There was a lockdown imposed in Beijing with travel restriction, which explained why the case load fell by 30% during COVID-19 period and the proportion of local patients in PCG is lower than in CG (3 [4%] vs. 16 [39%]; P < 0.001). Our hospital did not work like usual during COVID-19 period, changes include (1) medical staff must wear medical surgery mask or N95 mask, as well as disposable helmet, gloves and goggles, to protect them from potential infection; (2) appointment and triage protocols should be carried out through telephone, smartphone apps or Internet service and patients visit clinic based on reservation number and recommended time, to reduce crowds gathering and lower risks of cross infection; (3) for primary-care patients, triage nurses need to measure the temperature and investigate epidemiological history including travelling to Wuhan Province and nearby cities, meeting with people ever been those areas and contacting with confirmed or suspected cases within 14 days, as well as clinical manifestations including fever (> 37.3℃), fatigue and respiratory symptoms like coughing, and for those with history of travelling to associated areas, contacting with related cases or having suspected symptoms, the fever clinic screening had to be done first.
The COVID-19 outbreak alerted us the importance of infection control measures for pandemic diseases. Successful implementation of infection control required strict management of inpatients during this period. Due to disease consumption, malnutrition, coupled with chemotherapy, gastric cancer patients may be immunocompromised, which leads to more susceptible to COVID-19[4, 8].Therefore, we suggest that all outpatients should be triaged before admission to reduce the possibility of exposure in hospital.To screen suspected infection, more patients had performed chest CT scan besides abdominal CT before admission during COVID-19 period (PCG:22[32%]vs. CG:30[73%], p = 0.001). Making personalized diagnosis and treatment plans for gastric cancer patients by multidisciplinary team (MDT) are essential[11, 12]. Departments and staff members of MDT include: general surgery, oncology, radiology, radiotherapy, respiratory medicine, and infectious disease experts. It is recommended that patients should have completed gastroscopy, pathological examinations and imaging examinations (abdominal, pelvic CT or MRI, including PET-CT if necessary) at the local hospital before visiting our clinic. The MDT clinic comprehensively evaluates the gastric cancer patients based on clinical symptoms, pathological classification, imaging staging, and other examination, which resulted in precisely determination of the cTNM stage.
EMR or ESD are suggested for patients with early-stage gastric cancer lesions ≤ 2 cm in diameter without associated ulcer formation (cTis or cT1a). Surgery is the primary treatment option for cT1b patients. And patients with histologically confirmed gastric adenocarcinoma of cT2 to cT4a were suggested to receive perioperative chemotherapy. This shunt method allows patients to receive appropriate treatment, while reducing the number of hospitalized patients during the pandemic and reducing the risk of infection. Especially for patients who have finished neoadjuvant chemotherapy in several month later, they could benefit from avoiding the peak of the pandemic. However, for resectable gastric cancer patients with anemia, refusal of neoadjuvant chemotherapy, or low granulolymphatic ratio, delaying the time of radical surgery will not benefit the patient. Therefore, timely surgery might be a better choice. During the 'COVID-19' period, we recommend chest CT and new coronavirus nucleic acid tests to rule out patients with new coronary pneumonia and suspicious infection, which explains the longer waiting time before admission and higher chest CT scan rates in CG compared to PCG. In addition, the provinces were relatively isolated during the pandemic, therefore, compared with PCG, the proportion of local patients in CG had increased(3 [4%] vs. 16 [39%]; P < 0.001).
After admission,patients were isolated in separated single-room wards without contaction to surgeons or nurses, which helps us to observe whether they manifested elevated temperature or symptoms suspicious for COVID-19. If the patients did not had a fever of over 37.3℃ or other symptoms associated to pneumonia for 3 days since admission, the surgery would then be performed. Thus the waiting time before surgery was longer (3[IQR: 2,5] vs. 7[IQR: 5,9]; P < 0.001). During the pandemic, routine surgery should be based on the principles of safety and efficiency, with the main purpose of reducing the incidence of postoperative complications and accelerating the patient's recovery and discharge[12, 13]. Therefore ,it is necessary to avoid performing surgery beyond authoritative guidelines, including oversized lymph node dissections with uncertain effects and complex digestive tract reconstruction methods. Attention should be paid to clear anatomy and accurate operation during surgery to reduce the risk of bleeding during and after surgery due to the tight blood source in the blood bank during the pandemic period, which could decrease unexpected blood transfusion treatment.
Enhanced Recovery After Surgery(ERAS) pathway was initially established by Henrik Kehlet [14]in colorectal surgery,Since then the idea has gradually been accepted .However, the first ERAS guideline for gastric cancer were published in 2014, and most evidence of it based on western countries. Lacking of gastric cancer ERAS protocol appropriate to Chinese conditions hampered us from accepting it at the first time. However, in recent years we are gradually conducting clinical trials on ERAS for gastric cancer. In the light of COVID- 19 pandemic, ERAS for gastric cancer patients demonstrated considerable advantages since it could reduce the patient's surgical stress response, postoperative complications, and shorten the length of hospital stay, thereby reducing the chance of nosocomial infection. During COVID-19 period, more laparoscopic surgery were performed (PCG: 51[75%] vs. CG: 38[92%], p = 0.021). While, the total hospital stay of patients in CG was longer than that in PCG, which seems ERAS was not applied to patients in CG, (7[IQR: 6,8] vs.9[IQR:7,11] ; P < 0.001). However, considering that during the COVID-19 period, patients had to remove the stitches in outpatient clinics and local hospitals since discharged, which would increase the risk of unnecessary viral infections, It was better to stay longer in our department until stitches were removed. In addition, other ERAS procedures in the two periods were almost analogous., and hospital stay after surgery was longer (7[IQR: 6,8] vs.9[IQR:7,11] ; P < 0.001). There was no statistical difference in surgical time, pathological diagnosis, TNM staging, complication including pneumonia and blood transfusion, as well as highest temperature, screening test and reason for fever between two groups (P > 0.05). Because of longer hospital stay, the total cost of hospitalization increased during COVID period, (9.22[IQR:7.82,10.97] vs. 10.42[IQR:8.99,12.57]; p = 0.006), Medicine cost, treatment cost and other aspects including beds, cares, diets etc. were higher in GC(p༞0.05).
After surgery,If the patient had fever of unknown cause, appropriate ward isolation measures should be taken and postoperative blood routine, C-reactive protein, procalcitonin, chest CT, and new coronavirus nucleic acid tests are necessary.
Perioperative chemotherapy has significantly increased survival in patients with locoregional resectable gastric cancer. Capecitabine combined with Oxaliplatin or S-1(SOX or XELOX), has been applied as one of the standard perioperative chemotherapy strategy for patients with advanced gastric cancer in Chinese population[15–18]. The preoperative chemotherapy schedules were composed of Oxaliplatin (130 mg/m2 intravenously on day 1 every 3 weeks), combined with S-1 (40/50/60 mg orally twice daily for 14 days followed by 7 days off ,The does depends on surface area: < 1.25 m2 /1.25–1.5 m2 /> 1.5 m2 )(SOX)or Capecitabine (1000 mg/m2 twice daily for 14 days followed by 7 days off) (XELOX). Patients were admitted to daycare ward for intravenous injection of Oxaliplatin every 3 weeks, which shorten patient exposure time in hospital due to surgical treatment and reduce the risk of cross infection. The radical gastrectomy surgery would be performed in 4 weeks after 2–4 cycles neoadjuvant chemotherapy, at that time, the peak of the pandemic might pass.