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.