key: cord-0951598-hxbmlhjl
authors: Zaid, Waleed; Schlieve, Thomas
title: “The early effects Of COVID-19 on head and neck oncology and microvascular reconstruction practice: National survey of oral and maxillofacial surgeons enrolled in the head and neck special interest group”
date: 2020-07-17
journal: J Oral Maxillofac Surg
DOI: 10.1016/j.joms.2020.07.012
sha: e5774b8f6e9546a696ec3484d7badfb32bc575f1
doc_id: 951598
cord_uid: hxbmlhjl

PURPOSE The coronavirus disease-2019 (COVID-19) pandemic has affected healthcare systems across the nation. The purpose of this study is to gauge the early effects of the COVID-19 pandemic on head and neck oncology and reconstructive surgery (HNORS) practice and evaluate their practice patterns especially ones that might be impacted by COVID-19 and compare them to the current literature. METHODS This study is a cross-sectional study that surveyed fellowship-trained oral and maxillofacial surgeons in HNORS. This cohort of surgeons was contacted via a generated email list of surgeons enrolled in the American Association of Oral and Maxillofacial Surgeons pathology special interest group. An electronic survey contained 16 questions to assess the COVID-19 effect on HNORS practice and capture their practice patterns from mid-March to mid-April 2020. Statistical analysis was performed to analyze counts, percentages, and response rates. RESULTS We had a 60% response rate (39 of 64); 72% of our responders worked at academic institutions, 18% marked themselves as hybrid academic/private practice, and only 10% were considered hospital-based surgeons. Only 8% of the survey respondents were requested to pause head and neck cancer surgery, whereas 24% were requested to pause free flap surgery during the pandemic. Fifty-five percent agreed that the head and neck and reconstructive surgery should be conducted during a pandemic. Finally, 45% thought that two weeks was a reasonable delay for head and neck cancer cases, whereas 29% thought they should not be delayed for any amount of time. Regarding practice patterns, microvascular reconstruction was the favored method (100%). Respondents generally admitted patients to an ICU postoperatively (92%) and were kept on a ventilator (53%). CONCLUSION The COVID-19 pandemic had a small impact on the surgical treatment of patients with head and neck oncology. Most HNORS surgeons are practicing in accordance with recently published literature.

Introduction:

The global health organization announced COVID-19 as a pandemic, something reflected by the continuous surge in the number of infected patients in the US and worldwide. It is expected that only 20% of the population infected by the virus will need medical services. When we dissect the COVID-19 infected population further, calculated estimates are that 15% will have a severe illness, and 5% will have a critical illness with a mortality rate ranging between (0.25%-3% [PPE] , and strain to the healthcare system to provide diagnostic and therapeutic services (1) . Oral and maxillofacial surgeons (OMS), otolaryngologists, dentists, ophthalmologists, and anesthesiologists are considered high-risk service lines. This is clear from the rising number of articles, professional communications, and organization recommendations such as the american head and neck society, the american association of oral and maxillofacial surgeons (AAOMS), and the american college of surgeons (ACS) . Working in the head and neck region is considered a high risk for exposure to and contracting the virus. Providers manipulating this unique anatomic region might risk infecting other patients, healthcare providers, and their own families. This study will survey oral and maxillofacial surgeons who treat head and neck oncology and perform reconstructive surgery regarding the impact of the COVID-19 pandemic on their surgical practice during mid-March to mid-April 2020. We anticipate that the COVID-19

pandemic will impact the surgical practice of (OMS's) performing head and neck oncology and reconstructive surgery (HNORS). We also aim to compare current (HNORS) practice patterns, especially the ones that might be impacted by COVID-19 with the current published literature.

In our institution surveys are exempted from the need to obtain an IRB. For this cross-sectional study, we designed an anonymous survey for fellowship trained (OMS's) in (HNORS). This cohort of surgeons were contacted via a generated email list of surgeons enrolled in the AAOMS pathology Special interest group (SIG). The participants were contacted electronically via email message forwarded by the authors.

Confidentiality and protection of personal information of the participants were maintained. The email contained a brief introduction of the investigators and explained the purpose of the survey. A hyperlink to the electronic survey was provided with instructions on how to take the survey in that email. The hyperlink contained in the document opened directly to the page of the survey. Also, a QR-code was directly sent with the email to the survey to allow a smooth response from Smartphones, tablets, PC, and laptops. The online survey was designed and made available using Microsoft © Forms. This platform allowed participants to access and complete the survey without having to create a personal account and without entering any personal information. The account on the website was created and is maintained by the investigators, and once the participants choose to take the survey, a link included in the email message directly opens only the survey of interest and allows for immediate access. After answering the survey, the participants were asked to click on the "submit" box; their responses were saved and uploaded. This method provided confidentiality and simplicity. Participants were contacted twice via email with a two-week time frame between the first and second email communications.

The survey consisted of a 16-item questionnaire aiming to evaluate the impact of COVID-19 on clinical practice and their usual practice patterns of (HNORS). These questions are listed in 

Overall the response rate to the survey was 60% response rate (39/64), 72% of our responders worked at an academic institution, 18% marked themselves as hybrid academic / private practice, and only 10% were considered hospital-based surgeons. 43% of the participants of this study had less than five years' experience in managing Head and Neck oncology, 38% had more than five years, but less than ten years, and finally, 20% had more than ten years of experience.

The impact of COVID-19 on head and neck oncology and reconstructive surgery:

Only 8% of the survey responders were asked to pause head and neck oncology cases;

however, 23% were asked to pause free flap reconstruction during the COVID-19 pandemic.

Contributing circumstances to this situation included local policies and personal protective equipment; both were tied as the first reason. 55% agreed that head and neck and reconstructive surgery should be conducted during a pandemic. Finally, 45% thought that two weeks is a reasonable time to delay head and neck oncology cases, while 29% thought these cases should never be delayed.

97% of our responders performed head and neck reconstruction, and there was a recognized agreement that microvascular tissue transfer was the favored method of reconstruction. 92% kept their patients in an ICU environment, while only 8% transferred them to a specialized stepdown unit. In the ICU setting, 51% kept the patient on a ventilator were 47% extubated these patients at the end of the procedure. A simultaneous two-team approach was implemented in 82%. Tracheostomy is performed at an average of 64% of free flap cases among the survey respondents. 29% of respondents perform a tracheostomy in >90% of free flap cases, while 24% perform a tracheostomy in limited cases (<30% of the time).

The purpose of this study was to determine the impact of the COVID-19 pandemic on OMS's performing head and neck oncologic and reconstructive surgery. We anticipated that the Fortunately, only 8% of our responders were asked to delay head and neck cancer treatment, however, this unprecedented situation made surgeons face many ethical dilemmas, first "Is delaying head and neck cancer treatment " acceptable during the COVID-19 pandemic, the second ethical dilemma " if your institution/hospital allowed head and neck cancer cases to be performed but did not allow microvascular reconstructive surgery should we still perform ablative procedures without a proper reconstruction. This situation becomes more complicated when pre-COVID these patients were informed that microvascular reconstruction is the ideal reconstruction modality as it allows complex reconstruction of more than one subunit, can withstand the adverse impact from radiation therapy, can offer immediate dental implant placement, and allow these patients to start adjuvant therapy within the recommended time frame of 6-8 weeks post oncologic ablation. Ultimately the final decision rests with the patient who is under psychological distress from a cancer diagnosis while preparing to start a journey toward cure of their head and neck cancer.

Compare Free flaps to other reconstructive flaps:

The superiority of free microvascular tissue transfer (FMTT) to pedicled regional flaps and local flaps has been debated in the literature but is considered the gold standard for reconstructing head and neck defects arising from complex oncologic ablative procedures. (2) (3) (4) (5) . Abouyrad et al.

conducted a literature review of free tissue transfer management and outcomes and concluded that FMTT remains highly successful despite the lack of consensus regarding the care of patients receiving FMTT. (2) There are many reasons FMTT is considered the gold standard for head and neck reconstruction; first, these defects arising from head and neck ablation are complex, and they tend to involve multiple anatomic subunits, have proximity to vital structures, and the ultimate goal is to restore pre-ablative form and function. Success rates of FMTT vary in the literature, reaching 95% -97% irrespective of the setting of FMTT being performed at, such as academic institutions or a community hospital. (6) (7) (8) The selection process of the ideal reconstructive option for head and neck ablative defects depends on multiple variables, including available local resources. Gabrysz-Forget et al in a systematic review, found no statistical significance in terms of hospital length of stay between free flap and pedicled flap groups (9) ; however, the results were variable when FMTT was explicitly compared to the submental island or supraclavicular flaps. In this comparison, FMTT length of stay was longer.

Comparing FMTT to pectorals myocutanous flaps [PMCF], FMTT tended to have a shorter length of stay. Complications reported with PMCF ranged between 16%-63% while complications arising from FMTT is between 14%-30% (9). It is essential to mention that there are many published descriptions of PMCF as a "Workhorse" or "The flap the stood the test of time." (10) (11) (12) (13) However, it is essential not to confuse these terms with "Gold standard" that is often tagged to FMTT when it comes to head and neck oncologic reconstruction (14) . Tackling head and neck cancer reconstruction with a one size fits all approach is rarely optimal, and a pandemic should not be an excuse to apply old or outdated concepts. (3) This was well reflected in our survey, as all respondents selected FMTT as their preferred method of reconstruction Figure 1 .

FMTT allows predictable reconstruction of large and complex head and neck defects and tends to tolerate the adverse effects of radiation therapy. Besides, FMTT has a lower incidence of post-operative infection, dehiscence, and partial or complete flap necrosis (15) . In some ablative defects such as near-total mandibular composite defects, through and through buccal defects, or defects involving the temporomandibular joint local flap such as pedicled flap reconstruction cannot offer a comparable result while laying a solid foundation for dental rehabilitation with dental implants. or ventilator related lung injury. This risk persists even if a surgical airway is performed. (18) (19) (20) .

Many theories offer explanations for the positive correlation between operative time and surgical infections. Amplified exposure to airborne pathogens, elongated trauma resulting from prolonged surgical manipulation, and finally increased foot traffic in the operating room by the surgical team and axillary staff. Regarding COVID-19 specifically, we know that the virus targets mainly the lower respiratory tract, something that hypothetically might be amplified if a patient is infected with the virus after prolonged operating time. Many centers realized the adverse effects of prolonged operative times in head and neck cancer and reconstructive surgery. These centers adopted various approaches to reduce that time. They adapted a two-team approach to reduce operative time but now needs to be weighed against the shortage of PPE and exposure risk to an increased number of surgeons and assistants participating in high-risk procedures. 82% of respondents performed reconstruction surgery with a two-team approach.

One strategy to reduce operative time is computer-assisted surgery/planning. Surgical planning of the osseous ablative resection margins, osseous donor site cutting guides, and 3D printing modeling with the option of custom made plates (21, 22) .

Head and neck ablative or reconstructive procedures can be associated with a higher risk of upper airway obstruction. Therefore, many surgeons elect to perform a tracheostomy to eliminate this risk. Obstruction of the airway may be associated with an oversized, bulky reconstruction or specific anatomical sites, including the mandible, floor of mouth, and tongue.

Additionally, bilateral neck dissection has an increased risk of airway obstruction. Tracheostomy has been found to increase the cost of care and lengthen the operative time by 30-45 min.

Specific to head and neck surgery, airway protection with continued intubation rather than tracheostomy has demonstrated its safety in many studies. This is in addition to other advantages, including reduced lower respiratory tract infections, faster return to speech, and oral intake. Another advantage of this practice is the improved cost effectiveness by decreasing (24) , american dental association (ADA), american head and neck society [AHNS] (25) (30, 31) slightly lower than our survey (90%) Figure 3 . An ICU stay is proposed to provide many advantages, high nurse: patient ratios ranging from 1: (32) . What makes a shortage of ventilators different from other medical supplies is that ventilators might be necessary during a limited window in which the patient's life might be saved. The ventilation situation is also affected by local as well as healthcare guidelines. A good example; New York, developed guidelines with the concept of "Saving Most Lives" defined by the likelihood of this patient surviving this acute medical distress a set of guidelines designed in 2015 (33) . This preparation is shared among other states. Level I evidence from a prospective, double arm, 1:1 randomized controlled trial of head neck flap patients randomized to ICU vs. specialized ward /step down unit has been collected.

Flap monitoring protocols were shared among the two groups. In this cited study, the authors did not find any significant differences between the two groups regarding medical comorbidities, prior radiation therapy treatment or chemotherapy, ischemia time, blood loss, transfusion, or postoperative antibiotics use. In this RCT, the primary outcome was the length of stay, which did not show any statistical differences between the two groups. It should be noted that in this cited study patients who were assigned to the stepdown unit/specialized ward group that needed postoperatively to be transferred to the ICU for impending flap failure, medical disease like sepsis, delirium, or following a second surgery was still statistical analyzed as a stepdown/specialized unit (34) . These findings support other retrospective studies that compared ICU postoperative stay to the stepdown unit and were integrated into many clinical care pathways but frequently demonstrate similar or better endpoints in the step-down unit group (30, 35) .

Mortality rates from head and neck squamous cell carcinoma (HNSCC) are > 50%, accounting for 375,000 mortalities. The american joint committee on cancer (AJCC) indicated that tumor stage is the most critical prognostic factor for HNSCC in which we use the T, N, M staging system to come up with the clinical and pathological definitive stage (36) . Although this opinion is shared by the majority of head and neck surgeons, it does not take into account the wide variability of head and neck cancers like location/subsite, cancer related risk factors and overall patient prognosis. Extrapolating from oropharyngeal cancer data and despite this paper small sample size of 13 patients. Waaijer el al. observed that with a median scanning interval of 35 days, there was an increase in the radiographic tumor volume around 22 cm 3 (37) . A similar oral cavity cancer specific study with a more generous sample size of 38 patients showed a 62% increase in the primary tumor volume and a median increase of 46% of lymph node metastasis.

The time intervals were classified into three-time intervals. A less than two week period correlated with 33% tumor volume increase, 2-4 weeks' time period a 68% significant increase in tumor volume and finally more than four weeks a 70% increase in tumor volume (38) . It is estimated that 17% of HNSCC patients will progress in stage between the diagnostic workup and treatment. in Hemoglobin (Hgb), which happens postoperatively attributed to hemodilution augmented with postoperative anticoagulation protocols of the surgeon's choice. What complicates the surgeon's decision to transfuse is that anemia is linked with delayed recovery, poor wound healing, and overall fatigue that might interfere with post-surgical mobilization (18, 42) . Preferred method of reconstruction Factors that might impact head and neck oncology and reconstruction Postoperative ICU admission of free microvascular tissue transfer patients 

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

Controversies in free tissue transfer for head and neck cancer: A review of the literature. Head Neck

Management of complications and compromised free flaps following major head and neck surgery

Predictors of Adverse Outcomes in Free Flap Reconstruction: A Single-Institution Experience

Survival After Free Flap Reconstruction in Patients With Advanced Oral Squamous Cell Carcinoma

Simplifying head and neck microvascular reconstruction. Head Neck

Free tissue transfer: comparison of outcomes between university hospitals and community hospitals. Plastic and Reconstructive Surgery

Flap outcomes when training residents in microvascular anastomosis in the head and neck

Case Reports of Two Unusual Donor Site Complications of the Pectoralis Major Myocutaneous Flap and Literature Review

The Pectoralis Major Myocutaneous Pedicled Flap Revisited

Pectoralis major myocutaneous flap

Pectoralis major myocutaneous flap: analysis of complications in difficult patients

Pectoralis major myocutaneous flap. Oral and Maxillofacial Surgery Clinics of NA

Microvascular Reconstruction of the Mouth, Jaws, and Face: Experience of an Australian Oral and Maxillofacial Surgery Unit

Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review

Microvascular free flap reconstruction for head and neck cancer in a resource-constrained environment in rural India

Predictive factors for prolonged operative time in head and neck patients undergoing free flap reconstruction

Intraoperative Transfusion of Packed Red Blood Cells in Microvascular Free Tissue Transfer Patients: Assessment of 30-Day Morbidity Using the NSQIP Dataset

Effects of lung protective ventilation on postoperative pulmonary outcomes for prolonged oral cancer combined with free flap surgery

Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery: A Multicenter Study by the

Perioperative Research Network Investigators. JAMA Surg

Computer-assisted design and rapid prototype modeling in microvascular mandible reconstruction. The Laryngoscope

Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-guided preoperative planning. Head Neck

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance

Member Alert: Di_cult times; di_cult decisions. Always advocating for OMSs

AHNS COVID-19 Bulletin -American Head & Neck Society. 2020

COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures

Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients Directives concre`tes a` l'intention des e quipes de soins intensifs et d'anesthe śiologie prenant soin de patients atteints du coronavirus 2019-nCoV

Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients Directives concre`tes a` l'intention des e quipes de soins intensifs et d'anesthe śiologie prenant soin de patients atteints du coronavirus 2019-nCoV

A Clinical Care Pathway to Reduce ICU Usage in Head and Neck Microvascular Reconstruction. Otolaryngology -Head and Neck Surgery

A Comprehensive Clinical Care Pathway for Microvascular Maxillofacial Reconstructive Surgery

The Toughest Triage -Allocating Ventilators in a Pandemic

Ventilator allocation guidelines. Albany: New York State Task Force on Life and the Law

Use of a non-ICU specialty ward for immediate post-operative management of head and neck free flaps; a randomized controlled trial

Costeffectiveness analysis of a postoperative clinical care pathway in head and neck surgery with microvascular reconstruction

AJCC Cancer Staging Manual

Waiting times for radiotherapy: consequences of volume increase for the TCP in oropharyngeal carcinoma

Delay in the diagnosis of oral squamous cell carcinoma

Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction

Blood transfusion prediction in patients undergoing major head and neck surgery with free-flap reconstruction

Transfusion criteria in free flap surgery. Otolaryngology -Head and Neck Surgery

Management of anaemia and blood in patients having neck dissections or free flaps for head and neck cancer. British Journal of Oral & Maxillofacial Surgery. British Association of Oral and Maxillofacial Surgeons