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Evaluating the feasibility of performing elective gastrointestinal cancer surgery during the COVID‐19 pandemic: An observational study with 60 days follow‐up results of a tertiary referral pandemic hospital

Abstract Background The coronavirus disease 2019 (COVID‐19) pandemic has interfered with the treatment algorithm for patients with gastrointestinal (GIS) cancer, resulting in deferral of surgery. We presented the outcomes of our patients to evaluate whether surgery could be safely performed and followed‐up without delaying any stage of GIS cancer during the pandemic. Methods This was an observational study of 177 consecutive patients who underwent elective GIS cancer surgery between March 11 and November 1, 2020. They were assessed regarding their perioperative and 60 days follow‐up results for either surgical or COVID‐19 status. Morbidity was determined according to the Clavien‐Dindo classification (CDC). Continuous and categorical data were presented as median ± SD and number with percentage (%), respectively. Results The study included 44 gastric, 33 pancreatic, 40 colon, and 59 rectal cancer patients. All patients underwent surgery and received neo/adjuvant treatments without delay. The overall morbidity (CDC grade II–IV) and mortality rates were 10.1% and 3.9%, respectively. None of the patients or medical staff were infected with COVID‐19 during the study period. Conclusion GIS cancer surgery can be safely performed even within a pandemic hospital if proper isolation measures can be achieved for both patients and health workers. Regardless of the tumor stage, surgery should not be deferred, depending on unstandardized algorithms.

treatment of patients with COVID-19. These unprecedented demands on hospital resources mainly affected all surgical disciplines, eventually leading to the suspension of elective surgeries for an indefinite period. Moreover, in line with increasing recommendations from prominent surgical associations about triage and the management of cancer patients to mitigate the exposure to COVID-19, the treatment programs were rescheduled, resulting in a paradigm shift in the treatment of patients with precancerous lesions, early-stage or uncomplicated cancers. [1][2][3][4][5][6] However, concerning that short-term surgical delays may result in unpredictable negative outcomes even in the early stages of cancer, irrespective of their surgical branch, every specialist focused on finding a way to ensure their accustomed oncological practice while dealing with an enemy that was never faced before. 7,8 Due to our specialty, we focused on gastrointestinal system (GIS) cancer surgery during the pandemic. It deserves attention because of several concerns: (1) GIS cancers are frequently detected in patients aged 50 or older which is accepted as the highest risk group that may develop severe symptoms related to COVID-19 infection. (2) Agerelated comorbidities are the main factors that worsen the prognosis for both. (3) Although the mortality rate of GIS cancer is not solely specified, cancer has been regarded as a negative factor on the prognosis of COVID-19 infection with a mortality rate of 5.6%. (4) Prolonged hospital stays of patients undergoing GIS cancer surgery may amplify the risk of contamination with COVID-19. [9][10][11] On the other hand, regardless of these concerns, early detection and radical resection of the tumor is the key point to achieve a successful oncologic outcome in the treatment of GIS cancer patients. 12,13 It is well-known that delaying may cause a deleterious impact on the prognosis and survival of these patients. [14][15][16] According to the national health data of Turkey on December 31, 2020, we have a total of 2,208,652 infected patients with a total of 20,881 deaths since the beginning of the pandemic. We are still struggling with the COVID-19 outbreak since the first case. As observed during the pandemic, our concerns were justified, and no definitive treatment has been found so far, except for various vaccines whose long-term protective potential is not completely clinically proven. Likewise, the issue of "how to provide sufficient doses for the whole population?" is not well explained. Recently, the mutation of the virus has been another subject of debate. 17 This implies that the current situation will continue to prevail for a while, thus necessitating a prompt adaptation of the health care system to the existing conditions, which is essential for maintaining the treatment of patients with GIS cancer to prevent them from the negative impacts related to delay in surgery.
Considering the current literature, there are limited data regarding the surgical outcomes of patients undergoing elective GIS cancer surgery during pandemics. Therefore, we believe that contributing to the existing literature is essential to further elucidate the feasibility of surgery during this rapidly evolving condition, for both patients and clinicians. Considering the number, as well as the followup period of the patients included, this study may serve as a good reference to reflect the surgical aspect of pandemics. In the present study, we aimed to present the perioperative surgical approach and 60 days follow-up outcomes of patients who underwent elective gastric, pancreatic, and colorectal cancer surgeries since the beginning of the COVID-19 outbreak. The aim of this study was to provide a reference to all multidisciplinary oncologic teams whether surgery can be safely performed and followed-up without deferring any type or stage of GIS cancer during pandemics.   After discharge, all patients were followed-up every 15 days for COVID-19 symptoms until POD 60, either by a phone call or at our outpatient clinic. The preventive measures for COVID-19 and their importance were reminded to the patient at every meeting for consistent clinical awareness.

| STATISTICAL ANALYSIS
The data obtained were summarized in a computerized spreadsheet, and statistical analyses were performed using IBM SPSS Statistics 25.
Numerical data are presented as median ± standard deviation (SD), and categorical data are expressed as number and percentage (%). Similarly, neo/adjuvant treatment was uneventful. Furthermore, none of the medical staff enrolled in this study were infected by COVID-19 during the study period.

| RESULTS
The results are elaborated in Table 1.

| DISCUSSION
Although knowledge regarding the prognosis and treatment of COVID-19 is currently trivial, leading cancer-specific associations have abruptly presented low-evidence-based recommendations regarding the treatment of GIS cancers from the very early beginning of the pandemic. 1,4 The patients were prioritized according to the biological behavior and stage of their disease that triggered some debates among our colleagues about the treatment algorithm of GIS cancers. 1,4 Accepting their concerns about the treatment of particularly low-risk cancer patients during the COVID 19 pandemic, the negative impacts of delaying surgery on surgical outcomes were considered, because the response to the questions "How long can we defer surgery in low-risk GIS cancer patients?", "Do we know when will COVID-19 outbreak end?" "Do we underestimate the tumor biology?", "Do we trust the imaging studies at initial diagnosis? What if we stay under stage at initial diagnosis or encounter upstaged tumor according to the final pathology report?" was unclear.
Despite the patients having justified concerns about the negative impacts associated with deferring their treatments, a considerable number of either newly or already diagnosed GIS cancer patients displayed irrational behaviors such as canceling their hospital admissions without taking any expert opinion during the pandemic. This was absolutely due to their fear of being infected with COVID-19 during hospitalization as well as multiple hospital admissions during adjuvant treatment. This dilemma arose because they were inadequately informed about the process. They believed that "all operations were canceled, and all clinicians struggled with COVID-19 patients" Although not included in this study, unfortunately, we encountered a considerable number of patients with complicated or upstaged GIS tumors during the study period owing to this thought.
In fact, taking into account the clinical progress of the patients infected with COVID-19, the biologic behavior of COVID-19 was unstable. There was individual variability in terms of clinical symptoms and progress, and even death could be encountered in a patient without any comorbidities. Moreover, the risk of contamination was similar for everyone and everywhere. In contrast, the fact that deferring the surgical procedure results in a poor prognosis of GIS cancer is well known and is highly evidence-based. 12,13 It is also notable that once the treatment is deferred, the follow-up of the patient falls apart because of the high patient burden of the clinicians. Likewise, another point that needs to be highlighted is the SOZUTEK ET AL. Our hospital is located in Adana, which is the fifth-largest province in Turkey. Although its population is 3 million, we serve approximately 10 million more people, since it is a referral center for its neighboring provinces and countries, including Iraq and Syria. Although the geographic localization seems to be a high-risk factor for amplifying the spread of the disease, we achieved successful surgical outcomes. This was likely due to well-applied strict precautions, as well as the design of our hospital. It can be acknowledged that the configuration and infrastructure of our hospital were the main factors for successful outcomes.

CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.