American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

COVID-19 Guidelines for Triage of Colorectal Cancer Patients

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Phase I. Semi-Urgent Setting (Preparation Phase)

Few COVID-19 patients, hospital resources not exhausted, institution still has ICU ventilator capacity and COVID-19 trajectory not in rapid escalation phase.

Cases that need 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

Alternative treatment approaches to delay surgery that can be considered:

  • Locally advanced resectable colon cancer
    • Neoadjuvant chemotherapy for 2-3 months followed by surgery
  • Rectal cancer cases with clear and early evidence of downstaging from neoadjuvant chemoradiation
    • Where additional wait time is safe
    • Where additional chemotherapy can be administered
  • Locally advanced rectal cancers or recurrent rectal cancers requiring exenterative surgery
    • Where additional chemotherapy can be administered
  • Oligometastatic disease where effective systemic therapy is available 

Phase II. Urgent Setting

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 typically 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 hospital with capacity
  • Diverting stomas
  • Chemotherapy
  • Radiation

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