Commentary: Challenges to thoracic surgeons in the global coronavirus pandemic

Yang Zhang, MD (left), and Haiquan Chen, MD, PhD (right)

Central Message.

The global pandemic of COVID-19 brings challenges to thoracic surgeons. It is important to avoid unnecessary surgeries and to be alert to the risk of COVID-19 infection following thoracic surgeries.

See Article page 585.

On January 30, 2020, the World Health Organization officially declared the outbreak of coronavirus disease 2019 (COVID-19) as a public health emergency of international concern. During this virus outbreak, many elective surgeries have been postponed. However, thoracic malignancy, especially lung cancer, has a very high incidence. For thoracic surgeons, the risk of tumor progression with delay of definitive surgery cannot be ignored.

In this article, Peng and colleagues¹ investigated the clinical course of 11 patients diagnosed with COVID-19 after thoracic surgeries in January 2020. Of these patients, 7 underwent resection for lung cancer, 2 for esophageal cancer, 1 for pulmonary sclerosing pneumocytoma, and 1 for bronchiectasis. Three patients died of respiratory failure, 5 recovered and were discharged, and 3 remained hospitalized. Physiological changes after thoracic surgeries, such as leukocytosis, lymphopenia, and changes in computed tomography (CT) images, might overshadow early signs of viral pneumonia.

This article presented some important results for us to understand COVID-19 after thoracic surgeries. The COVID-19 infection rate after thoracic surgeries was high (11/121; 9.1%). There was also a high proportion of severe illness (36.4%) and mortality rate (27.3%) of COVID-19 after thoracic surgeries. Therefore, during the pandemic, patients planned for thoracic surgeries should be managed with great caution.

Most importantly, unnecessary thoracic surgeries should be avoided. For patients with lung ground-glass opacity (GGO) lesions, there must be a period (4-6 months) of follow-up before surgical resection.² During follow-up, benign GGO lesions may disappear. COVID-19, at its early stage, can also present as GGO lesions on CT scans. Follow-up CT scans can help to make the differential diagnosis. Even for patients with persistent GGO lesions highly suspicious of lung cancer, they usually do not have to receive surgery immediately, as GGO-featured lung cancer is generally indolent. For patients with solid lesions suspicious of lung cancer, a short period of follow-up or needle biopsy may be considered to reduce unnecessary resections of benign lesions.

In circumstances in which surgeries cannot be delayed, there should be strict measures to prevent COVID-19 transmission. As the incubation period of COVID-19 is generally within 14 days following exposure,³ patients with an epidemiologic history should be observed for at least 2 weeks before surgery. For suspicious patients, nucleic acid testing should be performed. During anesthesia in emergency surgeries, the endobronchial blocker may be a better choice than the double-lumen bronchial tube, since the lung is not directly exposed to the air. Surgery can cause adverse effects on immune functions, which may make these patients more vulnerable to COVID-19 infection. Therefore, strict infection control practices should be followed. Since the early signs of COVID-19 may be masked by physiological changes following thoracic surgeries, thoracic surgeons should cautiously monitor their patients and also protect themselves from infection.

The global pandemic of COVID-19 brings challenges to thoracic surgeons. It is important to avoid unnecessary surgeries and to be alert to the risk of COVID-19 infection following thoracic surgeries.