As of April 4, the Italian Health Ministry reports more than 120,000 total cases and
15,000 deaths from coronavirus disease 2019 (COVID-19) nationwide . Because of
the striking and often unforeseeable rapidity of respiratory deterioration, about
10–25% of hospitalized patients require invasive ventilation . This has led to
an unprecedented challenge for healthcare providers, especially in northern Italy,
the nation's center of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2)
outbreak. Although Italy's national health system has 3.2 hospital beds per 1,000
people (as compared with 2.8 in the USA), the ability to test, contain people with
suspected infection, and meet the needs of critically ill patients simultaneously
has been outpaced.
After a time-lag of few weeks, in other countries − including the USA − hospitals
are now overflowing with COVID-19 patients. With the aim of reducing unnecessary patient
traffic in the hospitals, protecting the safety of healthcare professionals, and allocating
potentially scarce resources for the care of COVID-19 patients, the American College
of Surgeons has recommended that hospital leaderships review and curtail all elective
procedures until the predicted inflection point of the SARS-CoV-2 exposure graph is
reached . However, most surgical cases in tertiary care hospitals are scheduled
for malignancies, which will continue to progress at variable, disease-specific rates.
Among solid tumors, pancreatic ductal adenocarcinoma portends a postoperative survival
rate of only 30–35 months when a multimodal treatment strategy, including chemotherapy
or chemoradiation is applied [4, 5]. Furthermore, the risk of PDAC progression with
care delay is very high . We herein describe the dynamics associated with SARS-CoV-2
outbreak at the Verona Pancreas Institute, a national referral center located in northern
Italy and performing about 500 pancreatic resections annually. Furthermore, we discuss
practical hints for patient triaging in pancreatic cancer surgery.
The number of COVID-19 cases skyrocketed in Veneto region and Verona area in mid-March.
Our hospital had been shortly after designated as a regional COVID hub. Because of
a very rapid shortage of ventilators, non-emergent surgical procedures were initially
halved and then canceled as of March 16, when the operating theaters were reshaped
into makeshift ICU. After 2 weeks, thanks to the opening of additional ICU spots,
pancreatic procedures were resumed at 25% of the usual volume.
The shortage of operative slots calls for a framework to guide the patient selection
process. More than 70% of patients operated at our institution are from outside Veneto
and live a considerable distance away. Although traveling is against the principle
of limiting people circulation, a selection process based primarily on geographical
criteria would contrast the patient's right of choosing his/her care providers, an
important aspect in pancreatic surgery, whereby the volume-outcome correlation is
well established. Nonetheless, the sharp reduction of domestic flights and high-speed
train frequencies has led some patients from southern Italy to withdraw from our waiting
list and seek immediate care at their local institutions.
The 2nd and most important question is which type of pancreatic malignancies prioritizes
for surgery. During the highest peak of SARS-CoV-2 outbreak, in a “damage-control
perspective,” there may be no room for pancreatic surgery because of the associated
postoperative complications (with a 20% rate of ICU admission), the elevated costs,
and the relatively poor oncologic outcomes as compared to other cancers. Yet, the
plateau phase Italy has entered − the duration of which could be in the range of several
weeks to months − will likely prolong the operative slots constraints and the surgical
waiting list. Therefore, in accordance with the Italian Society of Surgery and the
American College of Surgeons, an Oncological Review/Ethics Committee, composed of
surgeons, oncologists, radiation oncologists, anesthesiologists, radiologists, and
psycho-oncologists has been established to provide clear and equitable judgment (Fig.
1). The plans for case triage are also shared with hospital administrators to account
for local circumstances and site-specific COVID-19 prevalence. Recommendations based
on our approach to pancreatic surgery in a COVID hub with reduced resources for elective
cancer cases are as follows:
Upfront pancreatectomy for PDAC should be discouraged. The Oncological Review Committees
should always consider neoadjuvant therapy, which acts as a biology equalizer at every
stage of localized PDAC. Nonetheless, the authors are aware that in certain circumstances,
concern may arise as to whether chemotherapy-induced immunosuppression could increase
the risk of becoming seriously ill from COVID-19.
Patients eligible for surgical exploration following neoadjuvant/induction chemotherapy
or chemoradiation should be prioritized. It has been indeed shown that the rate of
post-pancreatectomy morbidity following neoadjuvant therapy is reduced, despite the
clinical burden of complications could be remarkable . However, there is a wide
spectrum of surgical candidates following primary chemotherapy, ranging from resectable
patients to patients exhibiting major solid tumor contacts with peripancreatic vasculature,
in whom vascular resection is anticipated. For these latter cases with a high likelihood
of prolonged operative time, blood loss, and postoperative ICU utilization, the risk
of surgical delay to the individual patient must be carefully balanced against the
imminent availability of these resources for patients with COVID-19.
Although PDAC is by far the most common malignancy, attention should be paid to other
cancer types, including ampullary and duodenal adenocarcinoma, which are associated
with a better prognosis relative to PDAC. Remarkably, no neoadjuvant strategies have
been established for these cancer types.
All patients scheduled for pancreatectomy should be tested for SARS-CoV-2 prior to
hospital admission. Positive testing imposes surgical delay and re-testing following
a 14-day quarantine period.
COVID-19 is a competing risk for patients requiring surgical care. Age and comorbidities
should be carefully weighed against the expected oncological outcomes and the risk
of severe symptoms and mortality in the circumstances of COVID-19 during the postoperative
period or recovery phase.
Pancreatectomies for low-grade or benign neoplasms should be delayed.
These hints can be coupled with general principles provided from surgical associations
around the world as we triage pancreatic cancer patients during the pandemic:
Prioritize the protection of all healthcare providers (#SavetheHospital).
Convert to virtual practices (electronic messaging, telephone, and vide ocalls) for
patient visits and multidisciplinary boards.
Allocate psychological-support resources to help patients, families, and providers
dealing with disruption of normal services.
Stay in touch with patients whose surgery has been delayed, in order to monitor their
clinical conditions and improve the quality of life during this difficult period.
This may prevent any feelings of abandonment that patients may experience.
Interrupt research programs on technical innovation in surgery (e.g., minimally invasive
surgery and robotic surgery programs) if funded by public institutions, given the
possible upcoming severe economic recession.
The authors are aware that these recommendations are not evidence based. However,
we are abruptly asked to make decisions for which many of us will not be prepared.
Shared recommendations by Oncological Review Committees can help optimizing the resource
allocation process and mitigate the enormous emotional burden to which we are individually
exposed in an unprecedented crisis. Because of its aggressive biology, PDAC would
virtually require immediate care. Many pancreatic cancer patients in Italy will receive
suboptimal care or even no treatment as referral hospitals are carrying the catastrophic
brunt of thousands of COVID-19 cases. These “indirect” deaths that will inevitably
occur, although hard to track, should be added to the overall lethality of SARS-CoV-2
as the outbreak has finally faded away. In these difficult times, our love (pancreatic
surgery) in the time of cholera (COVID-19) is tremendously struggling.
All authors declare no conflicts of interest.
The authors did not receive any funding.
All authors contributed equally.