Implications of Colorectal Cancer Surgical Outcomes During the Era of COVID-19

The ongoing COVID-19 pandemic has affected elective colorectal cancer (CRC) surgical practices, and its impact on mortality after CRC surgical resections has been slowly emerging.  Early on, studies done in Italy and the United Kingdom presented specific recommendations in hopes of reducing the impact on CRC surgical outcomes, but have yet to conclude which of the proposed ideas can be implemented.

During the early weeks of the pandemic, there was uncertainty surrounding the influence of the SARS-CoV-2 virus on CRC surgical patients as well as intensive care capacity. Various recommendations were put in place to alter CRC surgical practices, which in turn would help reduce mortality. Researchers in Italy proposed that a benefit of changing surgical practices would be that it would reduce postoperative complications such as anastomotic leaks. They hypothesized that laparoscopic surgery for CRC would be the answer, although there remains a lot of uncertainty in regards to whether or not the SARS-CoV-2 virus would survive in the CO2

used for the surgery. Hematologists in the U.K. suggested that another benefit would be to decrease the need for intensive care at a time when hospital resources are being redirected towards the pandemic. A third benefit would be to reduce complications which would drastically reduce the length of hospital stay while releasing bed space, which would in turn reduce the risk of hospital-acquired infections. Despite the benefits of the proposed changes in CRC surgical practices, elective CRC surgeries must continue in order to prevent delayed operations and/or an increase in emergency procedures at a later time. 

A cohort study at the University of Birmingham, U.K., conducted by Bhangu. A et a,l analyzed patients undergoing CRC resection without any suspicion of COVID-19. The data were collected on eligible patients from the first recorded case of COVID-19 through April 19, 2020. Eligible patients were 18 years and older, looking to undergo elective CRC surgery. The study particularly focused on patients who had a stoma, in which their surgeons were asked if this was their “normal practice” or a “change in practice due to COVID-19.” Patients with a stoma with a change in practice due to COVID-19 were labelled as “COVID-end-stoma.” The study concluded that the rate of stoma formation was 34.2% as opposed to the 27.2% which was seen before the pandemic started. A total of 1.8% of patients died within 30 days of surgery, 3.8% went onto develop postoperative COVID-19, and 4.9% had an anastomotic leak. While anastomotic leaks were lower pre-pandemic (4.9% vs 7.7%) and length of hospital stays was shorter (6 vs 7 days), mortality was higher post-pandemic (1.7% vs 1.1%). The causes of change in practice in patients who had a COVID-stoma were recommendations from specialty associations, to avoid possible complications requiring critical care, wish to reduce length of inpatient stay, fear of patients suffering from a SARS-CoV-2 infection postoperatively, lack of access to postoperative intensive care, and very difficult working conditions with donning full PPE.

Alterations in surgical practices for CRC surgeries is an effort to decrease the duration of surgery, resource usage, and hospital stay.