Good reminder from the start from @RCSEd and @PRCSEd on safety and testing.
If exposed as a healthcare worker, get tested! Protect self & protect patients va nosocomial infection. https://twitter.com/rcsed/status/1252205729693433856

2/n.
Huge reduction in cancer activity at present. Many choosing to monitor rather than operate.
- Free up ITU capacity
- Prioritise resource allocation
- Risk vs benefit

3/n
Oesophageal Ca:
- ? resect/delay & survey/convert to curative chemo-rad/prolong neoadjuvant chemo-rad?
- Consider vulnerability index
- Prioritisation panel- pt factors, cancer factors, alternative tx, risks form COVID, surgical factors, institutional factors & ethics input

Issues:
- PPE & testing for staff
- Networks & friends in other trusts
- Pt engagement & consent re: risks
- COVID-free cancer hubs

5/n
HPB:
- Some CA have alternative tx, others don't
- Different risks of delay in different malignancies
- Risk of pt contracting COVID

6/n.
Edinburgh HPB cancer surgery pathway: ( @ProfW_edinsurg)
- Pt isolate for 14 days
- Swab 1-2 days preop
- CT chest reported on day of surgery
- Surgery
- Minimise post-op ITU
- ERAS
- Post-discharge isolate at home for 14 days
- Phone follow up

7/n.
Colorectal Ca:
- Varying practice across UK so room for adaptation to different pathways in COVID-era
- 20% still present as emergency & need temporaising procedure (surgery/stent)
- Chemotherapy in context of COVID increases risk of mortality by 1-2 decades

8/n.
- Increased uptake of radiotherapy for rectal cancer
- Rationalise use of resources in diagnostics e.g. endoscopy
- Preliminary results of @CovidSurg suggest 66% elective pts developed COVID & of these approx 24% mortality

9/n.
Conflicting guidance re: isolation- 7 days vs 14 days?
- lacking evidence for either
- best adopt safest approach for staff & pts
- Regional advice varies and need to discuss & disseminate to share & reach consensus
- Important shared decision-making as part of consent

10/n
Lap colorectal Ca surgery:
- AGP risk? Consider potential harm to surgeon/theatre staff
- Emergency gen surg 3 risks- aerosol/blood/faecal transmission
- Adopt safest approach until evidence builds: @CovidSurg will help in this
- Can minimise risk of aerosol from lap surgery

11/n.
Lap surgery (cont.)
- risk may differ due to different risks from different procedures (e.g. upper vs lower GI)
- risk may differ by prevalence of COVID in geographical region....regional cancer hubs?

12/n.
Surgical pts often immunocompromised at baseline so increased risk of COVID
- 20-25% catch COVID postop from (limited) evidence exists available
- Developing COVID increases morbidity & mortality
- Consider time spent in high-risk setting e.g. theatre, ITU, hospital ward

13/n.
Staff eatiquette:
- More staff in theatre→ increased risk to staff→ increased likelihood of need for test, self isolation +/- being unwell
- Social distancing in hospitals can be improved to minimise cross-contamination. e.g. offices, team brief, ward, rest-places

14/n.
Pt consent must be rigorous if choosing to undertake elective surgery in midst of pandemic
- Advise safest practice: self isolation, swab, chest imaging
- Risks: acquisition, morbidity, mortality, post-op care, discharge implications

15/n.
Uncertainties raised so far in this @RCSEd Webinar are abounding:
- How long to self-isolate pre-op
- Is lap surgery safe?
- Is diathermy safe?
- Can we reuse PPE?
- Are primary anastomoses safe- risk of leak, ITU, return to theatre, recovery?

Why? We need more evidence!

16/n.
If operating in full PPE:
- Share operative load eg. 2 consultants operating for time efficiency
- Low threshold to unscrub & have break if needs be

17/17. Thank you @ProfW_edinsurg, @maynard_nick, @cam_colorectal & @PRCSEd for a fantastic @RCSEd webinar & stimulating much discussion. Diversity in Q&As and prioritisation of staff safety.