Commentary: Echoes of war

Gaetano Rocco, MD, FRCSEd

Central Message.

Aggressive identification of COVID-19 surgical candidates is mandatory to avoid lethal postoperative complications and prevent exposing surgeons to the contagion.

See Article page 585.

Patients with coronavirus disease 2019 (COVID-19) experience 1 of 3 possible pathways—minimal symptoms (home rest), shortness of breath (hospital admission), and need for ventilatory support (intensive care unit admission)—variably combined and yielding different outcomes.¹ The article by Peng and colleagues published in this issue of the Journal ² describes the postoperative onset of COVID-19 pneumonia in patients with ascertained exposure to the contagion before surgery. Once viral pneumonia is recognized, the outcome becomes unpredictable, irrespective of the type of surgery and the wide variety of treatment regimens used to control the infection.^{2 , 3} The lesson learned from Wuhan is that we need to strike a balance between the benefit of surgery and the risks of an undue exposure to the virus for both patients and surgeons by changing the principles of managed care.⁴ We hear from Europe, especially from Italy, of hospitalized patients developing COVID-19 after surgery, as well as thoracic surgeons intubated after heroically providing service to these patients. In addition, fewer and fewer thoracic surgical units are operative, with the majority converted to COVID-19 step-down wards.

In New York City, the new epicenter of the disease, we have just begun ramping up the curve of the contagion. The frightening 27% mortality risk reported by Peng and colleagues should make us rethink our strategies and reshape our approach to the patient.² The availability of human resources will affect the ability to continue to perform cancer surgery—those resources need to be protected.⁵ The implementation of telemedicine to triage perspective new visits and provide follow-up of operated patients is rapidly becoming a necessity.⁵ Strict personal hygiene, social distancing, and avoidance of external visitors are effective preventative measures, especially considering the risk of spreading the contagion from asymptomatic patients.⁵ Accurate selection of candidates for endoscopic staging may avoid an unmeasurable exposure of clinicians and staff to a patient’s exhalates. Surgical procedures that can potentially increase length of stay must be carefully selected and, if possible, postponed if we want to be ready with bed availability when the COVID-19 pandemic hits with its maximum strength. The paper from Wuhan transfers the echoes of war from the initial epicenter of the contagion.² For the first time after the era of tuberculosis, an airborne pathogen can potentially harm both the patient and the surgeon in the perioperative phase. In the supreme interest of both patients and surgeons, aggressive screening for COVID-19 should be used with surgical candidates, and COVID-19 should enter the differential diagnosis of postoperative complications after thoracic surgery.