The Italian Society of Colorectal Surgery (SICCR) has published its recommendations for good clinical practice in colorectal surgery in response to the novel COronaVIrus Disease (COVID-19) pandemic. The paper, ‘Italian society of colorectal surgery recommendations for good clinical practice in colorectal surgery during the novel coronavirus pandemic’, published in Techniques in Coloproctology, noted that all elective procedures (with the exception of anorectal emergencies - in these cases, the use of local anaesthesia and/or sedation in an outpatient setting can be proposed to avoid hospital admissions), including day case surgeries, have been cancelled in favour of emergencies. In addition, many regions are trying to identify centres of reference where oncological cases that are COVID-19 negative should converge.
The SICCR states that its recommendations are “based on the impact of the disease on the regional health organisations and according to the emergency level of every single hospital.” Paramount in the guidelines is that the guarantee of the same high standard of surgical care, should be considered, when considering the possibility of transferring a patient from a COVID-19 emergency hospital to a low emergency one.
The recommendations outline that telemedicine (virtual visit) must probably be considered as a first-line solution, since it is safe and effective (in this emergency context), providing rapid access to specialists who are not immediately available due to the viral outbreak. In addition, telephone calls, e-mail or social media should also be considered where possible.
Diagnostic procedures such as screening and surveillance endoscopy, anoscopy, endoanal ultrasound and anorectal manometry should be postponed according to the recent evidence of faecal COVID-19 transmission and the persistence of the virus in faecal samples for a longer period than in nasopharyngeal swabs. Upper or lower endoscopy in intermediate- or high-risk patients should be performed wearing special protective equipment and in negative pressure rooms.
Whilst patients with inflammatory bowel disease (IBD) taking immunosuppressive drugs may be at higher risk of infection, the 2nd interview COVID-19 ECCO Taskforce highlighted that there are no data demonstrating that immunosuppressive therapies increase the risk of complicated COVID-19.
IBD patients who are suspected to have a COVID-19 infection, if they are not at high risk of flare-up, should stop thiopurines, delay methotrexate injections and delay biologics, and in particular, JAK inhibitors which decrease the number of lymphocytes.
The risks and benefits of steroid treatment in COVID-19-positive IBD patients should be carefully considered. The recommends that physicians register their COVID-19-positive IBD patients on the SECURE-IBD (Surveillance Epidemiology of Coronavirus Under Research Exclusion) website. As of the 23rd of March, a total of 41 patients from 13 different countries were already enrolled.
Acute complicated diverticulitis
Regarding the management of acute complicated diverticulitis, the paper stated that this depends on the clinical manifestations and has not undergone changes following the outbreak of COVID-19, an initial conservative approach with observation and antibiotic treatment. In COVID-19 positive patients, open surgery may be preferred to laparoscopic surgery for Hinchey 3 and 4 patients to avoid aerosolised contamination. The paper recommends that all patients were tested for SARS-COV-2 before any elective or emergency surgical procedure, even if they are asymptomatic.
As COVID-19 has increased the need for anaesthesiologists and beds in intensive-care units, there have been recommendations by societies and experts to delay surgical treatment for stage I and stage II colorectal cancer for up to six months. In addition, neoadjuvant treatments have been recommended for high-risk colon and rectal cancer to defer as long as possible surgical admission with the use of preoperative chemotherapy for colon cancer or of consolidation chemotherapy after either chemoradiation or short-course radiotherapy for rectal cancer.
However, they acknowledge that none of the proposed neoadjuvant treatments have been shown to be superior to the more traditional approach and all involve prolonged chemotherapy that will further impair the patient’s immune system increasing the risk of COVID-19 complications.
“Within the context of a pandemic COVID-19 infection, it is reasonable to recommend less aggressive approaches for less aggressive cancers. For example, on approaching rectal cancer determined by clinical staging and magnetic resonance imaging (MRI) to be T3a-b N0 (The Good), upfront total mesorectal excision could be the best treatment as the benefits of chemoradiation therapy followed by total mesorectal excision in this group of patients are questionable.”
Nevertheless, they recommend that aggressive neoadjuvant therapies with induction or consolidation chemotherapy should be reserved for cancers with the highest risk of recurrence such as those with infiltration of the mesorectal fascia or clearly positive nodes in the mesorectum or pelvic extramesorectal lymph-node metastasis. Exclusion or delayed surgery should be recommended in those very exceptional situations where anaesthesiologists or operating rooms are unavailable. All these decisions should be made by a multidisciplinary oncology team and fully discussed with patients.
Surgical approach for colorectal cancer
Where non-surgical treatment may reach the same goal as surgical therapy, the non-surgical treatment should be preferred. For example: stents should be preferred to palliative resections. When evaluating different surgical options, the rate and severity of postoperative complications should be considered.
Rectum-sparing approaches (watch and wait) have been suggested as an option in rectal cancer patients with a complete or near-complete clinical response after neoadjuvant therapy. Whilst rectum-sparing approaches are feasible and oncological outcomes such as overall survival and disease-free survival are likely comparable to those after radical surgery provided that patient selection is optimal, these approaches are not standard of care, it seems reasonable to enter patients into prospective studies where conservative approaches are evaluated. Conversely, the authors discourage rectum-sparing approaches outside of research protocols.
The authors concluded that the COVID-19 epidemic should not lead to approaches that impair oncologic results or expose patients to excessive morbidity:
- In COVID-19-negative patients, elective surgery should be performed following the current guidelines, using the least aggressive treatment possible and providing treatments in COVID-19-free hospitals (hopefully) or in hospitals where COVID-19-positive and -negative patients follow clearly separate pathways.
- In COVID-19-positive patients, recovery from the infection is the priority and cancer surgery should be reserved only for life-threatening situations. In both COVID-19-positive and COVID-19-negative cancer patients with an emergent presentation, the treatment should be as conservative as possible, avoiding surgery if feasible, using stent placement for stenosing cancer as bridge to surgery or as palliative treatment.
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