Perioperative considerations
The data presented above reflect changing surgical practice in the early
days of the COVID-19 pandemic. The issues surrounding the
decision-making process and surgery itself in Head and Neck cancer
patients are discussed below:
Pre-operative considerations
Starting with a reduction in outpatient clinic visits, all routine
follow-up appointments (in asymptomatic patients who have recovered from
cancer treatment) have been postponed until May 2020 or later.
Additionally, all new patient visits are screened to determine urgency.
Along with the institutional and regional policies listed in Table 1,
these measures drastically reduced the number of patients seen at
outpatient clinics. Greater effort has been made to bundle patients’
multidisciplinary appointments on the same day, to reduce the frequency
of outpatient visits.
The weekly multidisciplinary treatment planning conference plays a
crucial role in achieving consensus recommendations for oncologic
therapy13. In compliance with social distancing and
stay home orders, teleconference facilitates discussion on the optimal
treatment for each individual patient in the context of the pandemic.
Additionally, a discussion should be held with the patient regarding the
potential increased risk of adverse outcomes of active cancer treatment
during the pandemic. There is recent evidence to suggest that if surgery
is performed in an asymptomatic patient during the incubation period of
COVID-19, the incidence of ICU stay and mortality is extremely high, at
44.1% and 20.5% respectively 14. Therefore, the
decision for surgery needs to be weighed against the risk of
complications, and other non-surgical treatment options may be
considered. However, there are unanswered questions regarding potential
challenges and possible increased risk of both radiation therapy and
systemic therapy during the COVID-19 pandemic that are discussed below.
Currently, most institutions likely have general guidelines on the
tiered urgency of surgical cases. At MDACC, a DoS Surgical Posting
Review Committee has been established to assess all planned surgeries.
The goals of the committee are to reduce bed utilization and optimize
resource utilization relative to the expected surge in COVID-19 cases.
Institutional oversight is crucial in managing the allocation of
resources such as ICU beds, ventilators, blood products and PPE such as
N95 masks. Specific departmental guidelines for treatment of
site-specific of cancers of the head and neck have also been developed12. Based on these guidelines, less aggressive cancers
or early-stage disease can have surgery deferred, potentially with
weekly telehealth visits to assess for change in clinical condition.
More aggressive cancers at risk of progression are favored to proceed to
surgery while advanced stage tumors are considered for non-surgical
options or neoadjuvant therapy if surgery is preferred. If the decision
for surgery has been approved, all patients undergo COVID-19 testing 24
hours prior to surgery, regardless of symptoms. While we have not
encountered a pre-operative test positive situation yet, there is
departmental consensus that oncologic treatment will be delayed until
the patient recovers from COVID-19.
Intra-operative considerations
Major head and neck oncologic surgeries often require radical resection
with flap reconstruction. Reconstructive selection is a complex process,
even in the non-pandemic environment. On the one hand, microvascular
free tissue transfer reconstruction provides greater diversity of tissue
quality when reconstructing head and neck defects, and can be associated
with improved quality of life outcomes (pain, swallowing, speech) and
lower rates of wound complications (infection, dehiscence)15. On the other hand, free flaps may be associated
with longer operative times, higher cost, require more intensive
post-operative monitoring and potentially longer hospital stay. Regional
flaps or pedicled flaps can achieve similarly excellent outcomes when
selected appropriately 16, 17. We continue to offer
free tissue transfer reconstruction at this time, having previously
reported fairly low complications rates and over 98% success rate for
the flaps18. However, we acknowledge that regional
flaps may be preferred during this pandemic, particularly where
resources are constrained. In situations where the defect has been
deemed to be borderline and there is low risk of communication with the
neck wound, for example, a partial glossectomy defect, another option
could be skin graft reconstruction, primary closure or delayed healing.
When free tissue transfer reconstruction is needed, a two-team approach
with simultaneous starts can lead to decreased operative time, and
anesthesia time, while also allowing each team to focus on a particular
element of the case 19. This appears to be the case in
the United States where 98.5% of programs report a two-team approach at
least some of the time, and has been widely adopted in 82% of hospitals
in the United Kingdom 19,20.
The use of tracheostomy for airway protection postoperatively is well
established. If a tracheostomy is not performed, the patient is either
extubated or in some institutions, remains intubated in an ICU setting
for a variable duration. While tracheostomies are indicated whenever
there is anticipated airway obstruction or difficulty handling
secretions, they can also lengthen hospital stay 20.
Where it is safe to do so, such as in the small lateral tongue, buccal
or palatal defect, there should be consideration to avoid
tracheostomies. At this time, it is unknown whether patients with
tracheostomies are at higher risk for acquiring COVID-19 given the
direct route to the patient’s airway. When elective tracheostomies are
being performed, we adhere to recommendations outlined by those with
experience during the Severe Acute Respiratory Syndrome (SARS) outbreak21.
There have been a number of excellent guidelines published on
recommended PPE for health care professionals performing head and neck
cancer surgery. At MDACC, all health care professionals have undergone
recent updated mask fitting for N95 respirators, and are using them for
all surgeries on the upper aerodigestive tract regardless of COVID-19
testing status. Despite pre-operative testing, it is known that the
sensitivity of nasal swab for detection of COVID-19 patients is 60-70%
in early studies.22,23 Therefore, all patients should
still be treated as if they are potential asymptomatic
carriers.24 Surgeons are also required to wear
eye-protection 25. During major complex ablative
procedures, we are keeping a minimum number of personnel in the
operating room. The use of high-speed oscillating and reciprocating saws
remain in use at this time, as they are deemed critical in performing
safe, expeditious ablative procedures. The use of high-speed drilling
procedures with a cutting or diamond burr has been discouraged in light
of evidence of significant aerosol contamination25.
Post-operative considerations
Changes in inpatient post-operative management are focused on reduction
of potential exposure to all persons in the hospital, as well as
conservation of PPE. For major head and neck reconstruction, free tissue
transfer reconstruction patients should be cared for in a unit with
nursing staff experienced in flap monitoring and tracheostomy care or if
in the ICU they should be moved out as soon as possible. Not only does
this reduce utilization of ICU, but also decreases potential exposure to
COVID-19 patients receiving ICU level care. For these reasons, in
Lombardy, Italy, oncologic surgery requiring ICU level post-operative
care and prolonged hospitalization was relocated to COVID-19 free
institutions.26
Patients who undergo tracheostomy and laryngectomy represent significant
source of aerosolization and high potential for viral transmission based
on studies performed during the 2013 SARS
outbreak.27,28 Droplet precautions are recommended for
all patients with tracheostomy or open airway during this pandemic
period, with the addition of N95 masks and protective eyewear for any
staff performing airway manipulation including suctioning, tracheostomy
exchange or nebulizer treatment.27,29 To reduce
droplet production during spontaneous cough, laryngectomy stomas and
tracheostomies should be covered when possible with a heat and moisture
exchanger (HME) which provides significant viral
filtration,28 or cap when possible. Early
decannulation should be considered, and in suitable candidates, patients
may be transitioned immediately to decannulation, rather than changing
to cuffless tracheostomy, with a capping trial to reduce airway
manipulation.
Streamlining care is recommended with examination of mucosal sites
limited only to essential staff. When possible, rounding teams should be
reduced to essential personnel and video- or photo-documentation can be
used to communicate clinical findings to those not present at bedside.
Similar to the outpatient setting, telemedicine should be utilized when
possible, including consultations that do not require physical exam,
such as management of some medical therapy, nutrition counseling and
discharge coordination services.
Visitors should be restricted to reduce potential transmission from
outside the hospital. While there is a no-visitor policy currently in
place at our institution, exceptions for a single visitor have been
granted to patients with limited communication, including aphonic
patients from laryngectomy, tracheostomy, and major oral cavity
reconstruction, severely disabled patients as well as non-English
speaking patients who have family members that assist in translation for
daily care. Visitors are required to shelter in place at the hospital to
reduce outside exposure, and are subject to daily temperature checks and
screening.
Upon discharge, post-operative appointments are bundled, and deferred to
telehealth visits if possible. A single follow-up visit to assess wound
healing after reconstruction is scheduled if required. and coordinated
with post-operative swallow evaluation or other aspects of
multi-disciplinary appointments to reduce frequent travel for patients.
Special considerations
Non-surgical treatment modalities can play a role in reducing surgical
volume in the treatment of patients with HNC. In patients requiring
surgery, neo-adjuvant therapies can be used to defer surgical treatment
until the peak of the pandemic has passed. However, potential associated
risks with these modalities should be considered as well.