Introduction

The COVID-19 pandemic has put health systems under immense pressure worldwide. In addition to the necessary preparation and reorganization of the system to meet a new and growing demand for patients with COVID-19, providing care of non-COVID-19 patients is a challenge¹.

The restriction imposed by the pandemic along with relocating and redirecting human and material resources for the treatment of COVID-19 patients resulted in the impossibility of keeping up with normal care for other diseases. It was then necessary to establish criteria for prioritizing non-COVID-19 patients. Postponing elective surgeries as long as possible was a measure that was rapidly established². This measure allowed, on the one hand, economizing human and material resources and, on the other hand, avoiding the higher morbidity of elective surgery in COVID-19 positive patients.

Oncological surgeries, especially for pancreatic cancer because its particular biological severity, should not be considered elective surgeries. However, according to several surveys and papers published in other countries, their frequency decreased significantly during the pandemic with consequences that are expected to be extremely unfavorable for the patients³.

The aim of this paper is to analyze pancreatic surgery during the pandemic in the period between March and June 2020 in a public and a private institution. The number of surgeries, their complications and mortality were analyzed. The percentage of pancreatic surgeries, complications and mortality during the pandemic were compared in each institution with the same period of the previous year.

Material and methods

The number of pancreatic surgeries performed in a public hospital (Hospital Argerich) and a private institution (Clínica Bazterrica) between March 11 and June 24, 2020, were analyzed. March 11 was chosen because on that day the WHO declared COVID-19 a pandemic. Pancreatic surgery was defined as the resection of all or part of the pancreas. All the surgeries were performed by the same surgical team. The procedures were divided in cephalic pancreaticoduodenectomy, left pancreatectomy and total pancreatectomy. Necrosectomies due to pancreatic necrosis, head resections due to chronic pancreatitis and enucleation of neuroendocrine tumors were excluded.

At the private center, two patients with cystic lesions with worrisome features voluntarily postponed their surgery. Three patients with resectable pancreatic cancer in the head (n = 2) and body (n = 1) were transferred from the public institution to other public hospitals.

Age, sex, comorbidities according to the American Society of Anesthesiologists (ASA) physical status classification, pathological diagnosis, complications, and mortality were determined. The specific mortality was classified according to the International Study Group for Pancreatic Surgery (ISGPS)⁴. The number of pancreatic surgeries, frequency of adenocarcinomas, morbidity and mortality of patients undergoing surgery during the pandemic were compared with those performed during same period in 2019.

In all surgeries, the surgical team and the anesthesiologist used a complete set of personal protective equipment (PPE) (N95 respirator, goggles, face shield and fluid-resistant gowns).

Besides the standard informed consent used before any surgery, all the patients signed the COVID-19 consent form, with information about additional risks: coronavirus infection during hospitalization and increased risk of mortality in patients with COVID-19.

Results

A total of 23 pancreatic resections were performed in both institutions during the pandemic. The epidemiological data are described in Table 1. In all the cases, surgery was indicated due to confirmed or suspected malignancy.

Twenty surgeries were performed in the private center and 3 in the public hospital. The type of resection is detailed in Table 2. Vascular resection was performed in three patients operated on in the private center: two lateral resections and one partial resection with end-to-end anastomosis. Two patients in the private center received previous neoadjuvant therapy. Two laparoscopic left pancreatectomies were performed in the private center.

The pathological diagnoses are detailed in Table 3. Adenocarcinoma was the most common diagnosis (16/23). Eight patients presented one or more postoperative complications: grade B pancreatic fistula in four patients managed with a conservative strategy, four intra-abdominal abscesses treated with percutaneous drainage, and two patients developed pneumonia. There were no reoperations or deaths.

Table 4 compares the number of surgeries during the pandemic with those performed during the same period of the previous year. The number of surgeries decreased in both centers, with a significant reduction in the total number of surgeries in both centers during the pandemic (36 vs. 23, p = 0.04). Yet, the reduction was not significant in the private center (22 vs. 20, p = 0.88). On the contrary, the number of pancreatic surgeries was significantly lower in the public center (14 vs. 3, p = 0.009).

There were no significant differences in the frequency of surgeries for adenocarcinoma before the pandemic (22/36) and during the pandemic (16/23) (p 0.55). Postoperative complications before and during the pandemic were not different (10/36 vs. 8/23; p = 0.58). There were no deaths in both periods.

None of the patients in both centers were tested for COVID-19 before surgery. Seven patients developed fever and were managed with the COVID-19 protocol: five during hospitalization (four in the private center and one in the public center) and two in the private center after discharge. In all the patients the swab test was negative. The IgG/IgM rapid test was negative in all the members of the surgical team by June 22, 2020.

Discussion

Our results show that the pandemic had no impact on the number of pancreatic resections in the private institution. In contrast, there was a significant decrease in the number of resections during the pandemic in the public hospital. This difference can be explained by the access to the system and the public responsibility of each institution. The access to the outpatient clinic was never closed in the private institution, as opposed to the public hospital, where the outpatient clinic was closed from the beginning of the pandemic and still remains closed for elective appointments. Many of our patients are transferred from other provinces, but this was not possible in the public system during the pandemic. In contrast, in the private system, two patients with pancreatic cancer who finally underwent pancreaticoduodenectomy were transferred from their respective provinces on medical flights.

Unlike the private centers, the public health systems of the Autonomous City of Buenos Aires (CABA) have been reorganized to provide top priority for the management of the COVID-19 pandemic. One of the first measures adopted was the cancellation of elective surgeries. The restrictions for performing elective surgeries were stricter in the public setting than in the private one. In particular, our hospital - due to its complexity - was designated one of the referral centers for COVID-19 patients. The possibility of transferring patients to COVID-19-free hospitals within the public system allowed for a more severe restriction in patients with cancer that require beds in intensive care units after surgery.

On March 20, with very few cases, the government declared social, preventive and mandatory isolation throughout the country, resulting in the cessation of almost all activities. One of the main goals of such a restrictive and early measure was to prepare and reorganize the health system and reduce the number of infections in order to “flatten” the epidemic curve. In this way, after the restricted period, the system would be able to adequately deal with the infections that were occurring during the pandemic without collapsing. This strategy was inspired in an article by Tomás Pueyo⁵, an engineer from Silicon Valley, titled “The Hammer and the Dance”, which was published on the Medium platform with millions of visits and consultations from governments. This article and a previous one encouraged politicians and businessmen to take drastic, early and urgent measures to contain the advance of COVID-19, anticipating an otherwise catastrophic situation. Pueyo stated that to fight the pandemic you must apply a heavy hammer with measures of social isolation, massive testing and tracing of contacts, and then monitor the progression according to the risk (the dance). This, he says, will allow “life to be reasonably similar to what it was before until a vaccine is available”. The projection was that two weeks after the strong measures were applied, the number of daily infections would reach its peak and, in a period of three to seven weeks, would start to be close to zero. Then the second phase, “the dance”, could start. In the hammer and the dance strategy, both the hammer and the dance are necessary. The importance of reaching the dance as soon as possible is that the cost of holding the hammer over time is extremely high.

The same hammer and dance dynamics can be applied to health systems. Both systems canceled non-cancer elective surgeries at the beginning of the pandemic to reorganize. In the private system, the demand for intensive care beds due to the pandemic never exceeded 20% of the capacity and remained constant throughout the pandemic, therefore there were never any restrictions on cancer surgeries. Nowadays, the private center is progressively moving into the “dance” and, when the hospitalization rate due to COVID-19 will not exceed 50% of all the beds available, elective non-cancer surgeries will be authorized. On the contrary, the demand for intensive care beds in the public system and especially in our hospital has been growing. When this paper was written, the hospital had 20 of the 30 intensive care beds occupied by COVID-19 patients. In the case of the public hospital, “the hammer” is extending with still unmeasurable consequences for non-COVID patients.

Early diagnosis and treatment of many types of cancer, especially pancreatic cancer, has significant benefits for survival. However, it is getting harder to convince people of the importance of maintaining these quality standards in cancer treatment in health care institutions currently focused on emergency care for COVID-19 in the short term. The scientific surgical societies have rapidly provided recommendations for adapting or replacing standard treatments with other options with lower morbidity and mortality. On 24 March, the American College of Surgeons published guidelines prioritizing this type of therapeutic strategy during the peak of the pandemic². However, a month later these guidelines were modified and included recommendations for returning to standard treatments according to the recovery phase of the pandemic, taking into account the number of cases and the capacity of the health systems⁶.

The fear created in the population about the risk of COVID-19 infection in health centers, together with excessive restrictive measures to preserve material and human resources for the care of the pandemic, prevented the normal treatment of cancer⁷. Once the diagnosis is made, rapid treatment is also important. A study that analyzed databases of more than 4 million patients established the safe period for postponing cancer surgery. Beyond this period, mortality increases and survival decreases. This period is called safe postponement period (SPP) and is 3 weeks for pancreatic cancer treated with surgery and 6 weeks for patients with pancreatic cancer treated with neoadjuvant therapy⁸. This period provides a framework for determining the timing for surgical intervention in cancer patients within this dynamic context of the pandemic.

Several publications have shown the impact of the pandemic on elective and cancer surgeries⁹. Most centers have reported a decline in volume; however, in many centers this reduction is not significant, and others have been able to maintain adequate volume despite the pandemic. A survey conducted in Italy regarding the oncological surgical activity in 54 surgical units in 36 hospitals showed that surgical procedures decreased from 3.8 per week before the pandemic to 2.6 per week after (p = 0.036). In Lombardy, the most involved district, the decrease was not significant: the number decreased from 3.9 to 2 procedures per week¹⁰. In another survey involving 337 surgeons from 37 countries, the number of pancreatic surgery cases per week decreased from 3 to 1 (p < 0.001)¹¹.

In conclusion, in the setting of the pandemic, the private center managed to maintain the number of pancreatic surgeries and perform them safely for both patients and doctors. Conversely, the priority for treating patients with COVID-19 in the public center resulted in a significant decrease in pancreatic surgeries. The possibility of transferring patients to other public institutions avoided prioritizing their treatment. In view of our epidemic curve, we believe that standard treatment of patients with confirmed or suspected pancreatic cancer should not be postponed or prioritized. Our responsibility, and that of the medical societies, is to maintain quality standards in the treatment of non-COVID patients. Probably, postponing cancer surgery without considering its implications can cost more lives than those potentially saved if all the surgical resources are diverted to the care of COVID-19.