Editor
The concept that medical facilities and health workers might be an important contamination route in the pandemic has brought to consequences and attitudes for the population as well for legislators. In the pandemic period, most of the patients requiring intervention for gastrointestinal malignancy are in emergency, no-deferrable conditions. We reviewed the results of operative endoscopy to treat emergencies secondary to gastrointestinal malignancy during the lock down period in Italy, from March 11th to April 28th. The study was approved by the Ethical Board of the University. All patients gave written informed consent. Endoscopy for no COVID 19 patients was performed in a dedicated room. COVID 19 and no COVID 19 patients had completely different routes. Protections were those suggested by the WHO 1–3. Seventy patients underwent emergent endoscopic operative procedures. There was no operative mortality and no major complication. Out of the 70 operative procedures, 21 were performed for malignancy-related emergencies (Table 1). Retrospective review by the surgical team considered that in usual times, 10 of those patients might have had open or laparoscopic surgery. During the same period 199 patients underwent diagnostic operative endoscopy; eight patients were COVID19 positive. At a mean follow-up of 1 month from the procedure, all the health workers and the initially negative COVID19 patients were asymptomatic and COVID19 negative. In the pandemic surgeons have postponed or cancelled many elective treatments, reserving admission to the hospital only to patients with malignancy which could pose a threat to survival. Even patients with malignancy try to avoid medical facilities if possible. There is a general attitude to prefer therapeutic schema which imply reduced risk for complications and hospital admission 4,5. Visits from relatives are not allowed, so that the patient undergoing major surgery should expect a significant isolation time with inevitable negative psychological consequences. Cancer and cancer-related treatments frequently cause immune suppression, and patients with cancer have excess mortality risk from severe acute respiratory syndrome. General anesthesia with endo-tracheal intubation, postoperative pain, Intensive Care Unit permanence are some of the most common risk factors for postoperative pulmonary complications. Operative endoscopy generally requires shorter operative time, no general anesthesia and tracheal intubation, and less organizational efforts. Hospital stay is shorter. Pulmonary complications and infection-related complications are lower after operative endoscopy. A smaller number of health workers is involved, intensive care unit is rarely required. Operative endoscopy should be evaluated in the pandemic differently than in usual times. Endoscopic procedures which have the same results of standard surgery, or even a marginal less effective result, should be preferred. The possibility to defer the standard, more effective surgical operation at later times, after having resolved the emergency situation by a less risky endoscopic procedures, is a reasonable clinical perspective. Placement of self-expandable metal stents to relieve malignant colorectal or gastric obstruction represents a valid temporary choice, deferring definitive surgery, if required in more convenient times. Malignant obstructive jaundice, associated or not with gastric outlet obstruction, can be relieved by stent placement. The endoscopic removal of a bleeding small colorectal cancer (Carcinoma in situ-T1-T2) may represent a valid choice, deferring any major resection if any during the follow-up period.
Table 1.
Endoscopic operative procedure during COVID 19 pandemic in patients with malignancy-related emergencies. Percutaneous Endoscopic Gastrostomy (PEG); Endoscopic Retrograde Cholangio- Pancreatography (ERCP); Self-Expandable Metallic Stent (SEMS); Endoscopic Variceal Band Ligation (EVBL); Argon Plasma Coagulation (APC) laser
| Procedure | Age | Sex | Indications | General Conditions | Complications | SARS-CoV-2 |
|---|---|---|---|---|---|---|
| SEMS Positioning | 80 | F | Antro-pyloric cancer | Serious but stable clinical conditions | Vomiting in the 3 days following the procedure | Negative |
| 51 | F | Colonic cancer | Serious but stable clinical conditions | No complications | Negative | |
| 66 | F | Antro-pyloric cancer | Serious but stable clinical conditions | No complications | Negative | |
| 67 | M | Rectal cancer | Serious but stable clinical conditions | No complications | Negative | |
| 60 | M | Colonic cancer | Serious but stable clinical conditions | No complications | Negative | |
| ERCP (with metallic biliary prosthesis positioning SEMS) | 44 | F | Carcinoma of the head of the pancreas | Fair clinical conditions | Hyperamylasemia and hyperlipasemia | Negative |
| 68 | M | Serious but stable clinical conditions | No complications | Negative | ||
| 57 | M | Fair clinical conditions | No complications | Negative | ||
| 70 | M | Serious but stable clinical conditions | No complications | Negative | ||
| 74 | M | Serious but stable clinical conditions | No complications | Negative | ||
| 66 | F | Fair clinical conditions | No complications | Negative | ||
| 47 | M | Fair clinical conditions | Hyperamylasemia and hyperlipasemia | Negative | ||
| EMR (carcinoma in situ-T1) | 52 | M | Faecal occult blood + | Fair clinical conditions | No complications | Negative |
| 67 | M | Faecal occult blood + | Fair clinical conditions | No complications | Negative | |
| Polipectomy (Carcinoma in Situ) | 75 | M | Polyps of the colon | Fair clinical conditions | No complications | Negative |
| 65 | F | Faecal occult blood + | Fair clinical conditions | No complications | Negative | |
| 60 | M | Anemia | Fair clinical conditions | No complications | Negative | |
| 63 | F | Rectal bleeding | Fair clinical conditions | No complications | Negative | |
| 69 | M | Rectal bleeding | Fair clinical conditions | No complications | Negative | |
| 79 | M | Anemia, Faecal occult blood + | Fair clinical conditions | No complications | Positive |
The appropriate therapeutic approach to patients should be tailored considering also the capability of the local health care system to meet existing and projected needs after surgery, including level and phase of the pandemic and local facilities inevitably limits, In the pandemic period operative endoscopy may represent a valid alternative (definitive or temporary) to generally accepted standard surgical solutions. Each patient should be evaluated in his/her specificity considering clinical conditions, expectations, personal needs and level and stage of the pandemic.
References
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