. 2020 Apr 22;36(2):121–131. doi: 10.5578/turkjsurg.4812

Table 6. Society of American Gastrointestinal and Endoscopic Surgeons Recommendations Regarding Surgical Management of Gastric Cancer Pa- tients During the Response to the COVID-19 Crisis (https://www.sages.org/sages-recommendations-surgical-management-gastric-cancer-covid- 19-crisis/).

Gastric Cancer
T1a cancers - these patients may be candidates for EMR or ESD and referring them for a same-day procedure. These may be considered in Phase I depending on hospital resources. If not, then weekly“check-ins”to reassess the stage are reasonable to find the best“window”. In Phase II - III, these should be deferred. Also note, there are concerns for aerosolization with endoscopic procedures (EMR/ESD) and thus we recommend delaying these procedures and ensuring patient is COVID-19 negative. T1b and T2 cancers - these patients need surgery, however, a 4-6 week window to time the operation when hospital resources are optimal (rela- tively-speaking) is reasonable. Minimally invasive options are preferable as they will likely decrease the length of stay in the hospital. T3 or higher cancers, or those who are clinically node positive - these are patients in whom neoadjuvant chemotherapy is recommended, allowing physicians a 3-4 month window to plan surgery (likely after the crisis phase has passed). Staging Diagnostic Laparoscopy - although patients with this stage of gastric cancer typically have staging with diagnostic laparoscopy prior to the initiation of chemotherapy to rule out occult metastatic disease, if hospital resources and space are critical at the time and the patient is at higher risk due to age or comorbidities, then consideration for proceeding straight to chemotherapy is reasonable. Plan for diagnostic laparoscopy after chemotherapy is completed and prior to operation. Obstructing and Bleeding Gastric Cancers - for gastroesophageal junction cancers, immediate initiation of chemotherapy and radiation thera- py may obviate the need for a stent for gastric outlet obstructions. If the obstruction is complete and the patient requires admission to a hospital, then proceed with gastrectomy. However, for near-complete obstructions, chemotherapy may improve the ability to eat within 2-3 days. Avoid stents as they make as they could make subsequent procedures more challenging. For a bleeding lesion, non-surgical approaches (IR and or endoscopy) should be attempted first. When not able to control otherwise, a surgical resection may be indicated. 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 3-6 weeks during which surgery can be planned without losing the opportunity for potential cure. For some patients, consider speaking with the medical oncologist about adding an additional 1-2 cycles of chemotherapy to bridge the patient through the worst of the pandemic crisis and plan surgery there after.

Gastric Cancer

T1a cancers - these patients may be candidates for EMR or ESD and referring them for a same-day procedure. These may be considered in Phase I depending on hospital resources. If not, then weekly“check-ins”to reassess the stage are reasonable to find the best“window”. In Phase II - III, these should be deferred. Also note, there are concerns for aerosolization with endoscopic procedures (EMR/ESD) and thus we recommend delaying these procedures and ensuring patient is COVID-19 negative.
T1b and T2 cancers - these patients need surgery, however, a 4-6 week window to time the operation when hospital resources are optimal (rela- tively-speaking) is reasonable. Minimally invasive options are preferable as they will likely decrease the length of stay in the hospital.
T3 or higher cancers, or those who are clinically node positive - these are patients in whom neoadjuvant chemotherapy is recommended, allowing physicians a 3-4 month window to plan surgery (likely after the crisis phase has passed).
Staging Diagnostic Laparoscopy - although patients with this stage of gastric cancer typically have staging with diagnostic laparoscopy prior to the initiation of chemotherapy to rule out occult metastatic disease, if hospital resources and space are critical at the time and the patient is at higher risk due to age or comorbidities, then consideration for proceeding straight to chemotherapy is reasonable. Plan for diagnostic laparoscopy after chemotherapy is completed and prior to operation.
Obstructing and Bleeding Gastric Cancers - for gastroesophageal junction cancers, immediate initiation of chemotherapy and radiation thera- py may obviate the need for a stent for gastric outlet obstructions. If the obstruction is complete and the patient requires admission to a hospital, then proceed with gastrectomy. However, for near-complete obstructions, chemotherapy may improve the ability to eat within 2-3 days. Avoid stents as they make as they could make subsequent procedures more challenging.
For a bleeding lesion, non-surgical approaches (IR and or endoscopy) should be attempted first. When not able to control otherwise, a surgical resection may be indicated.
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 3-6 weeks during which surgery can be planned without losing the opportunity for potential cure. For some patients, consider speaking with the medical oncologist about adding an additional 1-2 cycles of chemotherapy to bridge the patient through the worst of the pandemic crisis and plan surgery there after.