ACS: COVID-19 Guidelines for Operating on Colorectal Cancers

From the ACS online March 24, 2020

Guidelines are based on what COVID response "phase" currently facing an institution

Phase I:

Semi-Urgent Setting (COVID Preparation Phase): Settings with few COVID-19 patients, hospital resources not exhausted, institution still has ICU ventilator capacity and COVID-19 trajectory not in rapid escalation phase.

Cases to be done as soon as feasible (recognizing status of each hospital likely to evolve over next week or two):

• Nearly obstructing colon

• Nearly obstructing rectal cancer

• Cancers requiring frequent transfusions

• Asymptomatic colon cancers

• Rectal cancers after neoadjuvant chemoradiation with no response to therapy

• Cancers with concern about local perforation and sepsis

• Early stage rectal cancers where adjuvant therapy not appropriate

Diagnoses that could be deferred 3 months

• Malignant polyps, either with or without prior endoscopic resection

• Prophylactic indications for hereditary conditions

• Large, benign appearing asymptomatic polyps

• Small, asymptomatic colon carcinoids

• Small, asymptomatic rectal carcinoids

Consider alternative treatment approaches to delay surgery:

• Locally advanced resectable colon cancer: neoadjuvant chemotherapy for 2-3 months before surgery

• Rectal cancer with clear and early evidence of downstaging from neoadjuvant chemoradiation: where additional wait time is safe and additional chemotherapy can be administered

• Locally advanced rectal cancers or recurrent rectal cancers requiring exenteration: where additional chemotherapy can be administered

• Oligometastatic disease: where effective systemic therapy is available 

Phase II:

Urgent Setting: Settings with many COVID-19 patients, ICU and ventilator capacity limited, OR supplies limited

Cases that need to be done as soon as feasible (recognizing status of hospital likely to progress over next few days):

• Nearly obstructing colon cancer where stenting is not an option

• Nearly obstructing rectal cancer (should be diverted)

• Cancers with high (inpatient) transfusion requirements

• Cancers with pending evidence of local perforation and sepsis

Cases that should be deferred:

• All colorectal procedures that would typically be scheduled as routine

Alternative treatment approaches:

• Transfer patients to hospital with capacity

• Consider neoadjuvant therapy for colon and rectal cancer

• Consider more local endoluminal therapies for early colon and rectal cancers when safe

Phase III:

Hospital resources are all routed to COVID 19 patients, no ventilator or ICU capacity, OR supplies exhausted.  Patients in whom death is likely within hours if surgery deferred.

Cases that need to be done as soon as feasible (status of hospital likely to progress in hours)

• Perforated, obstructed, or actively bleeding (inpatient transfusion dependent) cancers

• Cases with sepsis

All other cases deferred

Alternate treatment recommended

• Transfer patients to a hospital with capacity

• Diverting stoma

• Chemotherapy

• Radiation