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.