Editor
Many surgeons have advocated the continuation of cancer services during the COVID-19 pandemic to prevent delays in diagnosis and treatment1. Yet, there are concerns regarding the impact of strained resources and manpower fatigue on the quality of postoperative cancer care. In Singapore, February marked the turning point when there was a severe reduction in healthcare resources. Teams were segregated to minimize cross-infection. We compare immediate postsurgical outcomes in the six months preceding February with the three months following.
There were no differences in patient demographics. Importantly, there was also no increase in emergency load (40·3 per cent vs 36·0 per cent; p = 0·707), stoma creation rates (44·7 per cent vs 30·4 per cent; p = 0·253), or the use of laparoscopy (46·8 per cent vs 60·9 per cent; p = 0·269). Post-operative complications, including rates of surgical-site infection (SSI) (10·6 per cent vs 13·0 per cent; p = 0·766) and anastomotic leakage (2·1 per cent vs 4·4 per cent; p = 0·600) were similar. There were no differences in time to diet (5·2 days vs 3·9; p = 0·477) or total length of stay (10·7 days vs 8·3; p = 0·352). We did not notice histological differences in the colorectal cancers operated on. There was also no increase in 30-day readmission (8·7 per cent vs 4·4 per cent; p = 0·511) or 30-day mortality (4·0 per cent vs 0; p = 0·331). Full details can be found in Table 1.
Table 1.
| Variables | Pre-pandemic (n = 67) | Pandemic (n = 25) | p-value |
|---|---|---|---|
| Age, mean (SD) | 66·6 (12·2) | 67·2 (14·1) | 0·847 |
| Male sex, n (%) | 40 (59·7) | 12 (48·0) | 0·314 |
| ASA, n (%) | |||
| I – II | 40 (59·7) | 18 (72·0) | |
| III – V | 27 (40·3%) | 7 (28·0) | 0·277 |
| Comorbidities, n (%) | |||
| IHD | 8 (11·9) | 1 (4·0) | 0·254 |
| DM | 15 (22·4) | 5 (20·0) | 0·805 |
| CVA | 6 (9·0) | 1 (4·0) | 0·425 |
| CKD | 7 (10·5) | 1 (4·0) | 0·329 |
| Dyslipidemia | 25 (37·3) | 12 (48·0) | 0·352 |
| Hypertension | 33 (49·3) | 13 (52·0) | 0·815 |
| Urgency, n (%) | |||
| Elective | 40 (59·7) | 16 (64·0) | |
| Emergency | 27 (40·3) | 9 (36·0) | 0·707 |
| Site, n (%) | |||
| Right colon | 16 (23·9) | 13 (52·0) | |
| Left colon | 31 (46·3) | 10 (40·0) | |
| Rectum | 20 (29·9) | 2 (8·0) | 0·015 |
| CEA (μg/L), mean (SD) | 50·4 (181·5) | 78·1 (245·7) | 0·591 |
| Laparoscopic approach, n (%) | 22 (46·8) | 14 (60·9) | 0·269 |
| Conversion | 3 (13·6) | 1 (7·1) | 0·546 |
| Stoma creation, n (%) | 21 (44·7) | 7 (30·4) | 0·253 |
| Operation time (min), mean (SD) | 187·2 (73·1) | 212·2 (65·3) | 0·169 |
| Complications, n (%) | |||
| UTI | 4 (8·5) | 0 | 0·150 |
| Pneumonia | 4 (8·5) | 1 (4·4) | 0·525 |
| AMI | 0 | 0 | |
| CVA | 3 (6·8) | 0 | 0·200 |
| DVT/PE | 0 | 0 | |
| SSI | 5 (10·6) | 3 (13·0) | 0·766 |
| OSI | 3 (6·4) | 1 (4·4) | 0·730 |
| Anastomotic leak | 1 (2·1) | 1 (4·4) | 0·600 |
| Reoperation | 2 (4·3) | 1 (4·4) | 0·986 |
| Clavien-DIndo ≥3 | 3 (6·4) | 2 (8·7) | 0·724 |
| Outcomes, mean (SD) | |||
| Time to diet | 5·2 (8·8) | 3·9 (1·9) | 0·477 |
| LOS, intensive care | 0·9 (3·6) | 0·4 (1·1) | 0·529 |
| LOS, total | 10·7 (12·0) | 8·3 (4·6) | 0·352 |
| TNM Stage, n (%) | |||
| PCR | 1 (1·9) | 0 | |
| 1 | 4 (7·7) | 3 (12·5) | |
| 2 | 11 (21·2) | 4 (16·7) | |
| 3 | 18 (34·6) | 14 (58·3) | |
| 4 | 18 (34·6) | 3 (12·5) | 0·189 |
| Histological findings, n (%) | |||
| Grade | |||
| Well | 1 (2·4) | 3 (13·0) | |
| Moderate | 37 (88·1) | 17 (73·9) | |
| Poor | 4 (9·5) | 3 (13·0) | 0·194 |
| Lymphovascular invasion | 15 (34·9) | 4 (17·4) | 0·135 |
| Perineural invasion | 6 (14·0) | 6 (26·1) | 0·223 |
| Extramural venous invasion | 12 (27·9) | 7 (30·4) | 0·829 |
| Clear margins | 40 (93·2) | 22 (95·7) | 0·670 |
| Lymph node, mean (SD) | |||
| Positive | 1·7 (2·5) | 3·7 (6·1) | 0·053 |
| Total | 18·2 (8·3) | 20·9 (5·6) | 0·161 |
| Discharge disposition change, n (%) | 6 (13·0) | 5 (21·7) | 0·352 |
| 30-day readmission, n (%) | 4 (8·7) | 1 (4·4) | 0·511 |
| 30-day mortality, n (%) | 2 (4·0) | 0 | 0·331 |
Since February, our hospital has drastically reduced outpatient, endoscopic and surgical resources to support reallocations to emergency departments and intensive care units. Due to the pressing need to maintain a colorectal cancer service, all outpatient referrals are vetted by specialist colorectal surgeons, and cancer cases continue to be performed in a dedicated cancer operating theatre. Our results demonstrate that prioritizing cancer care can maintain quality to pre-pandemic levels. We did not notice an increase in delayed cancer presentations, while acknowledging that we are still early in the fight against this pandemic.
References
- 1. Downs JS, Wilkinson MJ, Gyorki DE, Speakman D. Providing cancer surgery in the COVID-19 crisis. Br J Surg 2020; 107: e248. [DOI] [PMC free article] [PubMed] [Google Scholar]