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Management Considerations for the Surgical Treatment of Colorectal Cancer During the Global Covid-19 Pandemic.

OBJECTIVE
The COVID-19 pandemic requires to conscientiously weigh "timely surgical intervention" for colorectal cancer against efforts to conserve hospital resources and protect patients and health care providers.


SUMMARY BACKGROUND DATA
Professional societies provided ad-hoc guidance at the outset of the COVID-19 pandemic on deferral of surgical and perioperative interventions, but these lack specific parameters to determine the optimal timing of surgery.


METHODS
Using the GRADE system, published evidence was analyzed to generate weighted statements for stage, site, acuity of presentation and hospital setting to specify when surgery should be pursued, the time and duration of oncologically acceptable delays, and when to utilize non-surgical modalities to bridge the waiting period.


RESULTS
Colorectal cancer surgeries - prioritized as emergency, urgent with (a) imminent emergency or (b) oncologically urgent, or elective - were matched against the phases of the pandemic. Surgery in COVID-19 positive patients must be avoided. Emergent and imminent emergent cases should mostly proceed unless resources are exhausted. Standard practices allow for postponement of elective cases and deferral to nonsurgical modalities of stage II/III rectal and metastatic colorectal cancer. Oncologically urgent cases may be delayed for 6(-12) weeks without jeopardizing oncological outcomes. Outside established principles, administration of nonsurgical modalities is not justified and increases the vulnerability of patients.


CONCLUSION
The COVID-19 pandemic has stressed already limited health care resources and forced rationing, triage and prioritization of care in general, specifically of surgical interventions. Established guidelines allow for modifications of optimal timing and type of surgery for colorectal cancer during an unrelated pandemic.