Original article
RESULTS OF THE SARS-COV-2 PANDEMIC IN THE SURGICAL TREATMENT OF COLORECTAL CANCER IN ELDERLY PATIENTS
Yenny Quiroga1; Analía Potolicchio2; Nicolás Lucas3; Lourdes Buey3; Pablo Catalano4
Hospital Español de Buenos Aires
1: Coloproctology Fellow. 2: Gastroenterological Surgery Staff. 3: General Surgery Staff. 4: Head of Coloproctology
The authors declare no conflicts of interest.
Yenny Quiroga: draquiroga1911@gmail.com
Received: September 2021. Accepted: December 2022
Yenny Quiroga: 0000-0003-0700-447x
Analía Potolicchio. 0000-0003-0414-8363
Nicolás Lucas: 0000-0002-4874-3386
Lourdes Buey: 0000-0001-6614-3707
Pablo Catalano: 0000-0001-7582-2162
ABSTRACT
Introduction: Colorectal cancer is the second most frequent malignancy in Argentina and it occurs in people over 50 years of age in more than 90% of cases, with a peak between 60 and 75 years.
Objective: To qualitatively and quantitatively evaluate the impact of COVID-19 pandemic on surgical treatment and stage of colorectal malignancy.
Material and methods: Retrospective and descriptive study based on a prospective database of patients undergoing colorectal cancer surgery during the periods January-December 2019 (Pre-pandemic-Group A) and March 2020- February 2021 (Intra-pandemic-Group B), in the Hospital Español de Buenos Aires.
Results: Although the number of patients treated surgically during the study period is not significant enough to draw conclusions, a higher mortality was observed in patients undergoing surgery in 2020 than in those operated on in 2019 (19.6 vs. 9.7%, respectively). This may be attributed to the fact that most the 2020 patients had emergency procedures, and not to SARS-CoV-2 infection.
Most patients were COVID-19-negative, except for one COVID-19-positive patient who required emergency surgery due to intestinal occlusion. No hospital-acquired postoperative SARS-COV-2 infections were detected.
Conclusions: Although the number of patients in both groups was similar, the percentage of emergency surgeries vs. scheduled ones was reversed. This is a consequence of the SARS-CoV-2 pandemic, when scheduled surgery was suspended and priority was given only to emergency and oncologic cases.
The oncologic stages were similar, since most patients in our population are diagnosed in advanced stages.
Keywords: colorectal cancer; surgical treatment; COVID-19; SARS-CoV-2; pandemic
INTRODUCTION
In Argentina, colorectal cancer is the second most frequent type diagnosed each year, with an incidence of 14.5% in men and 10.8% in women, and represents the second cause of cancer mortality.1 Seventy-five percent of cases are sporadic and 25% have a genetic influence or are associated with inflammatory diseases.2 More than 90% of cases occurs in people over 50 years of age, with a peak incidence between 60 and 75 years.
Colorectal tumors are initially asymptomatic, so when the screening methods proposed for their early detection (FOBT, colonoscopy) are not implemented, they are diagnosed when causing symptoms of bleeding, anemia, perforation or intestinal obstruction. At that time of diagnosis, it is often in advanced stages.
Survival depends to a large extent on how widespread the disease is at the time of diagnosis. If there are no involved nodes and the deep layers of the organ are not invaded, the five-year survival rates reach 80 or 90%.3
The outbreak of the SAR-CoV-2 (COVID-19) pandemic has modified outpatient care; it compromised both face-to-face care and the possibility of carrying out complementary studies,4 generated delays in the diagnosis and treatment of cancer patients, and increased cancer stages and emergency surgeries.
The aim of this study is qualitatively-quantitatively evaluate the impact of the COVID-19 pandemic on surgical treatments and stages of colorectal oncologica disease, at the Hospital Español de Buenos Aires. Additionally, to assess mortality in patients treated surgically in times of pandemic compared to the control group.
MATERIAL AND METHODS
This is a retrospective and descriptive study based on a prospective database of patients undergoing colorectal cancer surgery in the Hospital Español de Buenos Aires during the periods January-December 2019 (Pre-pandemic-Group A) and March 2020- February 2021 (Intra-pandemic-Group B).
The previous year was chosen as the control group since the current surgical group of coloproctologists was effectively established in 2018, and has maintained both outpatient clinic activity and surgery to the present.
Postoperative morbidity and mortality were evaluated according to the Dindo-Clavien classification.5
Rectal tumors were defined as those located up to 15 cm from the anal verge by rigid rectosigmoidoscopy and colon tumors as those located in the rest of the colon by colonoscopy. Urgent surgery was defined as surgery performed due to acute gastrointestinal occlusion or perforation, and palliative surgery was considered when an ostomy was performed without anastomosis.
Bearing in mind that the progression of adenomas towards CRC (adenoma-carcinoma sequence) is a process in stages that develops slowly, estimated to take more than 10-15 years for adenomas smaller than 1 cm, and that screening should begin at age 45 to 50 years, we included patients older than 60 years in our study.
Following the recommendations of various academic associations, in order to prevent intra-procedure viral aerosolization, open surgery was considered the gold standard and the laparoscopic approach was discouraged.6 In turn, according to the same guidelines, it was determined not to perform primary anastomosis on emergency colorectal cancer patients, not only to prevent postoperative complications and hospital infections that could increase the length of stay and the need for ICU,7 but also for the age group treated in our institution, almost entirely frail elderly adults with multiple co-morbidities which were exacerbated and under-treated due to the lack of follow-up by GPs.
After the first quarter of the pandemic, with the designation of the Hospital as referral center for PAMI COVID-19-positive patients, the building was refurbished and the health personnel redistributed. It was decided the swabbing of emergency patients upon admission and a negative swab 72 hours prior to elective surgery, rescheduling COVID-19-positive patients.
RESULTS
In the group A, 54 patients were operated on. Of them, 38.6% were women and 61.4% men, with a mean age of 76 (range 62-95) years. Urgent surgery represented 31.5% (17 patients), and selective surgery 68.5% (37 patients).
The staging of colorectal cancer patients undergoing emergency procedures was: EII 5.9%, EIII 23.5% and EIV 58.8%. That of elective surgery patients was: EI 21%, EII 25%, EIII 37% and EIV 17%. There was 1 case of lymphoma and another of breast cancer metastasis (5.9%, each) (Fig. 1).
The group A represented 54.5% of the surgical procedures performed by the Coloproctology Section in 2019. Of the total number of patients operated on for cancer, 61.2% (41 patients) corresponded to colon cancer and 38.8% (16 patients), to rectal cancer. For colon cancer, curative surgery was performed in 80.7% of patients and palliative surgery in 19.3%, while for rectal cancer it was 62.5% and 37.5%, respectively.
Morbidity and mortality were assessed according to the Dindo-Clavien classification. In group A, of the 41 patients operated on for colon cancer, the complications were: grade I 7.3%, II 4.9%, III 12.2%, IV 7.3%, and V 9.7%. In the patients operated on for rectal cancer, the complications were: grade I 0%, II 6.2%, III 6.2%, IV 6.2%, V 18.7%.
Figure 1. Stages of colorectal cancer in patients operated on in 2019.
In group B, 67 patients were operated on, 41.8% were women and 58.2% men, with a mean age 73.6 (range 62-94) years. Emergency surgery represented 62.7% (42 patients) and elective surgery 37.3% (25 patients).
The cancer stage in patients operated on urgently were: EI 4.8%, EII 23.8%, EIII 28.6%, EIV 42.9%; for elective surgery were: E0 4%, EI 8%, EII 32%, EIII 40%,E IV 16% (Fig. 2).
The oncologic surgery represented 63.8% of all procedures performed by the Coloproctology Section in 2020; 61.2% (51) were colon and 38.8% (16) rectal procedures.
For colon cancer, surgery with curative intent was performed in 82.4% patients, and palliative surgery in 17.6%, while for rectal cancer it was 50%.
In the 51 patients operated on for colon cancer, complications were grade I 2%, II 15.7%, III 9.8%, IV 5.9%, V 19.6%. For rectal cancer patients, the complications were: grade I 6.2%, II 0%, III 6.2%, IV 0%, V 6.2%.
Figure 2. Stages of colorectal cancer in patients operated on in 2020.
DISCUSSION
After the WHO declared the COVID-19 pandemic on March 11, 2020, following the trend in accordance with international recommendations, the scheduled activity from outpatient clinics in our institution was limited, as well as the invasive diagnostic and surgical procedures for benign pathologies in order to direct institutional resources to the care of patients affected by SARS-CoV-2.
Various changes in outpatient management and hospital routine forced the limitation of consultations, to avoid crowding in waiting rooms. The time interval between patients was extended, therefore the total number of consultations decreased.
Simultaneously, the adoption of new protocols in carrying out endoscopic procedures, with the requirement of personal protection equipment and the safety time between patients, led to greater complexity in their execution, reduced number of studies performed and, consequently, the possibility of early detection of colorectal cancer and staging.
Additionally, the social and psychological factors of the patients directly led to fewer outpatient visits.
Although the number of patients treated surgically in both periods is not significant enough to draw conclusions, we observed that the surgical mortality rate in 2020 was higher (19.6%) than in 2019 (9.7%), and this was not related to SARS-CoV-2 infection.
Except for one COVID-19-positive patient who required emergency surgery due to intestinal occlusion, most patients were COVID-19-negative, and no in-hospital postoperative SARS-CoV-2 infections were detected.
Regarding the oncologic stages, there were no significant differences between groups, since most of the patients in our population are diagnosed in advanced stages.
The closure of outpatient clinics and the suspension of elective endoscopies delayed consultation, both for initial diagnosis and for staging and pre-surgical studies.
Likewise, our population of older adults, with multiple comorbidities, in need of intensive care beds for the postoperative period, often had to be rescheduled due to full occupancy with positive cases of COVID-19, which led to more surgeries due to acute complications. Whether this will have an impact on long-term survival remains to be assessed.
CONCLUSIONS
Although the number of patients in both groups was similar, the percentage of emergency surgeries vs. scheduled ones was reversed. This is a consequence of the SARS-CoV-2 pandemic, when scheduled surgery was suspended and priority was given only to emergency and oncologic cases.
The oncologic stages were similar, since most patients in our population are diagnosed in advanced stages
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