Effects of COVID-19 pandemic on colorectal cancer surgery

ABSTRACT BACKGROUND: The coronavirus disease-19 (COVID-19) pandemic has changed the course of diseases that require emergency surgery. OBJECTIVE: To evaluate the effect of the COVID-19 pandemic on colorectal cancer disease stage. DESIGN AND SETTING: Retrospective analysis in the city of Rize, Turkey. METHODS: This was a comparative analysis on two groups of patients with various symptoms who underwent surgical colorectal cancer treatment. Group 1 comprised patients operated between March 11, 2019, and December 31, 2019; while group 2 comprised patients at the same time of the year during the COVID-19 pandemic. RESULTS: Groups 1 and 2 included 56 and 48 patients, respectively. The rate of presentation to the emergency service was higher in Group 2 (P < 0.02). The stage of the pathological lymph nodes and the rate of liver metastasis was higher in Group 2 (P < 0.004 and P < 0.041, respectively). The disease stage was found to be more advanced in Group 2 (P < 0.005). The rate of postoperative complications was higher in Group 2 (P < 0.014). CONCLUSION: The presentation of patients with suspicious findings to the hospital was delayed, due both to the fear of catching COVID-19 and to the pandemic precautions that were proposed and implemented by healthcare authorities worldwide. Among the patients who presented to the hospital with emergency complaints and in whom colorectal cancer was detected, their disease was at a more advanced stage and thus a higher number of emergency oncological surgical procedures were performed on those patients.


INTRODUCTION
Cancer is a problem with worldwide importance and is the second leading cause of death globally. 1 Colorectal cancers, with an incidence of 9%, are the fourth among all cancers, following lung, breast and prostate cancer. This rate varies between different countries and ethnicities. 2 The countries with the highest incidence rates include Australia, New Zealand, Canada, the United States and parts of Europe. The countries with the lowest risk include China, India and parts of Africa and South America. 3 During the last 30 years, the incidence of colorectal cancer has decreased from 66.3 to 45.3 per 100,000 population in the United States. 4 The most important cause of this reduction has been the development and extensive implementation of colorectal cancer screening programs, which have made a positive contribution to the prognosis for the disease, through early detection and diagnosis. 5 The first cases of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that were reported were in Wuhan, China, in December 2019. 6 A global pandemic was declared by the World Health Organization on March 11, 2020. 7 Coronavirus disease-19  has seriously jeopardized the health of the whole world, but especially that of healthcare workers. 8 The number of cases of all other diseases presenting to hospitals and emergency services decreased significantly after cases of COVID-19 began to be seen on March 11. A decision was made by the Turkish Ministry of Health on March 17, to delay all elective surgical procedures while pandemic precautions were continuing to be implemented. In addition to these precautions, the fear of contracting COVID-19 also impacted the rate of access to the country's healthcare services. 9 This raises various questions, such as: "If patients' presentations to hospitals were delayed despite the presence of suspicious symptoms, were the procedures of colorectal cancer surgery The numbers of emergency and elective operations were 13 (23%) and 43 (77%) in Group 1, respectively; and 25 (52%) and 23 (48%) in Group 2, respectively. The number of patients undergoing emergency surgery was significantly higher in Group 2 (P = 0.02) ( Table 1). Among the patients undergoing emergency surgery, the indication for the operation was ileus in 10 (18%) and tumor perforation in three (5%) in Group 1; while in Group 2 it was ileus in 16 (33%), tumor perforation in eight (17%) and gastrointestinal (GIS) bleeding in one (2%) ( Table 1).
The mean duration of the postoperative hospital stay was 9.3 days and 10.8 days in Group 1 and Group 2, respectively, with no difference between the groups (P = 0.332) ( Table 1).
Mortality in the early period was seen in three cases (5%) and four cases (8%) in Group 1 and Group 2, respectively with no difference between the groups (P = 0.209) ( Table 1).
The histopathological diagnosis was adenocarcinoma in all patients in Group 1 (100%); while in Group 2 it was adenocarcinoma in 46 patients (96%), medullary carcinoma in one patient (2%) and neuroendocrine carcinoma in one patient (2%). No difference in terms of histopathological diagnosis was found between the groups (P = 0.304) ( Table 2).
The disease stage at presentation was stage 1 in nine patients  Table 2). Similarly, the rate of liver metastasis was also significantly different between the groups, in favor of Group 2. Liver metastasis was present in four patients (7%) and 10 patients (21%) in Group 1 and Group 2, respectively (P = 0.041) ( Table 2). The presence of synchronous tumors and peritoneal carcinomatosis was similar in the two groups (P = 0.516 and P = 0.651, respectively) ( Table 2).

DISCUSSION
The COVID-19 outbreak seriously changed the structure of healthcare systems globally. Many surgical associations recommended that elective surgical operations should cease and that permission should only be granted for presentation of patients with emergency conditions, while cancer surgery could continue. [10][11][12] Many papers have highlighted the precautions that would need to be taken while carrying out emergency and elective surgical procedures during the COVID-19 pandemic. [13][14][15][16] Consequent to the COVID-19 pandemic, there have been many new changes regarding re-planning of departments within hospitals, with measures applied to reduce the risk of transmission to the hospital staff, and emphasis on the importance of using of personal protective equipment. 17,18 These changes have greatly extended operating times and the time taken to clean operating rooms between surgeries. Moreover, given that surgeons and operating room workers do not want to endanger their own health, they may have even been avoiding operations on cancer cases unless emergency conditions occur.
At the same time, the protective equipment that surgeons and the entire operating team had to use due to the pandemic restricted the movement of the entire operating team, especially surgeons.
Benitez et al. reported that the use of personal protective equipment adversely affected the performance of the surgeons. 19 Here, in the present study, our aim was to evaluate the situation regarding delayed colorectal cancer disease diagnosis and its consequences. In our study, the age and gender of the patients operated on were similar in the two groups ( Table 2).
Syllaios et al. reported that the number of emergency colorectal cancer surgeries increased by approximately 30% and that the number of minimally invasive surgical procedures decreased during the COVID-19 outbreak. 20 The rate of occurrence of emergency surgery was found to be significantly higher in Group 2 in the present study ( Table 2). Hence, it can be stated that patients with suspicious findings probably ignored their situation and preferred to wait at home. This result raises two possibilities: either the patients feared contracting the disease through exposure to the outside environment and consequently stayed at home, or delays in accessing healthcare services and in getting a diagnosis occurred due to pandemic precautions.
Algorithms relating to the approach to be taken in cases of emergency surgery have changed many times during the pandemic. For example, conservative approaches such as antibiotic therapy instead of surgery in acute appendicitis cases and application of laparotomy instead of laparoscopy have been preferred. [21][22][23] Laparotomy was performed at a rate of 81% during the COVID-19 period with no significant difference between the groups, according to the results from our study (P = 0.243) ( Table 1).
Comorbidities and disease stage have been investigated in order to determine the outcomes from colorectal surgical treatment. 24,25 In a study involving 887 patients undergoing major colorectal surgery, Ragg et al. reported that a high number of comorbidities was a risk factor for morbidity and mortality. 26 Postoperative complications are known to be an important surgical factor affecting morbidity. In the present study, the rate of postoperative complications was also found to be significantly higher in Group 2 (P = 0.014) ( Table 1). The rate of postoperative complications may have increased through reduction of the capacity to exert effort due to insufficient physical activity levels during the COVID period, diminished immunity due to advanced stage tumor and greater complexity of surgery.
In the literature, the rate of postoperative mortality has been reported to be 3-8%. 27,28 The mortality rates in Group 1 and Group 2 of the present study were 5% and 8%, respectively, and these rates were consistent with findings in the literature. Although there was no significant difference in these mortality rates, mortality was high in Group 2 ( Table 1).
In the present study, no significant increase in the pathological tumor stage (T) was seen during the pandemic. However, pathological lymph node (N) status was significantly higher ( Table 2).
In addition, liver metastasis was seen at a significantly higher rate in Group 2 ( Table 2). According to these factors, the pathological stage of the patients in the pandemic was observed to be significantly more advanced (P = 0.005) ( Table 2).
The Hartman procedure is frequently preferred in colorectal cancer surgery performed under emergency conditions. 29 In parallel with the increase in the number of emergency surgeries during the pandemic period, we observed that colostomy was performed more often in Group 2 in our study.
However, no significant difference was found between the groups (P = 0.390) ( Table 2).
Individuals with suspicious findings relating to colorectal cancer disease may have preferred to wait at home and self-treat, instead of presenting to a healthcare institution. This may have been due either to limitations on the number of outpatient examinations and substantial selectivity regarding endoscopic and surgical procedures, or due to the precautions taken; or because of the fear of contracting COVID-19. This idea is supported by the observation that emergency operations on the symptoms manifested were performed more frequently and that tumors were only detected at more advanced stages.

CONCLUSION
Through the COVID-19 pandemic, surgeons have been faced with patients presenting greater complications and disease at more advanced stages, due to delayed presentation at healthcare facilities.
In addition to irreversible complications due to these delays in presentation, the increased rates of morbidity and mortality, longer duration of hospital stay and higher patient costs also need to be taken into consideration.
More advanced social understanding is needed in order to address patients' fears, in order to ensure that patients will promptly attend healthcare facilities in the event of a new COVID-19 wave with variant strains.
Moreover, if the course of colorectal cancers during such occurrences can be ascertained, policymakers and healthcare providers can become better organized with regard to disease management.