“Is Too Much”

MORTALITY CASE
PRESENTATION
Shereen S. Lucman
Hamil Romulo P. Guerrero
1st year Surgery Resident
October 8, 2020
8AM
OBJECTIVES
GENERAL OBJECTIVE

To present a mortality case of S.N. 68 years old, female who

presented with Gastric Outlet Obstruction secondary to
Signet Ring Carcinoma Stage IIIA (cT3N0M0)
OBJECTIVES
SPECIFIC OBJECTIVES

To have a multi-disciplinary discussion of our post-operative

patient with COVID 19

To site journals regarding peri-operative management of

surgical patient with COVID 19
 IDENTIFYING DATA

• SN
• 68/F
• Filipino
• Maranao
• Islam
• Pagalamatan Gambai, Marawi City
• Admitted last August 3, 2020
INFORMANT
Patient
95% reliability

CHIEF COMPLAINT
Vomiting
 HISTORY OF PRESENT ILLNESS

3 months PTA 2 months PTA

Epigastric pain Epigastric pain
Early satiety Chest pain
Postprandial vomiting Dysuria
Vomiting

Consultation done
COMPLICATED
-Gaviscon
UTI; Type 2 DM
UTZ WA:
Normal-sized liver with fatty infiltrations
Small Hepatic Cysts
Atrophic uterus
Ultrasonically normal gallbladder, pancreas, spleen, kidneys and
urinary bladder
 HISTORY OF PRESENT ILLNESS

1 month PTA Amai Pakpak

Medical Center

Epigastric pain
Vomiting
 sds EGD WITH PUNCH BIOPSY
(07/23/20, APMC)

IMPRESSION:

Erosive Gastritis, L.A. Grade C;

Large gastric mass, antrum causing luminal obstruction most likely
malignant; S/P biopsy
 HISTORY OF PRESENT ILLNESS

4 days PTA Amai Pakpak

Medical Center

Bilous vomiting
Epigastric pain
Loss of appetite
Body weakness
PAST MEDICAL HISTORY
(+) Previous hospitalization
No history of surgical operation
No known allergies to food and drinks
(+) HPN
(-) DM
(-) Asthma
 
FAMILY HISTORY
No known heredofamilial diseases
 PERSONAL-SOCIAL HISTORY

• Patient is a housewife

• Non-smoker and non-alcoholic beverage drinker

• Denies illicit drug use

• Usual diet consist of rice, fish and vegetables

 
REVIEW OF SYSTEMS
GENERAL (-) fatigue, (-) weight loss

SKIN (-) itchiness, (-) rashes

(-) headache, (-) trauma;

(-) tearing, (-) sore eyes, (-) blurring vision, (-) eye
discharges
HEENT
(-) tinnitus, pain and aural discharges;
(-) nasal stuffiness, (-) nasal discharges;
(-) sore throat, (-) hoarseness
REVIEW OF
SYSTEMSRESPIRATORY (-) cough, (-) hemoptysis (-) DOB (-) orthopnea

CARDIOVASCULAR (-) palpitations (-) chest pain

GASTROINTESTINAL
(-) hematochezia, (-) melena, (-) diarrhea, (-)
constipation
GENITOURINARY
(-) oliguria, (-) dysuria, (-) hematuria, (-)
discharges
HEMATOLOGIC
(-) easy bruising, (-) bleeding, (-) past blood
transfusion
REVIEW OF
SYSTEMS
MUSCULOSKELETAL (-) joint/bone pain, (-) limited range of motion

NEUROLOGIC
(-) fainting spells, (-) seizures, (-) tremors, (-)
numbness
ENDOCRINOLOGIC
(-) growth disturbances, (-) heat or cold
intolerance
PSYCHIATRIC (-) anxiety, (-) behavioral changes, (-) irritable
PHYSICAL EXAMINATION
GENERAL SURVEY:
ambulatory, weak-looking, not in respiratory distress

VITAL SIGNS:

BP = 80/50 mmHg
Temp = 36.2 deg C
PR = 70 bpm
O2 sat = 98%
RR = 19 cpm
PHYSICAL EXAMINATION
ANTHROPOMETRIC MEASUREMENTS:

Weight = 50 kg
Height = 152 cm
BMI = 21.7 kg/m2

PERFORMANCE STATUS

ECOG - 1
KARNOFSKY - 90
PHYSICAL EXAMINATION
SKIN: dry, poor turgor

HEENT:
Head – normocephalic, (-) scalp lesions
Eyes – anicteric sclerae, pale palpebral
conjunctivae, no sunken eyeball
pupils equal and reactive to light and
accommodation
Ears – well-formed pinnae, (-) tenderness, (-)
discharges
Nose – (-) alar flaring, (-) discharges
PHYSICAL EXAMINATION
Mouth & throat – dry lips and oral mucosa

Neck: supple, trachea at midline, (-) lymphadenopathies

PHYSICAL EXAMINATION

Chest & Lungs:

symmetric, equal chest expansion, (-) retractions
equal tactile fremitus
resonant over both lung fields
clear breath sounds
PHYSICAL EXAMINATION

Heart:
PMI at the 5th ICS LMCL (-) heaves/thrills, CAD not enlarged,
regular rate and rhythm, (-) murmurs
PHYSICAL EXAMINATION

Abdomen:
INSPECTION: Flabby, (-) scars, (-) discolorations
AUSCULTATION: Normoactive bowel sound
PALPATION: Soft abdomen, (-) palpable ln on the
umbilical area, (+) tenderness on the upper quadrant
PERCUSSION: Tympanitic on all quadrants
PHYSICAL EXAMINATION

Extremities: strong and equal pulses, (-) edema

PHYSICAL EXAMINATION

DRE:
(-) external hemorrhoids/ skin tags
good sphincter tone
smooth rectal mucosa, (-) internal hemorrhoids
 SALIENT FEATURES
HISTORY
VIDEOGASTROSCOPY
• 68 years old (07/23/20, APMC ):

• Epigastric pain EROSIVE GASTRITIS, L.A. GRADE C;

LARGE GASTRIC MASS, ANTRUM CAUSING
• Early satiety LUMINAL OBSTRUCTION, MOST LIKELY
MALIGNANT;
• Postprandial vomiting S/P BIOPSY
 PRIMARY IMPRESSION

Gastric Outlet Obstruction secondary to Antral Mass

probably malignant
Stage IIIA (cT3N0M0);
S/P EGD and Biopsy (7/23/20, APMC)
 CONSIDERATIONS

Pyloric Cicatrization
 CONSIDERATIONS

Pancreatic head mass

 CONSIDERATIONS

Gallstone obstruction
DIAGNOSTICS
 HEMATOLOGY
  8/3/2020 Normal Values
ER
WBC 6.88 5.0-10.0x109/L
Neutrophils 66.00 50-70%
Lymphocytes 25.00 20-40%
Monocytes 9.00 0-5%
Eosinophils 0.01
Basophils
RBC 5.02 4.0-5.5x1012/L
Hemoglobin 14.70 14.0-18.0g/L
Hematocrit 0.43 0.35-0.45
Platelet 203 140-340x109/L
MCV   80-96 ft
MCH 27-31 pg
MCHC 33-36 g/dl
Bleeding time 01’48” 1-6 mins
Clotting time 03’44” 2-6 mins
 CHEMISTRY
  8/3/20 8/4/20 8/6/20 8/10/20 8/11/20 8/13/20 8/14/20 Normal Values
ER
FBS           130.00   70-105 mg/dl
BUN 15.00         22.00   7.94-20.1 mg/dl
Creatinine 1.04     0.60   0.60 0.70 0.40-1.40 mg/dl
Uric acid 6.90             2.7-7.7 mg/dl
Cholesterol           182.00    
Triglycerides           256.00    
HDL-CHOL           26.00    
LDL-CHOL           104.80    
SGPT 31.00         16.00   up to 32 U/L
SGOT 24.00 20.00 up to 31 U/L
Sodium 138     140.00 140.003. 142.00 140 135-155 mmol/dL
Potassium 3.00 3.20 2.87 50 2.90 3.80 3.5-5.3 mmol/dL
Magnesium 0.70-1.0 mmol/dL

HBsAg                
Total Bilirubin               0-1.5 mg/dl
B1 (Indirect) 0-1.0 mg/dl
B2 (Direct) 0-0.5 mg/dl

Total protein   5.20           6.6-8.7

Albumin   3.50   4.00 4.00     3.3-5.1 g/dl
Globulin 1.70  
A/G Ratio   2.05:1           0.5:1 – 2.5:1
 URINALYSIS
  8/4/20 Normal
Values
Color Dark Yellow Yellow
Transparency Clear Clear
Reaction (pH) 7.0 5.5-6.5
Sp. Gravity 1.020 1.010-1.030
Sugar negative negative
Protein +1 negative

RBC 4-8 0-2/hpf

WBC 8-12 0-5/hpf
Epithelial Cells Few few
Bacteria Few few
 COAGULATION
PROTHROMBIN TIME
  PATIENT CONTROL Normal Values
RESULT 11 11.3 10 – 14 sec
% ACTIVITY 109 105.63 >70%
INR 0.93 0.82 <1.16
APTT
RESULT 28.8 30.1 24 – 39
 CHEST X-RAY

IMPRESSION:
Atheromatous aorta
Thoracic spondylosis
sds CT SCAN WA
(07/27/20, APMC)

IMPRESSION:

Gastric mass, Antrum, Likely Malignant;

Simple Hepatic cyst;
Bilateral Small Renal Cortical cysts;
Retroverted Atrophic uterus with Mockenberg
Calcifications;
Lumbosacral spondylosis
 FIRST VIDEOGASTROSCOPY PROCEDURE (July 23, 2020)

PROXIMAL ESOPHAGUS DISTAL ESOPHAGUS

 FIRST VIDEOGASTROSCOPY PROCEDURE (July 23, 2020)

BODY OF THE STOMACH FUNDUS AREA

 FIRST VIDEOGASTROSCOPY PROCEDURE (July 23, 2020)

ANTRUM – GASTRIC MASS CONSTRICTED PYLORUS

 FIRST VIDEOGASTROSCOPY PROCEDURE (July 23, 2020)

CONSTRICTED PYLORUS DUODENAL BULB

 sds EGD WITH PUNCH BIOPSY
(07/23/20, APMC)

IMPRESSION:

Erosive Gastritis, L.A. Grade C;

Large gastric mass, antrum causing luminal obstruction most likely
malignant; S/P biopsy
 SURGICAL PATHOLOGY REPORT
(8/6/2020)

Histopathological diagnosis:

Nonspecific Inflammation
SECOND VIDEOGASTROSCOPY PROCEDURE (August 7, 2020)

C-E JUNCTION BODY OF THE STOMACH

SECOND VIDEOGASTROSCOPY PROCEDURE (August 7, 2020)

ANTRAL MASS ANTRAL MASS

SECOND VIDEOGASTROSCOPY PROCEDURE (August 7, 2020)

ANTRAL MASS ANTRAL MASS

SECOND VIDEOGASTROSCOPY PROCEDURE (August 7, 2020)

ANTRAL MASS OBSTRUCTED PYLORUS

 sds EGD WITH PUNCH BIOPSY
(08/06/20, APMC)

IMPRESSION:

Erosive Gastritis, L.A. Grade C;

Large gastric mass, antrum causing luminal obstruction most likely
malignant; S/P biopsy
 SURGICAL PATHOLOGY REPORT

Histopathological diagnosis: Gastric Mass (Antrum), Punch Biopsy

A.) CHRONIC GASTRITIS

POSITIVE FOR HELICOBACTER PYLORI, MILD

B.) SIGNET RING CELL CARCINOMA, GRADE 3

RT PCR

POSITIVE
 PRE-OPERATIVE DIAGNOSIS

GASTRIC OUTLET OBSTRUCTION SECONDARY

TO SIGNET RING CARCINOMA,
STAGE IIIA (T3N0M0);
S/P EGD AND BIOPSY (8/7/20, APMC);
S/P EGD AND BIOPSY (7/23/20, APMC);
COVID 19, CONFIRMED
 PRE-OPERATIVE PLAN

Exploratory Laparotomy (Distal gastrectomy

vs Tube jejunostomy)
CONDUCT OF SURGERY
 Procedure done

Exploratory Laparotomy
Distal Gastrectomy with Roux –en Y Reconstruction and D1 Resection

Operative Time: 3hrs 14 mins

Blood Loss: ~350cc
Abdominal Incision
Exploration
Mobilization of the distal stomach  
Mobilization of the distal stomach
Mobilization of the distal stomach
Mobilization of Antropyloric area
Distal Gastric Resection
Distal Gastric Resection
Distal Gastric Resection
Distal Gastric Resection
Reconstructio
n- Roux-en Y
D0 Resection -Lymphadectomy
 POST-OP DIAGNOSIS
Gastric Outlet Obstruction secondary to Signet Ring
Carcinoma, Stage IIIA (T3N0M0);
S/P Exploratory Laparotomy Distal Gastrectomy with
Roux –en Y Reconstruction and D1 Resection
(8/14/20, APMC);
S/P EGD and Biopsy (8/7/20, APMC);
S/P EGD and Biopsy (7/23/20, APMC);
Covid 19, confirmed
HOSPITAL DAY 12
POST-OP DAY 1
•S
(+) febrile episode (T max 38.8 C), (-) dyspnea, (-) BM, (-) Flatus

•O
Awake, coherent, not in respiratory distress
BP- 90/70
HR- 83
RR- 20
T- 36.1
UO- 0.3 cc/kg/hr
HOSPITAL DAY 12
POST-OP DAY 1
•A
Gastric outlet obstruction secondary to signet ring carcinoma,
Stage IIIA (T3N0M0); S/P Exploratory Laparotomy Distal Gastrectomy with Roux –en Y Reconstruction and D1
Resection; S/P EGD and Biopsy (8/7/20, APMC); S/P EGD and Biopsy (7/23/20, APMC); Covid 19, confirmed

•P
Keep on NPO
Continue IVF and medications
Repeat CBC, Serum Na K Crea
Continue TPN
Monitor NGT output and record without fail
Daily wound care
HOSPITAL DAY 13
POST-OP DAY 2
•S
(+) febrile episodes(T max 39.2 C), (-) dyspnea, (-) BM, (-) Flatus

•O
BP-110/70
HR-110s
RR-25
T-38.1
UO- 0.2 cc/kg/hr
•A
GASTRIC OUTLET OBSTRUCTION SECONDARY TO SIGNET RING CARCINOMA,
Stage IIIA (T3N0M0); S/P Exploratory Laparotomy Distal Gastrectomy with Roux –en Y
Reconstruction and D1 Resection; S/P EGD and Biopsy (8/7/20, APMC); S/P EGD and Biopsy
(7/23/20, APMC); Covid 19, confirmed
•P
Keep on NPO with NGT open to drain
Continue TPN
Change dressing done
For repeat chest Xray
HOSPITAL DAY 14
POST-OP DAY 3
•S 8/15/2020 Normal Values
(+) febrile episodes(T max 38.7 C), WBC 12.16 5.0-10.0x109/L
Neutrophils 93.00 50-70%
(+) episodes of dyspnea, (-) BM, (-) Lymphocytes 5.00 20-40%
Flatus Monocytes
Eosinophils
2.00
 
0-5%
0.01
Basophils

RBC 3.90 4.0-5.5x1012/L

•O Hemoglobin 11.70 14.0-18.0g/L
BP- 90/60 Hematocrit 0.34 0.35-0.45
Platelet 174 140-340x109/L
HR- 120s
RR-34
T-38.7 C
IMPRESSION:
Pneumonia, right paracardiac
Atherosclerotic aorta
•A
GASTRIC OUTLET OBSTRUCTION SECONDARY TO SIGNET RING CARCINOMA,
Stage IIIA (T3N0M0); S/P Exploratory Laparotomy Distal Gastrectomy with Roux –en Y
Reconstruction and D1 Resection; S/P EGD and Biopsy (8/7/20, APMC); S/P EGD and Biopsy
(7/23/20, APMC); Covid 19, confirmed; T/C Pneumonia

•P
Maximize medical management
• Patient was deteriorating at 7: 20 PM.
• (+) Febrile episodes, (+) Episodes of hypotension, (+) Dyspnea, (+)
Abdominal pain, (+) Changes in sensorium

• For intubation, but refused. Patient was prognosticated and family opted
DNR/DNI

• Patient expired at 12:40 am (8/18/2020)

Cardiac arrest secondary to multi-organ failure secondary to
SARS COV-2 infection; Gastric Outlet Obstruction
secondary to Signet Ring Carcinoma, Stage IIIA
(cT3N0M0); S/P Exploratory Laparotomy Distal
Gastrectomy with Roux –en Y Reconstruction and D1
Resection;
S/P EGD and Biopsy (8/7/20, APMC);
S/P EGD and Biopsy (7/23/20, APMC)
 FINAL SURGICAL PATHOLOGY REPORT

Antrum, stomach; Subtotal gastrectomy with antrum with Billroth II

Signet ring cell carcinoma, Diffuse type.
Positive invasion to serosa (visceral peritoneum)
Positive perineural and perivascular invasion.
Positive for metastasis. 2 of 7 peri-gastric lymph nodes
Negative for tumor : Resection margin
 FINAL DIAGNOSIS

GASTRIC OUTLET OBSTRUCTION SECONDARY TO SIGNET

RING CARCINOMA, STAGE IV (PT4N1M0);
S/P EXPLORATORY LAPAROTOMY DISTAL GASTRECTOMY
WITH ROUX –EN Y RECONSTRUCTION AND D1 RESECTION
(8/14/20, APMC)
S/P EGD AND BIOPSY (8/7/20, APMC);
S/P EGD AND BIOPSY (7/23/20, APMC);
COVID 19, CONFIRMED
JOURNALS
 Title

Mortality and pulmonary complications in patients

undergoing surgery with perioperative SARS-CoV-2
infection: An international cohort study
Dmitri Nepogodiev*, James C Glasbey*, Elizabeth Li*, Omar M Omar*, Joana FF
Simoes*, Tom EF Abbott, Osaid Alser, Alexis P Arnaud, Brittany K Bankhead-Kendall, Kerry A Breen,
Miguel F Cunha, Giana H Davidson, Salomone Di Saverio, Gaetano Gallo, Ewen A Griffiths, Rohan R
Gujjuri, Peter J Hutchinson, Haytham MA Kaafarani, Hans Lederhuber, Markus W Löffler, Hassan N
Mashbari, Ana Minaya-Bravo, Dion G Morton, David Moszkowicz, Francesco Pata, George Tsoulfas,
Mary L Venn, Aneel Bhangu
 Population
• All patients undergoing surgery who had SARS-CoV-2 infection
diagnosed within 7 days before or 30 days after surgery

• Patients undergoing surgery for any indication (including benign

disease, cancer, trauma, and obstetrics)
 Intervention

• International, multicentre, observational cohort study in patients

with SARS-CoV-2 infection who had surgery at 235 hospitals in
24 countries. Each participating hospital included all patients
undergoing surgery who had SARS-CoV-2 infection diagnosed
within 7 days before or 30 days after surgery

• This analysis includes 1128 patients who had surgery between

Jan 1 and March 31, 2020.
 Outcome

This study identified that postoperative pulmonary complications occur in half

of patients with perioperative SARS-CoV-2 infection and are associated with
high mortality. This has direct implications for clinical practice around the world.
The increased risks associated with SARS-CoV-2 infection should be balanced
against the risks of delaying surgery in individual patients; this study identified
men, people aged 70 years or older, those with comorbidities (ASA grades 3–5),
those having cancer surgery, and those needing emergency or major surgery as
being most vulnerable to adverse outcomes.
 Title

Factors Associated With Surgical Mortality and

Complications Among Patients With and Without
Coronavirus Disease 2019 (COVID-19) in Italy

Francesco Doglietto, MD, PhD; Marika Vezzoli, PhD; Federico Gheza, MD; Gian Luca Lussardi, MD; Marco Domenicucci, MD; Luca
Vecchiarelli, MD; Luca Zanin, MD; Giorgio Saraceno, MD; Liana Signorini, MD; Pier Paolo Panciani, MD, PhD; Francesco Castelli,
MD; Roberto Maroldi, MD; Francesco Antonio Rasulo, MD; Mauro Roberto Benvenuti, MD; Nazario Portolani, MD; Stefano
Bonardelli, MD; Giuseppe Milano, MD; Alessandro Casiraghi, MD; Stefano Calza, PhD; Marco Maria Fontanella, MD
 Population

Enrolled in the study – 123

With Covid 19 - 41
Without Covid 19 - 82

Doglietto, F., Vezzoli, M., Gheza, F., Lussardi, G. L., Domenicucci, M., Vecchiarelli, L., … Fontanella, M. M. (2020). Factors Associated With
Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy. JAMA
Surgery. doi:10.1001/jamasurg.2020.2713 
 Intervention
• This matched cohort study conducted in the general, vascular and thoracic
surgery, orthopedic, and neurosurgery units of Spedali Civili Hospital (Brescia,
Italy)

• Study period February 23 to April 1, 2020

• Positive test results for COVID-19 either before or within 1 week after surgery.

• Patients with COVID-19 were matched with patients without COVID-19

Doglietto, F., Vezzoli, M., Gheza, F., Lussardi, G. L., Domenicucci, M., Vecchiarelli, L., … Fontanella, M. M. (2020). Factors Associated With
Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy. JAMA
Surgery. doi:10.1001/jamasurg.2020.2713 
 Outcome

“Thismatched cohort study documents that surgical mortality and

complications are significantly higher in patients with COVID-19.
Pulmonary and thrombotic complications are significantly associated
with it. Different models (CLM and classification tree) associated
COVID-19 with complications, demonstrating that it is the primary
factor to be considered in surgical decision-making.”

Doglietto, F., Vezzoli, M., Gheza, F., Lussardi, G. L., Domenicucci, M., Vecchiarelli, L., … Fontanella, M. M. (2020). Factors Associated
With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy. JAMA
Surgery. doi:10.1001/jamasurg.2020.2713 
 SAGES RECOMMENDATIONS REGARDING
SURGICAL MANAGEMENT OF GASTRIC
CANCER PATIENTS DURING THE RESPONSE
TO THE COVID-19 CRISIS
 Management strategies for patients with
gastric cancers during COVID-19 pandemic:

• For patients presenting with new gastric cancers at this time, we

propose specific recommendations and guidelines to consider when
deciding whether to proceed or delay an operation for these patients.
In the following case scenarios, we are adhering to the 3 month-
rule (is the cancer likely to progress in the next three months without
treatment?)
• Stage of gastric cancer – For the specific stages below, surgeons need to
consider the hospital COVID-19 phase response (above ). For Phase I,
consider non-surgical alternatives, however, surgery may be acceptable. For
COVID-19 Phase II – III, surgery would be delayed until the pandemic abates
and resources return.
• For patients with stage-specific gastric cancer
1. T1a cancers – these patients may be candidates for EMR or ESD and referring
them for a same-day procedure. These may be considered in Phase I depending
on hospital resources. If not, then weekly “check-ins” to reassess the stage are
reasonable to find the best “window”. In Phase II – III, these should be deferred.
Also note, there are concerns for aerosolization with endoscopic procedures
(EMR/ESD) and thus we recommend delaying these procedures and ensuring
patient is COVID-19 negative

2. T1b and T2 cancers – these patients need surgery, however, a 4 – 6 week window
to time the operation when hospital resources are optimal (relatively-speaking) is
reasonable. Minimally invasive options are preferable as they will likely decrease the
length of stay in the hospital.
3. 3 or higher cancers, or those who are clinically node positive – these are patients
in whom neoadjuvant chemotherapy is recommended, allowing physicians a 3-4
month window to plan surgery (likely after the crisis phase has passed). Staging
Diagnostic Laparoscopy – although patients with this stage of gastric cancer
typically have staging with diagnostic laparoscopy prior to initiation of
chemotherapy to rule out occult metastatic disease, if hospital resources and space
is critical at the time and the patient is at higher risk due to age or comorbidities,
then consideration for proceeding straight to chemotherapy is reasonable. Plan for
diagnostic laparoscopy after chemotherapy is completed and prior to operation.

4. Obstructing and Bleeding Gastric Cancers – for gastroesophageal junction

cancers, immediate initiation of chemotherapy and radiation therapy may obviate
the need for a stent for gastric outlet obstructions. If the obstruction is complete
and the patient requires admission to a hospital, then proceed with gastrectomy.
However, for near-complete obstructions, chemotherapy may improve the ability to
eat within 2-3 days. Avoid stents as they make as they could make subsequent
procedures more challenging.
5. For a bleeding lesion, non-surgical approaches (IR and or endoscoy)
should be attempted first. When not able to control otherwise, a
surgical resection may be indicated

6. Patients who have completed Neoadjuvant treatment and are

Waiting for Surgery – these patients are difficult to manage, although
from last chemotherapy to operation there is a window of 3-6 weeks
during which surgery can be planned without losing the opportunity for
potential cure. For some patients, consider speaking with the medical
oncologist about adding an additional 1-2 cycles of chemotherapy to
bridge the patient through the worst of the pandemic crisis and plan
surgery thereafter.
Thank
You!