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      Elective colorectal cancer surgery at the oncologic hub of Lombardy inside a pandemic COVID‐19 area

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      , MD 1 , , MD 1 , , , MD 1
      Journal of Surgical Oncology
      John Wiley and Sons Inc.

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          Abstract

          Of more than 209 000 individuals positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in Italy up until 2 May 2020, nearly 37% live in Lombardy, and of the 28 710 coronavirus disease 2019 (COVID‐19) related deaths, 49% occurred there. 1 , 2 To provide the best care, the Lombard healthcare system interrupted elective surgery in both community and regional hospitals, converting them into COVID‐19 referral centers. Therefore, patients affected by colorectal cancer on a waiting list for surgery in “hot” COVID‐19 areas suddenly were left without any chance to be treated. Thus, the National Cancer Institute of Milan (Lombardy, Italy), a comprehensive cancer center, was identified as an oncologic hub to provide surgical treatment for those patients. The mission was to dispose of that impressive waiting list as soon as possible, keeping our hospital “COVID‐free” in the safest setting at the same time. From 9 March to 24 April 2020 at the Colorectal Surgery Unit of the National Cancer Institute of Milan, a total of 54 patients affected by colorectal cancer were managed. Of these, 29 (53.7%) were cases from the institutional waiting list and 25 (46.3%) from the Lombardy oncologic hub list, coming mainly from the province of Bergamo. To manage patients from both hub and our institutional waiting list, prioritization was applied to each patient as following: red code (high priority, within 2 weeks) for complicated/symptomatic colorectal cancer (obstruction, perforation, bleeding); yellow code (medium priority, within 4 weeks) for cT2‐T4, N0‐N + colon or rectal cancer with indication for upfront surgery or rectal cancer awaiting more than 8 weeks after completion of neoadjuvant chemoradiation; green code (low priority, within 8 weeks) for cT1N0 colon cancer or positive margins after endoscopic polypectomy. The day before hospitalization, patients were called by phone to rule out symptoms compatible with COVID‐19 disease, such as fever and/or cough, and/or dyspnea. If no symptom was reported, patients were admitted to our Institute the following day to complete the dedicated triage, consisting in blood analyses, and a chest computed tomography (CT) scan. In case of lymphopenia, increased biomarkers of inflammation, and/or radiological ground‐glass opacities, patients were immediately tested for SARS‐CoV‐2 by nasopharyngeal swab and discharged. All other patients were admitted for hospitalization. Patients from the hub list were re‐evaluated by a restricted multidisciplinary colorectal cancer team. Laparoscopic approach was suspended to reduce the risk of aerosolization and the surgical time. 3 One (3.4%) patient on the institutional waiting list and seven patients (28.0%) on the hub list failed to pass the pre‐hospitalization triage because of chest CT scans positive for interstitial pneumonia (P = .019). Of the latter seven patients, four resulted negative for SARS‐CoV‐2. After a period of 15 days at home, they had regression or stability on CT scans and were admitted for hospitalization. The other three patients resulted positive for SARS‐CoV‐2 and were kept at home for a 28‐day quarantine: one suddenly developed pneumonia and died of COVID‐19; the other two patients remained asymptomatic, and after two negative swabs and evidence of regression of CT scan findings, were admitted for hospitalization. Clinical and pathological variables are reported in Table 1. To minimize or to defer surgery, in two cT1 and in one cT0 restaged after neoadjuvant chemoradiation for rectal cancer, endoscopic full‐thickness resection or trans‐anal local excision were carried out. A shorter surgical time in the hub patients depended on minimizing surgery, sometimes avoiding colorectal anastomosis, as suggested by persistent but milder chest‐CT findings observed in 28% of them. In fact, in three hub rectal cancer patients over 80 years of age who were not fit for chemoradiation, Hartmann's procedure was performed. Moreover, in three patients with obstructive rectal cancer, a loop colostomy was fashioned before neoadjuvant treatment. Only 6 out of our 12 colorectal team members performed surgery on hub patients, to limit the risk. Postoperative morbidity rates were similar in the two waiting list groups, despite a significantly higher age, white blood cells count, platelets, number of chest CT scan findings, longer time from diagnosis to surgery, lower pathological stages 0‐I (28.0 vs 48.2%, P = .382), worse ASA scores III‐IV (52.0 vs 27.5%, P = .095), and a red‐code priority level in the hub group. Particularly, postoperative interstitial pneumonia was observed in two hub (8.0%) and three institutional cases (10.3%). All these patients were temporarily moved to a dedicated observation ward and subjected to nasopharyngeal swabs, which were negative in all cases. The unexpectedly favorable clinical trend of the hub group deserves a closer look, since the Bergamo area was heavily affected by COVID‐19. Surgeons, nurses and all the other healthcare workers were daily assessed for symptoms (dry cough and/or fever ≥ 37.5°C) and admitted at work only if asymptomatic. During this period, no surgeon or nurse of our Colorectal Surgery Unit staff developed COVID‐19. As of 28 April 2020 all our staff members were tested for anti‐SARS‐CoV‐2 immunoglobulin G, and none resulted positive. Centralized management of colorectal cancer patients in an oncologic hub proved effective during the COVID‐19 outbreak. Table 1 Clinical and pathological characteristics of patients Hub patients from COVID‐19 areas (n = 25) Institutional patients (n = 29) P value Age at diagnosis, y 71.0 (±11.4) 63.0 (±16.0) .045 Sex Male 14 (56.0%) 12 (41.4%) .413 Female 11 (44.0%) 17 (58.6%) WBC count (x103/uL) 8.1 (±2.6) 6.7 (±4.0) .018 Lymphocyte count (x103/uL) 1.6 (±0.4) 1.4 (±1.0) .355 Platelet count (x103/uL) 285.4 (±62.5) 237.0 (±64.0) .008 C‐reactive protein, mg/L 10.6 (±13.0) 16.1 (±62.9) .67 Chest CT scan findings Ground‐glass opacities 7 (28.0%) 1 (3.4%) .016 Other non‐suspect opacities 3 (12.0%) 10 (34.5%) No relevant findings 15 (60.0%) 18 (62.1%) Preoperative CEA, ng/mL 5.8 (±10.6) 2.2 (±20.4) .879 Preoperative CA 19.9, U/mL 14.0 (±4.4) 9.5 (±2.0) .344 Priority level Red: symptomatic cancer 15 (60.0%) 7 (24.1%) .006 Yellow: stage II‐III cancer 5 (20.0%) 18 (62.1%) Green: early cancer 5 (20.0%) 4 (13.8%) ASA score II 12 (48.0%) 21 (72.4%) .183 III 11 (44.0%) 7 (24.1%) IV 2 (8.0%) 1 (3.4%) Cancer localization Right colon 4 (16.0%) 4 (13.8%) .817 Transverse colon 4 (16.0%) 2 (6.9%) Left/sigmoid colon 2 (8.0%) 4 (13.8%) Rectum 13 (52.0%) 16 (55.2%) Others 2 (8.0%) 3 (10.3%) Clinical T stage cT0‐1 4 (16.0%) 4 (13.8%) .488 cT2 3 (12.0%) 8 (27.6%) cT3 12 (48.0%) 13 (44.8%) cT4 6 (24.0%) 4 (13.8%) Clinical N stage cN0 12 (48.0%) 17 (58.6%) .585 cN1‐2 13 (52.0%) 12 (41.4%) Clinical M stage M0 22 (88.0%) 29 (100.0%) .093 M+ 3 (12.0%) 0 (0.0%) Neoadjuvant treatment No 22 (88.0%) 21 (72.4%) .191 Yes 3 (12.0%) 8 (27.6%) Surgery Endoscopic full‐thickness resection 2 (8.0%) 1 (3.4%) .592 Right colectomy 3 (12.0%) 4 (13.8%) Transverse colectomy 2 (8.0%) 2 (6.9%) Left/sigmoid colectomy 2 (8.0%) 4 (13.8%) Anterior resection 10 (40.0%) 16 (55.2%) Others/colostomy fashioning 5 (20.0%) 2 (6.9%) Death before surgery 1 (4.0%) 0 (0.0%) Ostomy Yes 8 (32.0%) 9 (31.0%) 1.000 No 17 (68.0%) 20 (69.0%) Surgery time, min 141.4 (±61.8) 191.0 (±71.0) .009 Postoperative stay, d 6.9 (±3.8) 8.5 (±5.0) .197 Complications Postoperative ileus 1 (4.0%) 0 (0.0%) 1.000 Anastomotic leakage 2 (8.0%) 5 (17.2%) Bleeding 0 (0.0%) 1 (3.4%) Ureteral leakage 1 (4.0%) 0 (0.0%) No complications 20 (80.0%) 23 (79.4%) No surgery 1 (4.0%) 0 (0.0%) (y)pT stage pT0‐1 6 (24.0%) 5 (17.2%) .132 pT2 1 (4.0%) 9 (31.0%) pT3 10 (40.0%) 10 (34.5%) pT4 4 (16.0%) 4 (13.8%) Not applicable 4 (16.0%) 1 (3.4%) pN stage pN0 13 (52.0%) 19 (65.5%) .555 pN1‐2 8 (32.0%) 8 (27.6%) Not applicable 4 (16.0%) 2 (6.9%) Grading G1 6 (24.0%) 4 (13.8%) .433 G2 12 (48.0%) 20 (69.0%) G3 3 (12.0%) 3 (10.3%) Not applicable 4 (16.0%) 2 (6.9%) Margins status R0 19 (76.0%) 27 (93.1%) .426 R1 1 (4.0%) 0 (0.0%) Not applicable 5 (20.0%) 2 (6.9%) Abbreviations: CA, carbohydrate antigen; CEA, carcinoembryonic antigen; COVID‐19, coronavirus disease 2019, CT, computed tomography. John Wiley & Sons, Ltd. This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency. CONFLICT OF INTERESTS The authors declare that there are no conflict of interests.

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          Laparoscopy at all costs? Not now during COVID‐19 and not for acute care surgery and emergency colorectal surgery: a practical algorithm from a hub tertiary teaching hospital in Northern Lombardy, Italy

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            Author and article information

            Contributors
            marcello.guaglio@istitutotumori.mi.it
            Journal
            J Surg Oncol
            J Surg Oncol
            10.1002/(ISSN)1096-9098
            JSO
            Journal of Surgical Oncology
            John Wiley and Sons Inc. (Hoboken )
            0022-4790
            1096-9098
            31 May 2020
            : 10.1002/jso.26052
            Affiliations
            [ 1 ] Department of Surgery, Colorectal Surgery Unit Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
            Author notes
            [*] [* ] Correspondence

            Marcello Guaglio, MD, Department of Surgery, Colorectal Surgery Unit, Istituto Nazionale dei Tumori, Via Venzian 1, 20133 Milan, Italy.

            Email: marcello.guaglio@ 123456istitutotumori.mi.it

            Author information
            https://orcid.org/0000-0002-3963-2385
            http://orcid.org/0000-0002-8194-9810
            https://orcid.org/0000-0002-3462-0449
            Article
            JSO26052
            10.1002/jso.26052
            7300572
            32476133
            b9c626bf-e8c4-4a0d-bbbf-53c878f48e0c
            © 2020 Wiley Periodicals LLC

            This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

            History
            : 12 May 2020
            : 19 May 2020
            Page count
            Figures: 0, Tables: 1, Pages: 3, Words: 1440
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            Oncology & Radiotherapy
            Oncology & Radiotherapy

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