Surgical Management
The timeline and duration of COVID-19 is uncertain, and consequently,
triaging surgical cases poses an enormous challenge. Both the CAHNSO as
well as Wuhan University have held the view that surgical management
should be offered when a worse outcome is expected should surgery be
delayed more than 2-6 weeks. In practice this means operating largely on
patients with advanced mucosal disease, high grade salivary malignancy
with rapid progression, advanced melanoma, and other pathologies where
surgery could be potentially curative. Salvage surgery is being
approached with great caution given the poor oncologic results and
necessity to limit institutional resource use where
possible34,35. The Stanford University group have
recently outlined their stratification of urgency according to disease
process and show general agreement with these
suggestions36.
Within the operating room, significant thought has been put towards
minimizing exposure and conserving PPE. Resident trainees are either not
involved in cases or are brought in only for portions of the procedure
appropriate for their level of training. In head and neck oncology,
clinical equipoise often exists between various treatment modalities. In
an effort to limit operating room use and build intensive care unit
capacity, for patients who could expect equivalent results for radiation
or surgery, the former is preferred. An example is early stage glottic
cancer, where transoral laser microsurgery has traditionally been
discussed as a treatment option. As this is a high-risk aerosol
generating procedure, with similar oncologic outcomes to primary
radiotherapy, the latter is being preferentially used. Head and neck
cancer sites must also consider the potential future need for primary
radiation in the treatment of oral cancer. However, each patient must be
managed on a case-by-case basis, while considering other possible side
effects, such as chemotherapy and radiation induced immunosuppression.
Where surgery is required, we use a pre-huddle outside the operating
room prior to patient arrival that includes all team members. All
necessary surgical and anesthetic equipment is confirmed so that
circulating nurses do not have to enter and leave the room. Surgical
teams remain outside of the operating room during intubation and
extubation. At our institution in Toronto, in keeping with two cycles of
operating room air clearance, this equates to a 20-minute wait for each
intubation and extubation event. Given the nature of many oncological
procedures, the surgical team must remain vigilant, and accurate
communication between the anesthetic, nursing, and surgical teams is
paramount.
Reconstructive options should be further considered in the pandemic
setting, both as a function of the need for prophylactic tracheostomies
and as a consideration for reducing the total intraoperative time. Where
feasible, in Toronto, we currently consider transitioning to regional
flap reconstruction or delaying reconstruction altogether. Free flaps
are still required but are used judiciously. Patients should be
counselled about these management decisions, their risks, and future
steps to correct any unsatisfactory outcomes, such as tethering.
The use of secondary intention may, in select circumstances,
additionally negate the need for up-front tracheostomy and assists in
reducing the overall length of the procedure. We recognize in certain
cases this is not possible, and individual patient safety must be
weighed, as well as the risk of increased aerosolization should an
uncontrolled airway intervention be required. Our institutions have also
elected to reduce manipulation of tracheostomies as much as possible.
The use of non-fenestrated cannulas, delay of tracheostomy tube changes,
and corking of deflated, cuffed tubes have been employed to facilitate
this goal37,38.
From an adjuvant therapy perspective, both the radiation oncology and
medical oncology services across Toronto hospitals are adapting their
practices to help mitigate risk to head and neck cancer patients in the
wake of COVID-19. For instance, there has been increased consideration
placed towards hypofractionated or accelerated radiation schema, as well
as weekly outpatient cisplatin regimens for select cases; both with the
goal of reducing hospital visits. In cases where a regionalized cancer
centre in Ontario is no longer able to safely offer cancer services,
protocols are in place to transition care to another provincial care
centre.