When to operate, hesitate and reintegrate: society of gynecologic oncology surgical considerations during the covid-19 pandemic

The COVID-19 pandemic has challenged our abilities to provide timely surgical care for patients, including women with gynecologic cancer. In March 2020, the American College of Surgeons, The US Surgeon General, and many medical and surgical academic societies recommended postponing elective surgical interventions. Recognizing that the pandemic may oc cur in waves, special considerations should be made for appropriate indications for surgical intervention in the setting of strained resources and personnel to meet surgical demand and prioritize excellent patient care. The purpose of this white paper is to highlight all phases of gynecologic cancer surgical care during the COVID-19 pan demic and to illustrate when it is best to operate, to hesitate, and reintegrate surgery. Regarding prioritization, patients should be counseled on risks of surgical delay versus in-hospital or community-Acquired COVID-19 exposure in the perioperative setting. Patients should be informed that surgical prioritization is based on (1) local projected resources, (2) disease preva lence, (3) patient and tumor characteristics, and (4) expected outcomes from delays. Several prioritization algorithms have been developed that take into account disease characteristics, patient comorbidities, available personal protective equipment, length of hospital stay, local COVID-10 prevalence, and more. Most oncological procedures have been classified as semiurgent, with a high priority tier 3 designation (second to emergent cases and trauma). Published literature demonstrates that most women with newly diagnosed gynecologic cancer are unlikely to be impacted by a few weeks surgical delay. Those with malignancies with a propensity for metastasis or advanced stage ovarian and uterine malignancies that require interval cytoreduction should be prioritized when possible. For mitigation of complications before, during, and after surgery, patients should be educated on recommendations for so cial distancing, hand hygiene, and personal protective equipment such as face masks. Providers should abide by similar rec ommendations and use eye protection in the ambulatory and inpatient settings. N95 respirators or powered air-purifying respirators are recommended in the care of suspected or known COVID-19 patients. Clinical screening should be done at mul tiple points, COVID-19 testing should be done preoperatively, and a positive test result should delay surgery until asymptom atic for more than 14 days. Safety protocols are critical during procedural intubation and extubation, as this is the most hazardous aspect of surgery in a COVID-19-positive/unknown patient. Open surgery should not be considered safer than minimally invasive surgery. Practitioners for whom the risk of severe disease and death is highest should avoid participating in the surgical care of known COVID-19-positive patients, if possible. Telemedicine should be incorporated to limit provider and patient exposure in the postoperative setting. Virtual platforms have also demonstrated efficacy in virtual rounding as well as patient care settings to involve family members in treatment planning and discussions around diagnosis. Platforms emphasizing enhanced recovery time and same-day discharge should be prioritized, and measures should be taken to reduce delirium risk given lack of patient visitors. Reintegration efforts should focus on systematically prioritizing the nonurgent cases that were initially delayed. Surgical restrictions are likely to continue for some time, and institutional and departmental leadership will be paramount to optimize surgical manpower, support operative personnel, and use hospital resources equitably and responsibly.