgery can increase surgical times and, therefore, the overall consumption of resources. Thus, for the benefit of our patients, hospitals should individualize each case to optimize resources and make the health system more efficient, which will allow us to treat a greater number of patients whose surgeries were postponed due to the COVID-19 crisis.
In conclusion, we surgeons face new challenges in the face of this pandemic. The first challenge is protecting ourselves and our patients from possible coronavirus infection. The next challenge is to organize our material and human resources in the most efficient manner possible. It is essential to reduce the need for prolonged ICU stays and to reduce the expenses in materials and surgical time, as well as medical personnel. Following these steps, we will be able to increase the number of necessary oncological procedures.