Background

Ours is a rural India-based tertiary cancer center under the aegis of Tata Memorial Center, Mumbai, India. Most of the centers were dedicated to COVID-19 management after the first nationwide lockdown was announced in India in March 2020. Delaying the cancer treatment can have disastrous consequences for the patients; hence, as a uniform policy of Tata Memorial Center, we decided to continue with our cancer services.

Methodology

Electronic medical records were accessed for patient’s related data. Since there was no in-house COVID-19 testing facility and testing methods and policies were still being developed hence during the initial 3 months of the pandemic, preoperative reverse transcriptase polymerase chain reaction (RTPCR) test was not done for asymptomatic patients except for head and neck oncology cases. All visceral surgeries were admitted for 5 days in ward in the preoperative period to look for any COVID-19-related symptoms. After July 2020, all surgical patients were tested before surgery with RTPCR on nasopharyngeal swabs.

Results

A total of seven hundred and ninety-three cancer surgeries were performed. During surgeries, all COVID-19-related measures were taken by operation theatre staff including usage of personal protective equipment kits. As per the advisory by the institute, any health care worker with a COVID-19-like symptom was removed from active duty and tested for COVID-19. Disease management group (DMG) wise distribution of surgeries is shown in Table 1. Eight patients had unexpected postoperative period. Patient profile is shown in Table 2. All patients except S.No 2 were tested preoperatively for COVID-19. Patients were tested again in postoperative period if any doubtful symptom.

Table 1 Disease management group wise distribution of surgeries
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Table 2 Patient profile
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Discussion

COVID-19 can either infect upper respiratory tract (sinuses, nose, throat) or lower respiratory tract (trachea or lungs) [1]. Due to affinity for receptor of angiotensin-converting enzyme-2 (ACE 2), which is abundant on type II alveolar cells, lungs are most commonly affected [2]. GI organs are also affected, as there is abundance of ACE-2 receptors in the stomach, duodenum, rectum, and small intestine [3, 4].

Up to 1/3rd of patients may present with GI symptoms. A meta-analysis showed diarrhea is the most common symptom (11.5%) followed by nausea and vomiting and then abdominal pain [5]. Amongst critically ill COVID-19 patients, nearly 2/3rd patients have elevated liver enzymes [6]. Other GI symptoms in sick patients can be acute cholecystitis [7], acute pancreatitis [7], colonic pseudo obstruction [7], and mesenteric ischemia [7]. There is ambiguity on whether there is active viral replication in GI system or is it just the swallowed virus from respiratory infection.

Pathogenesis of hypercoagulable state with COVID-19 infections is unclear. Direct damage to endothelial cells by SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) virus has been seen. Presence of intravascular catheters and inflammatory cytokines promote vascular damage [8]. Prolonged immobilization in intensive care unit is an additive factor. Changes in circulating prothrombotic factors have been seen in critically ill COVID-19 patients [9, 10].

Renal problems in COVID-19 patients may manifest as acute kidney injury, hematuria, and proteinuria with an increased risk of mortality [11, 12]. Patients with severe SARS-CoV-2 infection can develop skin vasculitis and systemic arterial and venous thromboemboli. It has been attributed to factors such as viral sepsis, hypoxemia, immobility, and vasculitis [13].

Except the patient who underwent abdominoperineal resection, all of our study patients were tested with RTPCR for COVID-19 preoperatively and had a negative report. This alone patient was treated during the 1st wave of COVID-19 in India and rest during the 2nd wave. Fever, diarrhea, and wound breakdown were the most consistent presentation amongst our study patients. Postoperative fever was seen in almost all study patients and typically started after postoperative day 4 unlike usual fever after surgery, which happens within 48 h of surgical procedures. Diarrhea was seen in 4 out of 6 patients who had undergone abdominal visceral surgery. Vomiting was present in two cases. Initially, as expected, diarrhea was attributed to a variable postoperative course especially after a bowel surgery. But with experience we got more vigilant and early repeat testing was advised. Wound breakdowns were sudden and delayed without any antecedent surgical site infection or wound necrosis. Literature review could not provide any evidence of effect of COVID-19 on wound healing but it can be attributed to systemic thrombosis and emboli.

Since most of the problems mentioned above are frequently seen after any major surgery, it becomes very confusing for the treating surgeon to differentiate from COVID-19. The diagnosis is usually delayed and the only way forward is to keep a high index of suspicion especially in countries where the COVID-19 caseload is high.

Conclusion

To the best of our knowledge, this is the only study which has addressed the probable role of COVID-19 in altering the postoperative course in cancer patients. The other two studies in cancer patients from India [14, 15] were audits of surgical procedures and logistic problems faced. A surgeon should keep a high index of suspicion if there are unusual events even if preoperative COVID-19 testing is negative.