The rapidly ongoing outbreak of novel coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has attracted widespread concern not only within China but around the globe [1, 2]. As for cancer patients with COVID-19, whether it should discontinue cancer therapy or defer surgical treatment remains controversial. To our knowledge, the case reported here represented the first colon cancer patient with confirmed COVID-19, who successfully underwent and benefited from the aggressive surgical treatment. During the period of manuscript preparation, no more surgery was performed for colon cancer patient infected with SARS-CoV-2, and thus clinic data on safety of surgical treatment and prognosis of such patients are sorely lacking. However, there are still positive implications and certain guiding significances for the treatment of colon cancer cases with emergency situation during the health care crisis.
Although the radical right colectomy is a standard surgical procedure for gastrointestinal surgeons, it remains physically and technically challenging that performing the operation for colon cancer patient with confirmed SARS-CoV-2 infection in the specific period, because of its complexity which includes prolonged operative time and unclear vision, as well as discomfort and inconvenience caused by multiple sets of protective equipment. More importantly, several reasons make invasive diagnostic and surgical procedures less of a clinical priority, such as suddenness of the outbreak, high rate of transmission, vast patient volume in hospitals, and severe shortage of health care personnel , which indeed increases infection risk and mental stress for the medical team. In this case report, we successfully performed the operation for this patient with confirmed COVID-19. Everyone in our surgical team ensured to implement the standard tertiary protective measures against infectious diseases and applied active iodine on the surface of medical goggles to ensure a good surgical field, and then checked again with each other. Furthermore, we especially focused on responding to critical situations such as major bleeding, respiratory and cardiac arrest during the operation. Another two surgeons were on call at all times during surgery to deal with the shortage of surgical member due to significantly prolonged surgery time and excessive physical exertion of the surgeon. In order to minimize the production of iatrogenic aerosols, the anesthesiologist used continuous epidural anesthesia, but meanwhile have prepared the equipment required for general anesthesia and rescue for timely responding to emergencies such as anesthesia accidents and respiratory distress during the surgery. Moreover, surgery must be performed in a negative pressure operating room. Before entering the abdominal cavity, the operation must be gentle to prevent body fluid from splashing, which was also applicable during tissue dissection and surgical specimen removal.
A previous study has demonstrated that combining antiviral and anti-inflammatory treatments could simultaneously reduce viral infectivity, viral replication, and the aberrant host inflammatory response . Therefore, we recommended the preoperative treatment with combination of antiviral and anti-inflammatory medicine, so that patients could benefit great in the processes of undergoing surgery and postoperative rehabilitation. Of note, there are some special patients that has been cured and discharged recently appeared in Wuhan, China, whose retesting results of nucleic acid for SARS-CoV-2 were positive again during outpatient follow-up and was re-admitted to the hospital. Therefore, it is prudent and important to regard all patients as potentially infectious during an epidemic season and cautiously practice “universal precaution” in perioperative period. Fortunately, thus far, no case of surgeon, nurse or anesthetist in our team being infected by SARS-CoV-2 occurred.
During the earlier phase of the COVID-19 outbreak, there were a significant number of health care providers infected with SARS-CoV-2 in many hospitals in Wuhan, and patients in a same room were cross-infected, due to exposure to unknown transmission sources. This dramatically increased the risk of SARS-CoV-2 infection for everyone in the outpatient clinics, especially cancer patients. On retrospective analysis of the patient’s medical course, the underlying cause of the first fever might be tumor-derived, and then were cross-infected with SARS-CoV-2 due to outpatient exposure. The SARS-CoV-2 infection and tumor lesion together caused a synergistic mechanism of action and further aggravated the patient's condition, which partly was clarified by the fever eventually reduced to normal after surgery. Pathologic findings revealed that the obvious degeneration, necrosis and slough of focal intestinal and colonic mucosal epithelial cells surrounding the tumor, which was consistent with the findings in a previous autopsy report . Based on many cases with diarrhea observed clinically, it is probably one of evidences for gastrointestinal infection of SARS-CoV-2. However, these changes might also represent a nonspecific change with aging and could be considered as a largely secondary change caused by tumor. More cases with sufficient controls are necessary to further clarify these pathological changes. Nevertheless, it is of great significance for clinicians to pay more attention to cancer patients and pathological changes of digestive tract organs during the outbreak of COVID-19. We believe that it is meaningful and imperative to share our experience to provide references for optimizing treatment of cancer, at least for operative intervention which is absolutely necessary during the epidemic period.