Are We Doing Cancer Surgeries in Covid Times?

The plight of cancer patients:

Comprehensive cancer treatment of any organ takes at least a few weeks if not months. In India majority of the cancers are little more advanced and need a combination of surgery, radiation and chemotherapy.

An interruption in treatment significantly affects on the outcomes as well as survival in a negative manner. The present scenario has posed enormous problems for patients seeking cancer treatment in terms of maintaining continuity in the evaluation and treatment.

Considerable numbers of our patients are not from Mumbai, which means the lockdown has left them helpless in places where there are no options of optimal cancer treatment.

How things changed?

When the Janata lockdown was declared on March 22nd, we knew this is not a situation that is going to be over soon. Right at that time, several of our patients were still under evaluation waiting for biopsies, scans, endoscopies while several others were either waiting or in the middle of radiation and chemotherapy. Selected patients were also planned for cancer surgeries.

We were taking stock of the situation in Italy and Spain where people were dying in thousands. We realized the need for a plan of action to ensure timely treatment of our patients without compromising safety.

At the same time, guidelines were pouring in on how to proceed further. Even now, the guidelines keep getting updated in the wake of new developments. Many guidelines suggested and still suggest that most of the cancer patients have to be considered for neoadjuvant treatments, i.e. treatments offered before definitive surgeries.

This is in the form of either chemotherapy or radiation. While not all cancers need preoperative therapies, patients who do need such treatments have to go through a lot of hurdles to arrange for radiation and chemotherapy. And this is under normal circumstances leave aside the present conditions.

Not to mention the risk of reduced immunity that comes with chemotherapy which increases the risk of contracting COVID-19. But what about the patients who don’t need preoperative treatment or have completed such therapies? Delaying surgical treatment would rob these patients of a chance to get cured.

We at Specialty Surgical Oncology, sitting at home, one team member with suspected respiratory symptoms in late March, got on a zoom meeting to draw a plan of action. Most corporate hospitals had shut down admissions to general and semi-private wards, keeping only single rooms for surgical patients to prevent and contain the spread of the virus.

At the same time, several of these hospitals also had dedicated COVID ICU and WARDS. These developments posed two issues. One, patients are naturally scared to go to a hospital which is already catering to COVID patients. Second, even if they are ready to go there for the sake of treatment, not many were in a position to afford single room charges. At the same time, many smaller institutions had closed down due to detection of COVID either in their patients or their health care workers.

While affording patients who are willing to come to corporate hospitals were given such choices, we also had to think about our economically challenged patients as well. So, we had to earmark a low-cost centre to perform surgeries. This is where Dr Sanket and his surgeon father, Dr Sharad Mehta‘s Asha Polyclinic and Sheetal Nursing Home came into the picture.

We have been operating cancer patients in this centre for a long time, and we can safely say that it is a top-notch surgical facility. All the staff in the ward and OR is very experienced with cancer-related surgeries. The equipment and instrumentation are on par with the best in the business. Hence it was our natural choice.

The first step was laying down the rules. We laid down the following rules,

1. Admit only those patients who are planned for surgeries.
2. There will be only one patient per room, and the general ward will be used for other non-medical purposes.
3. Only one relative will be accompanying the patient, and that person will not leave the premises till discharge.
4. All patients to get COVID testing before admission.

When the BMC changed the rules on COVID testing’s we stopped the testing, and now we are getting CT thorax done for all patients to rule out COVID.

The second step was to select the hospital staff and create Rota to avoid overcrowding and allow smooth handling of responsibilities.

Another important aspect was to train hospital staff. We contacted Dr Kanishk Dawda, an infectious disease specialist, to lay down protocols and train our staff. He was kind enough to take on this responsibility and has been regularly following up to ensure adherence to the set protocols.

All the hospital staff was put on 8 hour Rota. There was an explicit instruction to everyone on how to conduct oneself back home so that social distancing and other safety measures were followed. At the hospital, everyone had to wear PPE kits as long as they are there. The OR staff were instructed not to go to the wards. At any given point of time, we had decided to have only 8 in- patients. Since Asha clinic does not have a pantry, we arranged food to be delivered to all the patients and relatives.

With this setup, we resumed our work. And fortunately, the team member with symptoms was COVID negative on all three tests.

Surgeries performed:

Till date, we have performed 38 cancer surgeries—the majority of them in Asha polyclinic. Operations requiring ICU were performed at Saifee Hospital, Jaslok Hospital, Sushrut Hospital, Apollo Hospital, and Asian Cancer Institute (Cumballa Hill Hospital).

1. Chemoport insertion    –    01
2. Breast cancer surgeries – Total –   15
3. Breast Cancer surgery with Oncoplasty –  05
4. Recurrent head and neck cancer-                       01
5. Tongue wide excisions and neck dissection-    03
6. Total glossectomy+ bilateral neck dissection+ free anterolateral thigh flap –  01
7. Segmental mandibulectomy+ neck dissection + hemithyroidectomy+ free fibula reconstruction – 01
8. VATS+ Laparoscopic esophagectomy – 03
9. Open total gastrectomy – 02
10. Pelvic exenteration –  01
11. Cytoreduction for ovarian cancer –  02
12. Palliative gastrojejunostomy – 01
13. Laparoscopic Anterior resection – 01
14. Open anterior resection –  01
15. Urethra and Vagina preserving Vulval region soft tissue sarcoma Wide Excision with Gracilis Muscle Flap – 01
16. Wide excision Lower end Femur osteosarcoma with Total Knee Replacement using Megaprosthesis –  02
17. Pelvic Bone Placmacytoma curettage with cementing –  01
18. Soft tissue sarcoma of groin region-wide excision with pedicled ALT flap – 01

Challenges faced:

1. Laparoscopy and VATS:

The risk of aerosol spread was taken into consideration. But an open thoracotomy has far more complications compared to VATS esophagectomy. Hence we decided to take adequate precautions to conduct VATS.

We stopped venting of the air from VATS ports to the OR environment. Instead, we connected a hepa-filter to one of the ports and attached that to an underwater seal containing hypochlorite solution.

So all the air that was vented from the port through the filtration process. At the end of the procedure again, all the air was suctioned out and was not vented out. This ensured the safety of the OR personnel and avoided potential contamination of the OR. Once we were sure of this technique, we applied the same protocol for laparoscopy as well.

2. Anaesthesia considerations:

Intubation: Intubation carries the highest risk of transmission. To minimize this, several steps were taken. All surgical patients were given chlorhexidine mouthwashes before they were wheeled inside the OR. Staff movement was kept to the minimum. Our anaesthetist wore full PPE kit all the time. Rapid sequence intubation with immediate insufflation of the cuff was practised. Extubation was done under barrier cover. Care was taken during extubation to prevent the patient from coughing.

3. Emergency patients arriving at the hospital:

All the emergency patients were seen outside the premises using PPE kits. They were given primary care and were referred to appropriate facilities.

4. Adherence to protocols:

The PPE kits are very cumbersome and uncomfortable but a necessary evil. We had to continually monitor and encourage the staff to wear them all the time.

5. OPD consultations:

We shifted to online consultations to reduce the risk of COVID transmission. Initial opinions were given through video conferencing. The patient was physically seen only when it was deemed necessary.

6. We also faced logistical issues with procuring N-95 masks and PPE kits for the hospital.

We continue to stick to the guidelines provided by BMC and IASO. We are committed to serving our patients. Although the number of

surgeries performed was a fraction of the number we used to do before the lockdown, we have strived to continue serving our patients, and are now geared to cater to a more significant number of patients.

The fact that none of our team members has contracted the virus and none of our patients who underwent surgery got infected is proof that by adhering to guidelines we can continue to provide care to our patients in these dire times.

With the easing of the lockdown and the lacunae in the present healthcare system, we expect that the scenario will be much more challenging before things calm down.