INTRODUCTION
The COVID-19 pandemic crisis has had a staggering impact worldwide. Confirmed cases have increased exponentially and the number of infected individuals has since exceeded a million [
1]. It is however important to realize that with limitations in testing, true infection rates may in fact be much higher [
2]. In addition, presymptomatic transmission of infected individuals has been documented in China and lately confirmed in Singapore [
3-
5]. Our local data suggests that this can occur in 6.4% of patients but has been reported to be as high as 30% in other studies [
6,
7].
Safe surgery has emerged as a topic of immense interest. As colorectal surgery accounts for a significant proportion of General Surgery workload [
8], the COVID-19 pandemic thus has immense implications for many general and colorectal surgeons. In this current juncture of the pandemic with dangers of viral transmission, surgeons need to achieve a balance between surgical safety and judicious consumption of personal protective equipment (PPE). While deferment of nonurgent cases may be an initial strategy, this approach is impractical in the long run. The COVID-19 pandemic will likely have a protracted course and the resultant backlog of cases from indiscriminate deferment may overwhelm surgical capacity in the near future and compromise clinical care [
9]. This is particular pertinent for common and time-sensitive pathologies like colorectal cancer.
In Singapore, COVID-19 management has been one of prompt contact tracing and isolation to prevent transmission. Curtailment of travel as well as safe distancing measures at work and social areas have all been imposed. Nonetheless, there have been a large number of imported cases with resultant community spread. In the authors’ hospital, there have been 290 (latest figures as of 23/4/20) positive COVIDs to date.
While there has been a gradual reduction of elective workload over the last 2 months since the onset of the disease outbreak in Singapore, there continues to be a reasonable volume of cases performed. In this article, we share our colorectal unit’s workflow (
Fig. 1) and recommendations (
Table 1) for safe practice in the COVID-19 era.
Workflow for patients undergoing elective colorectal procedures in the COVID-19 era:
Our workflow for evaluating patients scheduled for procedures (Endoscopy or Surgery) is illustrated in
Fig. 1. Preprocedure risk stratification is done for all patients at 3 stages. At the initial anesthetist assessment 1–2 weeks preoperatively a chest X-ray or computed tomography thorax for cancer cases will be obtained to assess for consolidative changes in the lungs. Three days prior to the surgery date, our admission team will contact the patient to obtain a travel declaration and to inquire if there are new flu-like symptoms. On day of admission, this process is repeated with a formal declaration form signed by the patient.
Patients who have any travel history within 14 days, or has contact with any member of the public who is positive for COVID-19 or on home quarantine, or has new onset of flu-like symptoms will be advised on postponement of procedure. The procedure would be postponed by 2 to 4 weeks to allow infected patients who may be within the incubation period of COIVD-19 to declare themselves.
If there is clinical urgency, the procedure may proceed with precautions taken as per a presumed COVID-19 positive patient (
Fig. 1). Clinical urgency refers to cases which necessitate intervention within 2 weeks. These include colorectal cancer cases with impending obstruction or with overt bleeding resulting in significant transfusion requirements. Postoperatively, such patients will undergo COVID-19 testing and will be nursed in isolation until their test results clear them from COVID-19 infection.
At the current moment, universal COVID-19 testing for all patients undergoing surgery is not performed. We only perform testing for patients who meet the suspect case definition stipulated by the Ministry of Health, Singapore. As of 16 April 2020, the case definition is as follows:
(1) A person with clinical signs and symptoms suggestive of Community-Acquired Pneumonia or community-acquired severe respiratory infection with breathlessness.
(2) A person with an acute respiratory illness of any degree of severity (e.g., symptoms of cough, sore throat, runny nose, anosmia), with or without fever, who, within 14 days before onset of illness had: (a) Travelled abroad (outside Singapore); (b) Close contact with a case of COVID-19 infection.