Allum, WH

Bhogal, RH

Chaudry, MA

Doran, SLF

Jiao, LR

Kumar, S

Patel, PH

Pollok, JM

Zar, S

English

UCL Discovery

  Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website.  Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.  lable at ScienceDirectEuropean Journal of Surgical Oncology xxx (xxxx) xxxContents lists avaiEuropean Journal of Surgical Oncologyjournal homepage: www.ejso.comApproach to upper GastroIntestinal cancer surgery during the COVID-19 pandemic e Experience from a UK cancer centreKeywords:OesophagealGastricHepato-Pancreato-BiliaryCancerCOVID-19CoronavirusAbbreviations: COVID-19, Coronavirus DisSevere Acute Respiratory Syndrome Coronavicreatico-Biliary; AUGIS, Association of Uppgeons; sMDT, Specialist Upper GI MGastrointestinal Stromal Tumour; HCC, HeICC, Intrahepatic Cholangiocarcinoma; ALPPStion with Portal Vein Ligation.https://doi.org/10.1016/j.ejso.2020.05.0220748-7983/© 2020 Elsevier Ltd, BASO ~ The AssociatiPlease cite this article as: Bhogal RH et al., Apa UK cancer centre, European Journal of Surpatient ctive oncoCoronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2 is anovel rapidly spreading infectious disease that has significantlyimpacted upon the delivery of oncological treatments. Early pub-lished case series and guidance from Public Health England identi-fied several patient groups that are at risk of severe diseaseincluding those with active cancer [1]. During the COVID-19pandemic in China, a nationwide network analysis demonstrateda significantly higher risk of severe adverse events in the IntensiveCare Unit (ICU) including death in patients with cancer [2]. Duringthe early phase of the pandemic in London, three of our patientsundergoing Hepato-Pancreatico-Biliary (HPB) intervention devel-oped COVID-19 pneumonia. Although these patients all recoveredfrom their COVID-19 infection, we utilised this early experience incombination with the NHS England Speciality Guide for Cancer &Coronavirus and the Association of Upper GastroIntestinal Sur-geons (AUGIS) guidance to inform our clinical prioritisation strat-egy for patients with Upper GI cancers [3,4]. This plan wasexpanded and the strategy refined when our centre became thedesignated Specialist ‘Cancer Hub’ for West London. This clinicalmodel was established to allow time-critical oncology surgery tobe delivered to all patients from across our cancer network. All elec-tive surgical cancer patients were requested to self-isolate for 14days before surgery, complete a COVID-19 symptom questionnaireand undergo mandatory pre-operative COVID-19 swab testing andCT thorax immediately prior to surgery. Every patient case wasreviewed in our Specialist Upper GI Multidisciplinary (sMDT)meeting and treatment plans were personalised taking account ofease 2019; SARS-CoV-2,rus 2; HPB, Hepato-Pan-er GastroIntestinal Sur-ultidisciplinary; GIST,patocellular Carcinoma;, Associating Liver Parti-on for Cancer Surgery, and the Eurproach to upper GastroIntestigical Oncology, https://doi.oromorbidities, tumour biology and availability of alterna-logical treatments. Our decision-making for the surgicalprioritisation also incorporated individual patient performance sta-tus/perioperative risk and potential resource implications. All pa-tients were requested to complete a COVID-risk consent form.Our strategy focused on clinical cases considered priorities 1 (i.e.,Emergency/Urgent) & 2 (i.e., surgery that can be deferred up to 4weeks). It was compulsory for theatre teams to wear full PersonalProtective Equipment including surgical masks or filtering facepiece respirators.Patients presenting with bleeding gastric tumours or gastricoutlet obstruction not amenable to endoscopic/interventionalradiological control were considered for surgical intervention.Oesophageal cancer emergencies (bleeding/perforation) weredeemed for endoscopic/radiological intervention during thepandemic period given the poor prognosis associated with this pre-sentation and the need for prolonged Level 3 care when surgery isundertaken. All T1a & T1b oesophageal/gastric tumours were eval-uated by a specialist Upper GI gastroenterologist and considered forendoscopic resection. Oesophageal or gastric cancer patients on anintention-to-cure pathway, who had completed their neoadjuvantchemotherapy and had undergone post-chemotherapy assessmentof resectability/treatment response in the sMDT, were consideredfor resection. Patients with stable Gastrointestinal Stromal Tu-mours (GIST) continued on imatinib treatment or surgery was de-ferred until all priority 2 cases had been completed. Ourinstitution undertook a safety-first approach and minimally inva-sive surgery was not feasible during the early phase of thepandemic e we agreed to postpone staging laparoscopy for newlydiagnosed patients until completion of neoadjuvant treatment.With limited endoscopy resources, patients presenting withpainless jaundice, radiological evidence of both pancreatic andbiliary duct obstruction and associated pancreatic mass were pri-oritised for resection. Patients presenting with a pancreatic massand gastric outlet obstruction not amenable to endoscopic stentingwere also considered for surgery. Our rationalised Upper GI endos-copy service was utilised to investigate patients with single ductobstruction or isolated pancreatic masses. In the absence of effec-tive neoadjuvant chemotherapy regimens, patients with primaryliver cancer (Hepatocellular Carcinoma (HCC) and IntrahepaticCholangiocarcinoma (ICC)) were considered for hepatic resection.We considered liver resection of 3 Couinaud segments or right/left hepatectomy appropriate during this period. Extended liver re-sections and Associating Liver Partition with Portal Vein Ligation(ALPPS) were not undertaken due to the known higher patientmorbidity and mortality. Patients requiring extended resectionwere considered for alternative oncological treatments. In patientsopean Society of Surgical Oncology. All rights reserved.nal cancer surgery during the COVID-19 pandemice Experience fromg/10.1016/j.ejso.2020.05.022R.H. Bhogal et al. / European Journal of Surgical Oncology xxx (xxxx) xxx2with colorectal liver metastasis, where multiple atypical/non-anatomical liver resections were required and future liver remnantvolumewas satisfactory, patients were considered for hepatectomy.Extensive bilobar liver metastasis were not considered for surgicalintervention. Pancreatic/liver cysts and neuroendocrine tumourswere deferred in line with our priority guidance.This framework has allowed us to triage Upper GI cancer pa-tients in a resource-limited environment and safely deliver themaximum number of potentially curative operations during theCOVID-19 pandemic.Declaration of competing interestNothing to report.References[1] Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patientsdying in relation to COVID-19 in Italy. J Am Med Assoc 2020 Mar 23. https://doi.org/10.1001/jama.2020.4683 [Epub ahead of print].[2] LiangW, GuanW, Chen R,WangW, Li J, Xu K, et al. Cancer patients in SARS-CoV-2infection: a nationwide analysis in China. Lancet Oncol 2020 Mar;21(3):335e7.https://doi.org/10.1016/S1470-2045(20)30096-6. Epub 2020 Feb 14.[3] Doran SLF, Patel PH, Chaudry A, Pollok JM, Kumar S, Bhogal RH. COVID-19 infec-tion inpatients followinghepato-pancreatico-biliary intervention: anearlyexpe-rience. Eur J Surg Oncol 2020 Apr 28. https://doi.org/10.1016/j.ejso.2020.04.045.pii: S0748-7983(20)30443-1. [Epub ahead of print].[4] https://www.augis.org/wp-content/uploads/2020/04/Oesophagogastric-Cancer-Covid-19-Guidance-Update-4.pdf & https://www.augis.org/wp-con-tent/uploads/2020/03/Statement-from-AUGIS-re-Hepatobiliary-and-Pancreas-Cancer-Patients.pdf.R.H. BhogalThe Royal Marsden Hospital, Department of Surgery, 203 FulhamRoad, London, SW3 6JJ, United KingdomInstitute of Cancer Research, Division of Radiotherapy & Imaging, 123Old Brompton Road, London, SW7 3RP, United KingdomPlease cite this article as: Bhogal RH et al., Approach to upper GastroIntesta UK cancer centre, European Journal of Surgical Oncology, https://doi.orP.H. Patel, S.L.F. Doran, S. ZarThe Royal Marsden Hospital, Department of Surgery, 203 FulhamRoad, London, SW3 6JJ, United KingdomJ.M. PollokThe Royal Marsden Hospital, Department of Surgery, 203 FulhamRoad, London, SW3 6JJ, United KingdomThe Royal Free Hospital, Department of HPB and LiverTransplantation, Pond Street, Hampstead, London, NW3 2QG, London,United KingdomL.R. JiaoThe Royal Marsden Hospital, Department of Surgery, 203 FulhamRoad, London, SW3 6JJ, United KingdomImperial College London, Department of Surgery & Cancer, 72 DuCane Road, London, W12 0HS, United KingdomW.H. Allum, M.A. Chaudry1The Royal Marsden Hospital, Department of Surgery, 203 FulhamRoad, London, SW3 6JJ, United KingdomS. Kumar*The Royal Marsden Hospital, Department of Surgery, 203 FulhamRoad, London, SW3 6JJ, United KingdomInstitute of Cancer Research, Division of Radiotherapy & Imaging, 123Old Brompton Road, London, SW7 3RP, United Kingdom* Corresponding author. Consultant Upper GI Surgeon, Departmentof Surgery, The Royal Marsden Hospital, Fulham Road, London,SW3 6JJ, United Kingdom.E-mail address: sacheen.kumar@rmh.nhs.uk (S. Kumar).20 May 2020Available online xxx1 Denotes joint senior authors.inal cancer surgery during the COVID-19 pandemice Experience fromg/10.1016/j.ejso.2020.05.022

Approach to upper GastroIntestinal cancer surgery during the COVID-19 pandemic - Experience from a UK cancer centre

https://discovery.ucl.ac.uk/10111740/1/Approach%20to%20upper%20GastroIntestinal%20cancer%20surgery%20during%20the%20COVID-19%20pandemic%20-%20Experience%20from%20a%20UK%20cancer%20centre.pdf

Approach to upper GastroIntestinal cancer surgery during the COVID-19 pandemic - Experience from a UK cancer centre

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