Comment on: “The management of surgical patients during the coronavirus disease 2019 (COVID-19) pandemic”

To the Editor:

We read with great interest the review by Spolverato et al¹ regarding the management of surgical patients during the coronavirus disease 2019 (COVID-19) pandemic. We want to congratulate the authors for this extensive and interesting review. However, we would like to introduce 2 considerations that we think could be interesting.

The management of cancer surgical patients remains one of the unsolved issues on this topic. Many societies suggest the reduction of surgical activity, including oncologic patients,² or tailoring every decision by a multidisciplinary team committee.^{3 , 4} This attitude could be appropriate or detrimental depending on the pandemic incidence and government policies. In Spain, the pandemic incidence was highly variable with rates in different areas ranging between 11.3% and 1.1%⁵; therefore, the effect on the health system resources were completely different. However, policies regarding cancellation of surgical activity, including oncologic patients, were generalized to prevention of a pandemic peak that never came in many regions.

The harm of delaying oncologic surgery results from the type of cancer and oncologic stage, the time added to the recommended optimal surgical treatment, and the increase in the waiting list of additional new oncologic diagnosed patients. On the other hand, time to “new normality” in hospitals after the pandemic peak could be highly variable and according to the most affected European countries decrease in new cases and intensive care unit bed occupancy, it could take around 50 to 60 days.⁶

In our opinion, an individualized staged plan should be designed according to the hospital resources and the estimated region impact of the pandemic while trying to maintain oncologic and surgical activity as long as possible instead of canceling the surgery prematurely.

Early detection of COVID-19 infected surgical patients constitutes another of the most important points for the surgical department. Generalized reverse transcription protein chain reaction (RT-PCR) detection of all surgical patients or clinically symptomatic patients remains the gold standard. However, as seen in many European countries, this diagnosis test was not available at the beginning of the pandemic⁷; therefore, intrahospitality infection resulted in one of the main transmissions concerns. At that time, we introduced 2 novel measures: a daily clinical patient and relatives screening and a chest computed tomographic (CT) scan before any surgical procedure.

The daily hospitalization screening identified 9 suspected cases. After isolation and PCR testing, 5 of them were negative and 4 resulted in COVID+. The 4 COVID+ cases were 2 patients and 2 relatives. This screening helped us to control the spread of the pandemic, preventing additional patient, relative, and professional infection.

The initial results of the screening chest CT scan included 58 thoracic scans were performed: 19 scheduled patients (30.6%) and 39 emergency patients (54.9%). Only 2 scans resulted in suspicion; however, the PCR test was negative in both cases. Despite the sensitivity of the chest CT scan remaining highly variable,⁸ the negative predictive value was high and could be adopted as an alternative when PCR CovSars-2 is not available.

We think managing the oncologic patients waiting list has to be individualized by each hospital and region while maintaining these surgeries as long as possible. The addition of patients and relatives clinical screening could help provide an early diagnosis of new cases. A chest CT scan screening protocol could be an alternative to RT-PCR in countries where there is limited access to it.

Conflict of interest/Disclosure

None of the authors report any conflict of interest.

Funding/Support

None.