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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 341-342

Perspectives on neurosurgical management of brain tumors during the COVID-19 outbreak


Department of Surgical Oncology, Tata Memorial Centre; Neurosurgery Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Insttitute, Mumbai, Maharashtra, India

Date of Submission05-May-2020
Date of Decision06-May-2020
Date of Acceptance06-May-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Aliasgar V Moiyadi
Neurosurgery Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_171_20

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How to cite this article:
Shetty PM, Singh V, Moiyadi AV. Perspectives on neurosurgical management of brain tumors during the COVID-19 outbreak. Cancer Res Stat Treat 2020;3:341-2

How to cite this URL:
Shetty PM, Singh V, Moiyadi AV. Perspectives on neurosurgical management of brain tumors during the COVID-19 outbreak. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 5];3:341-2. Available from: http://www.crstonline.com/text.asp?2020/3/2/341/287219



Jalali et al. provide a much-needed and timely summary of practice suggestions in the COVID “era.” As we write this, India has progressed into the community transmission phase of the pandemic, with the current number of COVID-19-positive cases being more than 40,000. The key metro cities have been adversely affected, directly and indirectly impacting the care of many patients with brain tumors. The article covers most aspects of management of patients with brain tumors, especially with adjuvant therapy.[1] Therefore, we would like to highlight some issues pertaining to the surgical management of brain tumors in the current context. Surgery for brain tumors is complex, to say the least, and the current circumstances make it no easier.

Department-specific policies (in line with hospital infection committee guidelines and institute protocols) should be put in place. COVID-19-specific operating room protocols and practices have been suggested and will have to be adopted, as COVID-19 cases are expected to continue for a long time. As pointed out, non-essential surgeries should be deferred during the acute phase of the pandemic. Triaging surgeries is essential, and risk stratification into acute (surgery within 24 h), subacute (surgery in 7–10 days), and chronic (elective cases requiring treatment within a month) cases is an important component of decision-making.[2],[3] In our clinical practice, we have scaled down our surgical list to 20% of our routine workload based on this triaging. Contrary to what the authors state, very few day surgeries can be performed. In fact, the cases that warrant urgent neurosurgical intervention often require postoperative intensive care, especially in the face of unforeseen postoperative complications, which are not uncommon. We had two patients (out of 12) who developed postoperative hematomas, which resulted in prolonged intensive care unit stays. Patients also need to be counseled regarding the higher postoperative morbidity which has been reported.[4],[5] Ironically, the most eminently treatable tumors are the benign/lower grade tumors, and hence, the risk stratification should be pragmatic rather than dogmatic. Thorough preoperative COVID-19 screening (clinical and reverse transcription-polymerase chain reaction based, as at our center) is recommended unless there is an acute emergency, in which case the surgery will have to proceed as per the “COVID-suspect” protocol (with bare minimum staff, full Grade 3 personal protective equipment [PPE], preferably in a negative pressure operating room [OR], and a senior faculty at the helm). Even for COVID-19-negative cases, a strict OR protocol with basic PPE should be followed, especially for specific phases of the surgery that are high risk (such as aerosol-generating steps during the use of high-powered drills or ultrasonic aspirators, which are best avoided). Endoscopic procedures are not advisable, and alternative approaches or modalities should be considered. If a patient tests positive for COVID-19, surgery should be postponed (if possible) till the patient becomes negative.[3],[6] Safety of the surgical team is very important, and smart deployment of staff should be done to this end. Moreover, it is essential to ensure adequate strength of staff to maintain services at any given point of time (shift rotation is recommended). Our strategy has been to assign divided surgical teams(consultant, fellow, and resident), strict risk stratification for surgical cases, institute-mandated preoperative screening policy, and meticulous protocol of OR safety, an approach that has stood us well. Strong institutional support and robust policies are crucial.[7] This can also provide an opportunity to put in place appropriate long-term institutional protocols. It is important to stress the need for team morale building, especially for the paramedical staff. Finally, as we face a rapidly evolving disease landscape, it is imperative that we remain flexible in our approach, avoid dogmas, and revisit guidelines periodically as more evidence accumulates, thereby balancing the need for treating patients in a timely manner and protecting the workforce at the same time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jalali R, Goda JS, Patil V. Coronavirus disease 2019 pandemic and its implications on triaging patients with brain tumors for surgery, radiotherapy, and chemotherapy. CRST 2020;3 Suppl S1:49-53.  Back to cited text no. 1
    
2.
Prem A, Patel S, Pai E, Pandey D. Surgical management of cancer during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:119-22.  Back to cited text no. 2
    
3.
Gupta P, Muthukumar N, Rajshekhar V, Tripathi M, Thomas S, Gupta SK, et al. Neurosurgery and neurology practices during the novel COVID-19 pandemic: A consensus statement from India. Neurol India. 2020;68:246-254. doi: 10.4103/0028-3886.283130. PMID: 32414996.  Back to cited text no. 3
    
4.
Bansal N, Ghafur A. COVID-19 in oncology settings. Cancer Res Stat Treat 2020;3 Suppl S1:13-4.  Back to cited text no. 4
    
5.
Wong J, Goh YQ, Tan Z, Lie SA, Tay YC, Ng SY, et al. Preparing for a COVID-19 response: A review of operating room outbreak response measure in a large tertiary hospital in Singapore. Can J Anaesth. 2020;67:732-45. doi:10.1007/s12630-020-01620-9.  Back to cited text no. 5
    
6.
Patel ZM, Fernandez-Miranda J, Hwang PH, Nayak JV, Dodd R, Sajjadi H, et al. Precautions for endoscopic transnasal skull base surgery during the covid-19 pandemic. Neurosurgery 2020. pii: Nyaa125.  Back to cited text no. 6
    
7.
Pramesh CS, Badwe RA. Cancer management in India DURING Covid-19. N Engl J Med 2020;382:e61. doi:10.1056/NEJMc2011595.  Back to cited text no. 7
    




 

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