Please visit
https://www.sages.org/video/surgical-guidelines-during-covid-19/
to watch the webinar and claim CME credits.
Reimagining surgical care for a healthier world
Please visit
https://www.sages.org/video/surgical-guidelines-during-covid-19/
to watch the webinar and claim CME credits.
Question: Does standard manual cleaning followed by high-level disinfection eradicate SARS-CoV-2?
Recommendation:
Question: Is there any specific new guidance to the reprocessing steps as outlined in prior guidelines for the SARS-CoV-2?
Recommendations:
Question: What changes are needed to prevent transmission from patients to the reprocessing staff?
Recommendations:
Question: Is there any special handling of endoscopes for known COVID-19 cases?
Recommendation:
Question: Are there any changes to the process needed to prevent transmission from staff to patients via handling of fully reprocessed endoscopes post high-level disinfection?
Recommendations:
Question: How should procedure rooms be cleaned after each patient during the COVID-19 pandemic?
Recommendations:
Question: How should a procedure room be cleaned after known COVID-19 cases?
Recommendations:
Question: Are there any special endoscope storage needs after use on suspected/confirmed COVID-19 patients?
Recommendations:
Question: How long can an endoscope be stored after it is fully reprocessed?
Recommendation:
Question: Are there any special instructions to reprocess the endoscopes before long-term storage?
Recommendations:
Question: Are there any instructions on cleaning reprocessing and storage areas prior to re-opening of endoscopy suites?
Recommendations:
Question: Are there any special instructions on handling reprocessing equipment when shutting down, during shutdown, and just before reopening endoscopy facilities?
Recommendations for prolonged full or partial closure:
Recommendations during the pandemic:
Recommendations for re-opening:
A number of guidelines recommend high-level disinfection (HLD) for the reprocessing of gastrointestinal (GI) endoscopes(8-11). Manual cleaning followed by HLD, when properly performed, effectively eliminates nearly all microorganisms from endoscopes during reprocessing(12). Transmission of viral infections during endoscopy is exceedingly rare and when it does occur, it is the result of noncompliance or deviation from the required steps of reprocessing.
Reprocessing of GI endoscopes has been outlined in a number of guidelines(8-11) and should follow endoscope manufacturer IFUs. Reprocessing staff should undergo necessary training and ongoing, annual assessment of competency. A reprocessing training curriculum that is evidence based and incorporates effective modalities for adult learning should be employed. Part of this curriculum should embed an auditing tool for reprocessing staff. It would be prudent at this time for endoscopy unit leadership to re-emphasize the importance of optimal reprocessing and ensure competency assessments are up-to-date.
SARS-CoV-2 is known to remain on some surfaces for up to three days(13). The recommendations above therefore reflect an even higher degree of surface cleaning than is performed under typical circumstances.
Current literature does not support a maximal outer duration for use of appropriately cleaned, reprocessed, dried, and stored flexible endoscopes. Reuse of endoscopes within 21, and perhaps even 56 days of appropriately reprocessed, dried, and stored flexible endoscopes appears to be safe(14).
Independent of the COVID pandemic, endoscopy units have been advised to evaluate the available literature, perform an assessment as to the benefits and risks around the optimal storage time for endoscopes, and develop a policy and procedure specific to their unit on endoscope storage time. Any endoscope not reprocessed for longer than the endoscopy unit’s own endoscope storage time policy ought to be reprocessed again prior to use.
Note: these recommendations are subject to change and update.
The care for all patients with cancer requires multidisciplinary review and decision-making, and entails the consideration of many factors in order to develop a sound plan of treatment. This requires a detailed assessment of patient, disease, surgical team, and hospital resources. (1) These principles remain critical and in fact, arguably more important now as we combat the COVID-19 pandemic than ever before. Thus a “one size fits all” recommendation would be unwise due to significant variability in patient presentation, individual comorbidities, disease severity, regional pandemic burden, and hospital-regional resources. It is important to recognize this document presents general recommendations. These are meant to be helpful to the surgeon while recognizing that the individual surgeon and patient will need to decide upon the course of therapy depending on local resources and individual situations.
The recommendations below are aimed to help guide practicing surgeons by providing a framework to address more urgent cancer cases, and to help stratify options that may diminish risk and improve outcomes. To address these concerns, we refer to several resources including the Elective Surgery Acuity Scale (ESAS) (2) as published by the American College of Surgeons (ACS).
As each surgeon assesses their patient, it should be kept in mind that at of the date of this publication, no region in the USA is thought to have peaked in this epidemic. Thus, conditions are expected to get worse before improving. Having said that, when areas experience a “flattening of the curve”, some non-emergent surgeries may be considered.
COVID-19 PHASE of Hospital or Healthcare System: |
||
Phase | Condition | Description |
0 | Unaffected | No COVID-19 patients, hospital operating as normal |
I | Semi-urgent | COVID-19 patients are in the hospital, but resources and ICU beds/ventilators are not threatened |
II | Urgent | Many COVID-19 patients are in the hospital, ICU beds/ventilator availability is strained and operative and/or PPE resources are limited |
III | Emergent | Crisis situation where most ICU/ventilator resources are directed to COVID-19 patients and operating room and/or PPE equipment are minimally or entirely unavailable |
Generally, cancer patients require resources and support services that are typically stressed during pandemics. Further, early reports in this pandemic show that viral infection with COVID-19 tends to be specifically more lethal in cancer patients (5). This highlights that surgeons and systems must recognize that all cancer patients are in a high-risk category.
Tier 1a | Tier 1b | Tier 2a | Tier 2b | Tier 3a | Tier 3b |
Low acuity surgery/healthy patient
Outpatient surgery Not life- threatening illness |
Low acuity surgery/unhealthy patient | Intermediate acuity surgery/healthy patient
Not life threatening but potential for future morbidity and mortality. Requires in hospital stay |
Intermediate acuity surgery/unhealthy patient | High acuity surgery/healthy patient | High acuity surgery/unhealthy patient |
Modified from COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures. American College of Surgeons, Clinical Issues and Guidance (2)
General comments on cancer patients as they relate to the ESAS tier system:
**When multiple options exist, especially for Tier 3b, the surgeon is encouraged to choose the treatment option that minimizes use of resources and decreases risk to patient and healthcare. (1)
***Disease site specific non-operative alternative measures are outlined below.
For patients presenting with new gastric cancers at this time, we propose specific recommendations and guidelines to consider when deciding whether to proceed or delay an operation for these patients. In the following case scenarios, we are adhering to the 3 month-rule (is the cancer likely to progress in the next three months without treatment?)
Optimally managing cancer patients within the confines of limited medical resources is a hurdle rarely encountered in modern times in the USA. Never before has our Hippocratic Oath come more into play. This document will be updated as new scenarios or suggestions are posted. Again, it is of paramount importance to recognize these as general recommendations are meant to be helpful to the surgeon, while recognizing that the individual surgeon and patient will need to decide upon the course of therapy depending upon local resources and individual situations.
We will all make difficult decisions and all stand behind one another, as we should always strive to do. Prioritizing the patient’s needs and wishes, the family, and standing by them in the surgeon-patient relationship whatever course is necessitated, remains our professional calling and commitment.
Note: these recommendations are subject to change and update.
The care for all patients with cancer requires multidisciplinary review and decision-making, and entails the consideration of many factors in order to develop a sound plan of treatment. This requires a detailed assessment of patient, disease, surgical team, and hospital resources. (1) These principles remain critical and in fact, arguably more important now as we combat the COVID-19 pandemic than ever before. Thus a “one size fits all” recommendation would be unwise due to significant variability in patient presentation, individual comorbidities, disease severity, regional pandemic burden, and hospital-regional resources. It is important to recognize this document presents general recommendations. These are meant to be helpful to the surgeon while recognizing that the individual surgeon and patient will need to decide upon the course of therapy depending on local resources and individual situations.
The recommendations below are aimed to help guide practicing surgeons by providing a framework to address more urgent cancer cases, and to help stratify options that may diminish risk and improve outcomes. To address these concerns, we refer to several resources including the Elective Surgery Acuity Scale (ESAS) (2) as published by the American College of Surgeons (ACS).
As each surgeon assesses their patient, it should be kept in mind that at of the date of this publication, no region in the USA is thought to have peaked in this epidemic. Thus, conditions are expected to get worse before improving. Having said that, when areas experience a “flattening of the curve”, some non-emergent surgeries may be considered.
COVID-19 PHASE of Hospital or Healthcare System: | ||
Phase | Condition | Description |
0 | Unaffected | No COVID-19 patients, hospital operating as normal |
I | Semi-urgent | COVID-19 patients are in the hospital, but resources and ICU beds/ventilators are not threatened |
II | Urgent | Many COVID-19 patients are in the hospital, ICU beds/ventilator availability is strained and operative and/or PPE resources are limited |
III | Emergent | Crisis situation where most ICU/ventilator resources are directed to COVID-19 patients and operating room and/or PPE equipment are minimally or entirely unavailable |
Generally, cancer patients require resources and support services that are typically stressed during pandemics. Further, early reports in this pandemic show that viral infection with COVID-19 tends to be specifically more lethal in cancer patients (5). This highlights that surgeons and systems must recognize that all cancer patients are in a high-risk category.
Tier 1a | Tier 1b | Tier 2a | Tier 2b | Tier 3a | Tier 3b |
Low acuity surgery/healthy patient
Outpatient surgery Not life- threatening illness |
Low acuity surgery/unhealthy patient | Intermediate acuity surgery/healthy patient
Not life threatening but potential for future morbidity and mortality. Requires in hospital stay |
Intermediate acuity surgery/unhealthy patient | High acuity surgery/healthy patient | High acuity surgery/unhealthy patient |
Modified from COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures. American College of Surgeons, Clinical Issues and Guidance (2)
General comments on cancer patients as they relate to the ESAS tier system:
**When multiple options exist, especially for Tier 3b, the surgeon is encouraged to choose the treatment option that minimizes use of resources and decreases risk to patient and healthcare. (1)
***Disease site specific non-operative alternative measures are outlined below.
Generally, surgeons are encouraged to avoid operative management of HPB oncologic surgery in high risk patients (see variables noted above ) until locoregional pandemic status improves. It is worth noting that following the recommendations below may result in an endoscopic procedure, which harbors the risk of aerosolization, in-lieu of operative management. This is thought to be appropriate since it protects the overall resources used to manage patients in this pandemic. It goes without saying that healthcare providers performing any high-risk procedure should be equipped and follow strict PPE precautions as outlined in other recommendations. [https://www.sages.org/recommendations-surgical-response-covid-19/]
In the table below are various treatment options that are employed in treating HPB disease.
Treatment options in the HPB cancer patient include: |
|
Liver |
|
Pancreatico-Biliary |
|
The clinical presentation of the patient along with the stress on hospital resources by the COVID-19 patient volume will determine the best treatment option. While surgery has maintained its primacy in the treatment of HPB cancers, there are clearly roles for each of the above therapies, which may offer a preferred “next-best option” depending on the COVID-19 Phase of the hospital. For the purpose of this discussion we will exclude COVID-19 Phase 0 situations as that essentially falls into a business as usual category.
Treatment of common HPB conditions as it relates to COVID PHASE of Hospital or Healthcare System (see above for phase description): |
||||
Organ | Clinical Situation | Phase I | Phase II | Phase III |
LIVER | HCC (12)
Very early stage(0)/ Early Stage (A) / < 3cm * *For later stages consider TACE, Medical therapy, supportive care as appropriate (e. |
Consider ablation/resection/transplant as appropriate | Consider TACE, ablation, or observation (ie delay of definitive tx) | |
Colorectal mets (13, 14)
|
Consider chemotherapy (Tier 2b or greater) vs resection (Tier 2a) | Chemotherapy | ||
BILIARY 15 | Intrahepatic cholangiocarcinoma | Consider chemotherapy (Tier 2b or greater) vs resection (Tier 2a) | Consider chemotherapy, embolic therapy | |
Hilar cholangiocarcinoma | Stenting as indicated.
resection, transplantation as indicated |
Stenting as indicated.
consider chemotherapy, chemoradiation, and/or transfer* |
||
PANCREATIC AND EXTRA-HEPATIC BILIARY 16,17,18 | Resectable | Resection or consider chemotherapy | Neoadjuvant chemotherapy | |
Borderline | Neoadjuvant chemotherapy | |||
Pancreatic IPMN, Cysts, low-mod grade neuroendocrine neoplasms | All: observation (i.e. delay surgical management)
Neuroendocrine: if metastatic or progressing, consider targeted therapy |
*transfer to a facility in a region in Phase 0 – II
Patients who have completed neoadjuvant treatment and are waiting for surgery – these patients are difficult to manage although from last chemotherapy to operation there is a window of up to 12 weeks during which surgery can be planned without losing the opportunity for potential cure. For some patients, consider discussing with the medical oncology team about adding an additional 1-2 cycles of chemotherapy to bridge the patient through the worst of this crisis and plan surgery thereafter (17). Alternatively, patients with borderline tumors who have completed their induction short course chemotherapy can undergo chemoradiation as indicated.(18)
Optimally managing cancer patients within the confines of limited medical resources is a hurdle rarely encountered in modern times in the USA. Never before has our Hippocratic Oath come more into play. This document will be updated as new scenarios or suggestions are posted. Again, it is of paramount importance to recognize these as general recommendations are meant to be helpful to the surgeon, while recognizing that the individual surgeon and patient will need to decide upon the course of therapy depending upon local resources and individual situations.
We will all make difficult decisions and all stand behind one another, as we should always strive to do. Prioritizing the patient’s needs and wishes, the family, and standing by them in the surgeon-patient relationship whatever course is necessitated, remains our professional calling and commitment.
Note: these recommendations are subject to change and update.
The care for all patients with cancer requires multidisciplinary review and decision-making, and entails the consideration of many factors in order to develop a sound plan of treatment. This requires a detailed assessment of patient, disease, surgical team, and hospital resources. (1) These principles remain critical and in fact, arguably more important now as we combat the COVID-19 pandemic than ever before. Thus a “one size fits all” recommendation would be unwise due to significant variability in patient presentation, individual comorbidities, disease severity, regional pandemic burden, and hospital-regional resources. It is important to recognize this document presents general recommendations. These are meant to be helpful to the surgeon while recognizing that the individual surgeon and patient will need to decide upon the course of therapy depending on local resources and individual situations.
The recommendations below are aimed to help guide practicing surgeons by providing a framework to address more urgent cancer cases, and to help stratify options that may diminish risk and improve outcomes. To address these concerns, we refer to several resources including the Elective Surgery Acuity Scale (ESAS) (2) as published by the American College of Surgeons (ACS).
As each surgeon assesses their patient, it should be kept in mind that at of the date of this publication, no region in the USA is thought to have peaked in this epidemic. Thus, conditions are expected to get worse before improving. Having said that, when areas experience a “flattening of the curve”, some non-emergent surgeries may be considered.
COVID-19 PHASE of Hospital or Healthcare System: | ||
Phase | Condition | Description |
0 | Unaffected | No COVID-19 patients, hospital operating as normal |
I | Semi-urgent | COVID-19 patients are in the hospital, but resources and ICU beds/ventilators are not threatened |
II | Urgent | Many COVID-19 patients are in the hospital, ICU beds/ventilator availability is strained and operative and/or PPE resources are limited |
III | Emergent | Crisis situation where most ICU/ventilator resources are directed to COVID-19 patients and operating room and/or PPE equipment are minimally or entirely unavailable |
Generally, cancer patients require resources and support services that are typically stressed during pandemics. Further, early reports in this pandemic show that viral infection with COVID-19 tends to be specifically more lethal in cancer patients (5). This highlights that surgeons and systems must recognize that all cancer patients are in a high-risk category.
Tier 1a | Tier 1b | Tier 2a | Tier 2b | Tier 3a | Tier 3b |
Low acuity surgery/healthy patient
Outpatient surgery Not life- threatening illness |
Low acuity surgery/unhealthy patient | Intermediate acuity surgery/healthy patient
Not life threatening but potential for future morbidity and mortality. Requires in hospital stay |
Intermediate acuity surgery/unhealthy patient | High acuity surgery/healthy patient | High acuity surgery/unhealthy patient |
Modified from COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures. American College of Surgeons, Clinical Issues and Guidance (2)
General comments on cancer patients as they relate to the ESAS tier system:
**When multiple options exist, especially for Tier 3b, the surgeon is encouraged to choose the treatment option that minimizes use of resources and decreases risk to patient and healthcare. (1)
***Disease site specific non-operative alternative measures are outlined below.
Below is a discussion of treatment options and guidelines to consider for patients with newly diagnosed colorectal cancers, including patients who are completing or have already completed neoadjuvant treatment. The best treatment for the patient will vary depending on the individual situation as well as the phase of COVID-19 in your region, including patient volume and the resulting strain on the hospital and its resources.
To set the groundwork for the discussion it is worthwhile to list various treatment options and clinical scenarios. It is helpful to categorize conditions surrounding the hospital and healthcare system in an effort to choose treatments wisely.
The clinical presentation of the patient along with COVID-related strain on hospital resources will determine the most appropriate plan of action. While surgery maintains its primacy in the treatment of colorectal cancer, there are clearly roles for each of the above therapies, which may offer the preferred “next-best option” based on the COVID-19 Phase of the institution. For the purpose of this discussion we will exclude COVID-19 Phase 0 situations, which fall into a “business as usual” category.
Treatment of common colorectal conditions as it relates to COVID-19 PHASE of Hospital or Healthcare System (see above for phase description): |
|||
Clinical Situation | Phase I | Phase II | Phase III |
Large or suspicious polyps
Hereditary Syndromes Dysplasia/Carcinoma in situ in biopsy specimens, Incomplete, questionable margins on polypectomy |
All of the above categories would be classified as Tier 1or 2a, and for COVID-19 Phase I – III Hospitals surgery would be delayed until the pandemic abates and resources return |
||
Early cancer in resected polyp: (Tier 2) | Consider deferring surgery vs resection | Defer Surgery | |
Asymptomatic Cancer
T1-2 N0 (Tier 2) |
Resect | Resect Vs Deferring surgery | Defer Surgery |
Asymptomatic Cancer
Colon T3-4, N0 and Tx N+ (Tier 2) |
Resect | Resect Vs Deferring surgery** | Consider Chemotherapy Vs transfer* |
Rectal T3-4, N0 and Tx N+ (Tier 2) | Induction chemotherapy versus chemoradiation versus radiation, consider extended chemotherapy, also consider delaying surgery up to 12-16 weeks following completion of radiation | ||
Symptomatic Cancers (Tier 3) defined as bleeding requiring transfusion, obstructing or near-obstructing, impending perforation | Resect | Resect, consider stent versus stoma | Stoma vs stent, Consider transfer* |
*transfer to a facility in a region in Phase 0-II
**While resection of locally advanced colon malignancies may be feasible during Phase II, the decision to defer may be justified based on anticipated impending COVID-19 surge and critical straining on institutional resources (transition from Phase II to Phase III may occur within days)
Optimally managing cancer patients within the confines of limited medical resources is a hurdle rarely encountered in modern times in the USA. Never before has our Hippocratic Oath come more into play. This document will be updated as new scenarios or suggestions are posted. Again, it is of paramount importance to recognize these as general recommendations are meant to be helpful to the surgeon, while recognizing that the individual surgeon and patient will need to decide upon the course of therapy depending upon local resources and individual situations.
We will all make difficult decisions and all stand behind one another, as we should always strive to do. Prioritizing the patient’s needs and wishes, the family, and standing by them in the surgeon-patient relationship whatever course is necessitated, remains our professional calling and commitment.