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surgery during the Covid-19 epidemic.
J.-J Tuech, A. Gangloff, F. Fiore, P. Michel, C. Brigand, K. Slim, Marc Pocard, L. Schwarz
To cite this version:
J.-J Tuech, A. Gangloff, F. Fiore, P. Michel, C. Brigand, et al.. Strategy for the practice of digestive and oncological surgery during the Covid-19 epidemic.. Journal of Visceral Surgery, Elsevier, In press,
�10.1016/j.jviscsurg.2020.03.008�. �hal-02552052�
Availableonlineat
ScienceDirect
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ORIGINAL ARTICLE
Strategy for the practice of digestive and oncological surgery during the Covid-19 epidemic 夽,夽夽
J.-J. Tuech
a,b,∗, A. Gangloff
c, F. Di Fiore
b,c, P. Michel
b,c, C. Brigand
d, K. Slim
e, M. Pocard
f,g, L. Schwarz
a,baRouenUniversityHospital,DepartmentofDigestiveSurgery,1,ruedeGermont,76031 Rouencedex,France
bNormandieUniversity,UNIROUEN,UMR1245Inserm,RouenUniversityHospital,Department ofGenomicandPersonalizedMedicineinCancerandNeurologicalDisorders,76000Rouen, France
cRouenUniversityHospital,DepartmentofDigestiveOncology,1,ruedeGermont,76031 Rouencedex,France
dDepartmentofGeneralandDigestiveSurgery,HautepierreHospital,StrasbourgUniversity Hospital,67200Strasbourg,France
eDepartmentofdigestivesurgery,CHUClermont-Ferrand,63003Clermont-Ferrand,France
fUniversitédeParis,UMR1275CAPParis-Tech,75010Paris,France
gServicedechirurgiedigestiveetcancérologiqueHôpitalLariboisière,2,rueAmbroiseParé, 75010Paris,France
KEYWORDS Coronavirus;
Covid-19;
Surgical complications;
Digestivesurgery;
Cancer
Summary TheCovid-19pandemicischangingtheorganizationofhealthcareandhasadirect impactondigestivesurgery.Healthcareprioritiesandcircuitsarebeingmodified.Emergency surgeryisstillapriority.Functionalsurgeryistobedeferred.Laparoscopicsurgerymustfollow strictrulesso asnottoexposehealthcareprofessionals(HCPs) toaddedrisk.The question loomslargeincancersurgery—goaheadordefer?Thereisprobablyanaddedriskduetothe pandemicthatmustbebalancedagainsttheriskincurredbydeferringsurgery.Foreachtypeof cancer—colon,pancreas,oesogastric,hepatocellularcarcinoma—morbidityandmortalityrates arestatedandcompared withtheoncologicalriskincurredbydeferring surgeryand/orthe tumourdoublingtime.Strategiescanbeproposedbasedonthiscomparison.Forcoloniccancers T1-2, N0, it isadvisable to defersurgery.For advancedcoloniclesions, it seemsjudicious toundertakeneoadjuvantchemotherapyandthenwait. ForrectalcancersT3-4 and/orN+, chemoradiotherapyisindicated,shortradiotherapymustbediscussed(followedbyawaiting
夽 NB:FrenchspeakersareadvisedtousetheTNCDupdates.DiFioreF,SefriouiD,GangloffA,SchwarzL,TuechJJ,PhelipJM,LepageC, AparicioT,ManfrediS,ALievre,DahanL,GiraultC,BoucheO,MichelP.Propositionsalternativesdepriseenchargedescancersdigestifs enfonctiondelasituationépidémiqueauCOVID19,selonlesdonnéesdelalittératureetdel’expériencechinoise.
夽夽Theobjectifofthispaperistoallowthesurgeonstoadapttheirpracticesduringthefirstphaseoftheepidemicuntilthepeakis reached.Whenthepeakisoveroursystemswillhavetoadapt,butpatientmaganementwillhavetobecomeoptimalagain.
∗Correspondingauthorat:DepartmentofDigestiveSurgery,HôpitalCharlesNicolle,Rouen,France.
E-mailaddress:jean-jacques.tuech@chu-rouen.fr(J.-J.Tuech).
https://doi.org/10.1016/j.jviscsurg.2020.03.008
1878-7886/©2020ElsevierMassonSAS.Allrightsreserved.
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period)toreducetimeofexposureinthehospitalandtopreventinfections.Mostcomplex surgerywith highmorbidity andmortality—oesogastric, hepaticorpancreatic—ismostoften bestdeferred.
©2020ElsevierMassonSAS.Allrightsreserved.
Introduction
Wearetodayinanunprecedentedsituationthatisputting alltheworld’shealthcaresystemstothetest.On11March 2020theWorldHealthOrganization(WHO)declaredthatthe epidemicofCovid-19hadbecomeapandemic.Everywhere intheworld,publicauthoritiesarerecommendingstrength- enedpreventivehygienemeasuresthatcallonthepublic’s civicresponsibility.Epidemiologicalpeaksandtheserious- nessoftheacuterespiratorydistresssyndromesthreatento swampourresuscitation andintensive careprovision. Our governmentsaretakingnecessarymeasuresto‘flattenthe curve’andspreadoutovertimetheinfluxofcasesrequir- inghospitalization.Meanwhile,theyaretakingmeasuresto increaseourconventionalhospitalandintensivecarecapac- ities.
The FrenchHealth Minister Olivier Véran set in action an early plan at the national scale to ‘avert a strangle- hold’.On12Marchthegovernmentinstructed‘‘allhospitals to promptly de-schedule all non-urgent surgery requiring post-operative recovery and resuscitation or continuous monitoring, without adversely affecting patients’ life- chances.Specialattentionisrequiredforpatientsincarefor cancer.Thepurposeofthismeasureisbothtofreeupbeds inrecoveryandresuscitationwards,andtoavoidexposing patientsrecentlyoperatedontoaharmfulvirusinfection.’’
ArecentarticlepublishedbyourChinesecolleagues[1]
suggests that patients with cancer are more likely to be infected by the virus because of their immunodepressed stateinducedbytheircancer,theirchemotherapyandtheir surgery.Thearticlealsoemphasizesthatthesepatientsare at higherrisk of developingsevere episodes(39% vs.8%).
Patientswho have been operated onor whohave under- goneanticancerchemotherapyinthemonthprecedingthe appearanceofthevirushadahigherrisk(75%)ofdeveloping asevereepisodethanthosewhohadnotundergonesurgery orchemotherapy(43%).Thisstudyadmittedlyconcernsonly asmallnumberofpatients,anditsscientificsoundnesscan be easily criticized, but decisions will have to be made beforemorepowerfulscientificfindingsbecomeavailable.
Ourfocushereisonhowtheoncologicalimpactofdefer- ringsurgicalcarecanbebalancedagainsttheaddedmor- talityriskofasevererespiratoryinfectionwithCovid-19.
Ourintentionistopoolthinkingandproposestrategiesto beimplementedtohelpmanage,atourscale,theunprece- dented health crisis that is facing us today. The thinking includes not only patientcare but also the protection of healthcareprofessionals(HCPs)whose work entails added exposuretocontamination.
General strategy for visceral surgery during the Covid-19 epidemic
Digestive and parietal disorders are the reason for large numbersofsurgicaloperations,accountingfor12%ofsurgi- calhospitalizationsin2015.
TheCovid-19epidemicisstillinitsearlystagesinFrance, but the situation is already serious and has commanded mobilization at an unprecedented scale. The situation is straightforwardforemergencycases(infection,ischaemia, obstruction,trauma),whichmustbedealtwithpromptly.
Health disorders that cannot be deferred for longer than one month must also be dealt with, if possible, by laparoscopy to minimizepostoperative impactonrespira- tory function.Inallcases,patientsmustbeconsideredas possiblyinfected,andsocross-infectionmustbeprevented.
Itisrecommendednottocarryoutelectivesurgeryfor benign disorders, becausesuchsurgery can beperformed withoutjeopardizingtheresultoncetheepidemichassub- sided.Itisimportanttoinformpatientsandtheirfamilies of the medical reasons for deferring surgery, namely col- lective welfare (freeing both ordinary and recovery and resuscitation hospital beds, relieving the HCPs) and indi- vidual precaution (preventing a more serious respiratory infectionaftersurgery).Itisalsousefultoinformpatients that theinterventiontheyneed willprobablybe deferred untilwellaftertheepidemichasabated,becausetherewill bemanyotherpatientsawaitingtreatment,whosenumbers willdependonhowlongtheepidemiclasts.
A special case is that of patients who are or may be infected by Covid-19 andwhorequireemergency surgery.
Inthissituation,twofactorsaretobeconsidered:
• protectionofHCPs;
• minimization ofthe respiratoryimpactof the interven- tion.Ample communication must bethe rule, withthe operatingtheatreteam,anaesthetistsandotherrelated HCPs,andtheoperationmustbeperformedwithstringent protection.
Theoperatingtheatremustifpossiblebeundernegative pressure to prevent outward diffusion and contamination ofpersonnelandsurfaces outside.The choiceofapproach mustfirstbediscussedcasebycasewiththeanaesthetist:
laparoscopy istobepreferredifthecausalconditionper- mitsitandifthepatient’scardiorespiratorystatusisstable;
otherwise,laparotomyisindicated.
Precautionsconcerninglaparoscopy (appendectomy, exploratory,etc.)
Laparoscopyhasmanyadvantages,essentiallyitsfavourable impactonrespiratoryfunctionandlengthofhospitalstay.
However,cautionisrequiredwhenperforminglaparoscopy because of therisk of exposure and infectionof the per- sonnelpresent. The mainrisk arisesfromthepresence of pathogensintheperitonealcavity,whichisfavouredbydis- section.Theaerosolreleasedintotheroomduringsurgery (leaks) or after the operation (exsufflation),can contam- inate personnel and all the furniture and surfaces in the roomviaairborneparticles.Ifthelaparoscopicapproachis chosen,surgeonsmust:
• makesurealltheinstrumentsareinorderandtheaspi- rationsystemoperatescorrectly; thislastmust beused systematically,beforeincisionviaachecklist;
• makeappropriateopeningstointroducetrocarswithout leakageanduseballoontrocarsifavailable;
• notcreatealeakifsmokeishinderingsurgery,butinstead usetheaspiratortoremovethesmoke;
• aspirate the whole peritoneal cavity before making an auxiliaryincision and when the operation is completed beforethetrocarsareremoved.
Ifindoubtorifexperienceinlaparoscopyisscant,laparo- tomyistobepreferred.
Adaptation of the post-operative period
After every surgical intervention, the medical, paramedi- cal and cleaning personnel must take the most stringent protection measures in line with national and local recommendations (French nosocomial infection control committees,CLIN).Likeprecautionsmustbetakenforthe recoveryroomorpost-anaesthesiacareunit(PACU).
Post-operatively,patientswillbeadmittedtoahospital wardadaptedtotheirrespiratorycondition.Ilisadvisable forhospitalwardstobesectionedoffintoindividualrooms duringtheepidemictoforestallcross-infectionwithother patients or visiting relatives. Individual rooms would also facilitateisolationmanagementifthisprovednecessary.It is important to clearly inform patients and their families thatvisitsarenotallowed.Thisbanisdesignedtoprotect patients, visitors andhospital staff.When care times per patientarelongerthanusualowingtotheespeciallystrict precautionstakentopreventcross-infections,itisadvisable toput in placeelectronicmeans of communication (tele- phone, email, etc.) withfamily members so they can be informedoftheirrelative’sstateofheath.Theimpossibility forrelativestocomeandvisitpatientsinhospitalgenerates stressandanxiety.Inadditiontotakingphonenumbers,it wouldthereforebeusefultotakeemailaddressesoffamily contacts.
Adaptationoftheconsultationsystem
All non-essential consultations must be cancelled or deferred. They can best be replaced by distance consul- tations using telemedicine applicationsor the telephone.
Reducingthenumberofconsultationswillreducetheriskof cross-infection.
Ifaconsultationisessential,itmustbescheduled,and patientsaskedwhethertheyfeelanyrespiratorydiscomfort.
Patientsmustbetoldtocomealoneorwithonlyoneother persontoreducethenumbersofpossiblecontacts.
Consultations must be scheduled with long intervals between successive consultations to prevent crowding in waitingrooms.
Contactswithpatientsmustbelimited.Ifaclinicalexam- inationisessential,thenitmustbecarriedoutwithgloved hands. HCPs must change their gloves immediately after comingintocontactwithpatients, bodyfluidsor contam- inated materials. Quick-drying water-alcohol gel must be usedfor hands.The relevantnosocomial infectioncontrol committees (CLIN in France)guidelines for HCPs must be strictlyadheredto,includingschedulesforchangingmasks.
Consultingroomsmustberegularlyventilatedandaired.
Surfacesmustbedisinfectedbetweensuccessivepatients.
Strategy for oncological digestive surgery practice during the Covid-19 epidemic
TheCovid-19epidemicisdisruptingnotonlyourdailylives but also how we manage patients, especially those with cancer.Thisnewcoronavirusispassedonmainlyinbreath droplets,butpossiblyalsobycontactandoro-faecally.The infection has an incubation time of 1—14 days. Asymp- tomatic infected patients may be contagious during the incubationperiod,andnegativetestsdonotruleoutinfec- tion.Cancer patients arefragile, often malnourishedand withan immune system compromised by both the cancer anditstreatment.Thereseemstobeanincreaseincasesof severeARDSinsuchpatients.Inaddition,inthecurrentsit- uationitisjudicioustoconservemedicalresources,though withoutcompromisingpatientprognosis.
In non-urgent cases, non-surgical treatments are to be preferred. Surgery can be done once the epidemic is quelled.However,evenaftertheepidemicisover,thereturn tonormalwilltakeplaceonlygradually,becausetheHCPs, especially anaesthetists and resuscitation teams, will be exhaustedby severalweeksofunstintingeffortstobattle theinfection.Therewillalsobemorepatientsawaitingcare owingtothedeferralofsurgeryduringtheepidemic.
Hencewemustdrawupareasonablecarestrategythat takesintoaccountboth managementoftheepidemicand treatment of the cancer. Saving time, while curbing the spreadoftheillnessduringtheepidemicandhasteningthe returntonormalisthechallengeweallhavetomeet.
Careprovision must be adapted tothe regionalhealth situation, forecasted evolution of the epidemic, and the risk that ourhealthcare systemsmay beoverwhelmed. It isadvisabletoplanfortheriskofoverloadandbereadyto switchtoa degradedwork mode.Apatientneeding post- operative respiratory assistance after major surgery or a complicationmightnotreceiveitifoursystemsweresatu- rated.
Care for cancer patients has several common impera- tives:
• combatmalnutritionbyfavouringabalanceddiet,provid- ingnutritionalsupplementsorbyenteraltubefeeding;
• avoid serious adverse effects on the immune system causedbyaggressivetreatments;
• avoid hospitalizations, visits, and hospital stays that favourcontaminationbythevirus;
• prefer a therapeutic sequence that does not require strictlytimedsurgerythatmightnotbefeasible;
• discuss care provision in multidisciplinary meetings to draw up an individual care plan best adapted to the patientandtotheepidemicsetting.Thesemeetingsare totakeplacevirtually(virtualmultidisciplinaryconsulta- tionmeetings)orinsmallgroups(segmentationofteams) topreventthevirusspreadingthroughthevariousmedical staff;
• offer psychological assistance to patients who have to copewithmanagingcancerandmeasurestoshelterthem andothersfromtheepidemic.
OurChinese colleagues have published severalarticles suggestingchangestopracticeandadaptationofstrategies [2—5].
Specific features of care by cancer type
Twoquestionsareessentialinourthinkingoncarestrategy:
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• whatarethe knownoperatingrisksandthenew added risks of respiratory infection? The latest research find- ingsshowthatpatientswithtumoursaremoreproneto infectionbyCovid-19owingtotheirsystemicimmunodefi- cientstatuscausedbythedisease,oncologicaltreatment (radiotherapy,chemotherapy)andsurgery.Patientsoper- ated on or undergoing chemotherapy in the months preceding the infection hada seriousform of infection in 75% of cases, representing a relative risk calcu- latedbymultivariateanalysisof5.34(CI95%1.80—16.18, P=0.0026) [1]. In this light, exposure of patients to addedriskofpost-operativemorbidityandmortalitymust be considered and factored into thechoice of strategy made;
• what would bethe oncological impactof a long defer- ral (6—12 weeks)due tothe epidemic?Time-to-surgery is often considered a measure of care quality. How- ever,whenwaitingtimeismostoftenduetooverloaded operating schedules, it has been shown that this time lapse can also be gainfully used to select the ‘‘best candidates’’ for surgery (true resectables) and pre- parethemforintervention(prehabilitation,management of anaemia if needed, preoperative nutrition). In the current situation, and given the risks incurred, it is essential to consider the oncological impact of defer- ral imposed by the exceptional demands made oncare provision.
Thesequestionswillnowbedetailedbyorgan.
Specific features of care for colorectal cancers
Morbidityandmortality
Incolorectalsurgery,post-operativemortalityandmorbid- ity were estimated at respectively 3.4% and 35% in the French surgery association (AFC) trial [6]. This prospec- tivetrialincluded1421patients,andmortalityat3months was 6.3%. Four mortality risk factors, accessible before surgery, were isolated: the urgency of the surgery (rela- tiverisk4.42),neurologicalantecedents(relativerisk3.85), weightloss above10%ofinitialweight(relativerisk3.42) and age above 70 years (relative risk 2.16). This study showedthatthegreaterthenumberof mortalityrisk fac- tors,thehigherthemortalityrate.Forrectalsurgery,the mostfearedcomplicationisanastomoticfistula,withafre- quencyof15—26%(Greccar5)andanassociatedmortalityof 6—39%[7].
Oncologicalimpactof deferral
Thisimpacthasnotoftenbeenmeasuredincolonicsurgery.
Inadvancedformsofrectalcancer,aneoadjuvanttreatment isnecessary,withatimelapsebetweentheendofchemora- diotherapyandsurgeryof8weeks,extendableto12weeks withnoharmfulconsequences(Greccar6trial)[8].Henceis itnotthepatientsatthestartorinthemiddleoftreatment whowillbecausingusproblems,butthepatientswhohave finishedtheirtreatmentandwhosesurgeryhasalreadybeen scheduled.
Summary
• Forpre-cancerouslesionswithgoodprognosis(T1-2, N0),itis advisedtodefersurgeryaccordingtothe stageoftheepidemic.
• For advanced colonic lesions, it is judicious to recommend neoadjuvant chemotherapy and wait until the peak of the epidemic has passed before proposing radical surgery. These situations will have to be discussed case by case to take into consideration the oncological risk, the risk of evolution towards occlusion, and the risk of induced immunodepression, which could be extremelyharmful.
• For cancers T3-4 and/or N+, chemoradiotherapy is indicated, shortradiotherapy is to be discussed (followed by a waiting period) to reduce the exposure time in hospital and avoid infections.
Inductionchemotherapycanalsobediscussed case bycase.
• For cancers with obstruction, a stoma will be performed followed by chemotherapy. Special attention will be paid during stoma care (contaminatingact)topreventinfectionofHCPs.
• For cancers at end of treatment, where surgery must be scheduled, the strategy will be adapted tothedurationof theepidemic, itspeak,andthe availablemedicalresources.Insomecases,interim chemotherapycanbeproposed[9].
Specific features of care for pancreatic cancers
Morbidityandmortality
Despite cumulated surgical, anaesthesiological and resus- citationefforts, andperi-operativeoptimization measures (improved rehabilitation, prehabilitation), morbidity and mortality for cephalic duodenopancreatectomies remain high. The latest review of data fromthe French medical informationprogramme(PMSI)estimatedthemortalityrate at 8.2% [10]. Overall and severe complication rates were respectively75%and30%with,inorderoffrequency,spe- cific complications (pancreatic fistula, haemorrhage) and infectiouscomplications[11].
After left splenopancreatectomy, although mortality rateswerelower(3%),therateofseverecomplicationswas about25%.
Oncological impactofdeferral
TworetrospectivecohortstudiesofNorthAmericannational registerdata[12,13]evaluatedtheimpactofwaitingtime before pancreatectomyfor cancer. Mirkinet al. [12]sug- gested that long-term survival was unaffected by waiting time. In the study published by Swords et al. [13] time- to-surgerywasshort(1—14days)for4.4%,medium(15—42 days)for51.6%,andlong(43—120days)for14%ofpatients.
Mortalityrateswerelowerfor patientswithmediumwait- ing times (hazard ratio 0.94, CI95% 0.90—0.97) and long waitingtimes (hazardratio0.91,CI95%0.86—0.96).There
was no difference in rate of ganglion invasion, locore- gionalnon-resectability,discovery ofmetastaticextension on exploration, or positive margins. Mortality at 90 days was lower in the group with medium waiting time (odds ratio0.75,CI95%0.65—0.85)andinthegroupwiththelong waitingtime(oddsratio0.72,CI95%060—0.88).
Summary
Ifthereisnohistologicaldocumentation:
• Forperi-ampullarytumours,deferralofsurgerywill beproposedaccordingtotheoperativerisksasthe epidemicunfolds.
• Forcorporocaudallesions,accordingtopossibilities of access to surgery and how the epidemic is evolving,surgerycanbeproposedtopatientsatlow operativeriskbutmustotherwisebedeferred.
• If there is histological documentation pointing to pancreaticadenocarcinoma:
◦ Interim chemotherapy can be proposed for cephalic lesions. These situations will be discussedcasebycasetotakeintoconsideration the oncological risk and the risk of induced immunodepression, which could be extremely harmful (biliary drainage and malnutrition in particular).
◦ Forlesions requiring left splenopancreatectomy, surgery can be proposed in patients at low operative risk (comorbidities, nutritional state), but must otherwise be deferred, with possible interim chemotherapy. These situations will be discussedcasebycasetotakeintoconsideration the oncological risk and the risk of induced immunodepression, which could be extremely harmful.
Specific features of care for oesogastric cancers
Morbidityandmortality
Surgery of œsogastric cancers carries a high risk of complications. Rates of major complications after upper polaroesophagectomyarehigh,at36—64%intheMIROtrial, with rates of major respiratory complications of 18—30%
[14].Aftertotalgastrectomy,ratesofmajorcomplications arelower, butstill 10—15%,mostly respiratoryand septic complications[15,16].
Oncologicalimpact ofdeferral
Localizedœsogastriccancersgenerallyprogressquiteslowly (whatever thehistologicalsubtype).The average progres- sion time from localized tolocally evolved or metastatic is34—44months,basedonAsianliteraturedata.Thedou- blingtimeofalocallyadvancedgastriccanceris6.2months [17,18].TheepidemiologyofoesogastriccancersinFrance andinEuropearedifferent,sothatthesedataneedtobe analysedwithsomeclinicalcircumspection.Tumoursdiag- nosedatanearlystagemakeupfewerthan5%ofpatients operatedon,andforacanceroftheoesphagustobesymp- tomatic, 80% of the lumen must be functionally blocked.
Summary
• In the light of these considerations and current strategies for pre-operative treatments (neoadjuvant chemotherapy (FLOT regimen in particular), neoadjuvant chemoradiotherapy) except for superficial forms, gastrectomies and oesophagectomiesmustbedeferred,withdiscussion ofhowtopursuepre-operativetreatmentifitends during the epidemic (maintenance chemotherapy according to modes discussed in multidisciplinary concertation meetings and adapted case by case, taking into account the non-negligible risk of chemo-inducedimmunosuppression).
• Forcancersrequiringpartialgastrectomy,giventhe lowerriskofcomplications,surgerycanbeproposed topatientsatlowoperativerisk,butmustotherwise bedeferred.
Specific features of care for liver tumours
MorbidityandmortalityThe risks of post-operative complications must be esti- matedaccordingtothestatusoftheunderlyinglivertissue (cirrhosis, steatosis) and the surgical act planned (minor ormajorhepatectomy,liversegments/sectorsconcerned).
Overallcomplicationratesare15%and45%afterminorand majorhepatectomyrespectively,and4%and20%forsevere complications[19].Oncirrhoticlivers,thelatestretrospec- tive AFC study recorded overall and severe complication ratesof44%and11%respectively[20].
Oncologicalimpactofdeferral
For hepatocellular carcinoma, the risk of tumour growth leadingtonon-resectabilityislowandisnotlife-threatening intheshortterm.Anetal.retrospectivelyanalysedthedata of175patientswithhepatocellularcarcinomawithouttreat- ment.Themedian tumourvolumedoubling timewas85.7 dayswithanupperextremumof851.2days[21].Fewsimi- lardataareavailableforintrahepaticcholangiocarcinoma.
Summary
Given the low risk of tumour growth over the durationoftheepidemic,surgerymustbedeferredfor patientswithearlylivertumours.
• In the case of alesion amenable tominorhepatic exeresis,accordingtothepossibilitiesofaccessto surgeryandhowtheepidemic unfolds,surgerycan be proposed to patients at low operative risk but mustotherwisebedeferred.
• In the case of a lesion requiring major hepatic exeresis, surgery must be deferred, with possible preparationbyportalembolizationifnecessary,and nutritional preparation. Special attention will be paidtohilarcholangiocarcinoma,asregardsseptic andnutritionalrisk.
• Patientswhoarecandidatesfortumourdestruction bythermalablationcanbetreatedaccordingtothe possibilitiesof accesstosurgeryandinterventional radiologyfacilitiesandhowtheepidemicunfolds.
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Disclosure of interest
Theauthorsdeclarethattheyhavenocompetinginterest.
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