Surgery for pancreatic tumors in the midst of COVID-19 pandemic

Table 1 COVID-19 phases in hospital or healthcare systems

Phase 0: No COVID-19 patients, hospital works as normal

Phase 1: Semi-Urgent Setting. Few COVID-19 patients, hospital resources not exhausted, institution has still enough ICU ventilator capacity and COVID case trajectory not in the rapid escalation phase

Phase 2: Urgent Setting. Many COVID-19 Patients, ICU beds and ventilator capacity limited, OR supplies limited or COVID case trajectory within the hospital in rapidly escalating phase

Phase 3: Emergent setting. All hospital resources devoted to COVID-19 patients, no ventilator, ICU beds, OR supplies exhausted

ICU: Intensive care unit; OR: Operation room.

Table 2 Modified elective surgery acuity scale for pancreatic tumor in hospital with low/no COVID-19 census

Tiers/Description	Description	Location	Examples of primary diseases	Action
Tier 1A	Low acuity surgery/healthy patient; Not life-threatening illness	Hospital with low/no COVID-19 census	BD-IPMN without worrisome feature, SCN < 40 mm, other asymptomatic benign pancreatic tumors	Postpone surgery
Tier 1B	Low acuity surgery/unhealthy patient	Hospital with low/no COVID-19 census		Postpone surgery
Tier 2A	Intermediate acuity surgery/healthy patient; Not life-threatening but potential for future morbidity and mortality; May require in-hospital stay	Hospital with low/no COVID-19 census	BD-IPMN with worrisome features, SCN > 40 mm, Asymptomatic PNET < 20 mm, Asymptomatic small SPN (< 20 mm), Mucinous cyst neoplasm	Phase 1: Postpone surgery if possible and active surveillance; Phase 0: Perform surgery under the maximum preparation for infection control
Tier 2B	Intermediate acuity surgery/unhealthy patient	Hospital with low/no COVID-19 census		Phase 1: Postpone surgery if possible and active surveillance; Phase 0: Perform surgery under the maximum preparation for infection control
Tier 3A	High acuity surgery/healthy patient	Hospital with low/no COVID-19 census	PDAC, BD-IPMN with high risk stigmata, Symptomatic PNET, PNET > 20 mm, PNET with lymphadenopathy, symptomatic or large (> 20 mm) SPN	Perform surgery under the maximum infection control
Tier 3B	High acuity surgery/unhealthy patient	Hospital with low/no COVID-19 census		Perform under the maximum infection control

PDAC: Pancreatic ductal adenocarcinoma; IPMN: Intraductal papillary mucinous neoplasm; BD-IPMN: Branch duct type IPMN; SCN: Serous cyst neoplasm; PNET: Pancreatic neuroendocrine tumor; SCN: Solid pseudo papillary neoplasm.