Trends of Microsurgical Head and Neck Free Flap Reconstruction and Safety during the COVID-19 Pandemic

Abstract

Background The coronavirus disease 2019 (COVID-19) pandemic poses unprecedented challenges among patients with head and neck (HN) cancer that require oncological and reconstructive surgeries. This study aims to identify differences in postoperative outcomes for patients who underwent microsurgical HN free flap reconstruction prior to versus during the COVID-19 pandemic.

Methods A retrospective observational study using the American College of Surgeons National Surgical Quality Improvement Program 2019 to 2020 database to identify patients with HN cancer who underwent a vascularized free tissue transfer was undertaken. Two cohorts were created: pre- and during COVID-19. Fisher's exact test and the unpaired Student's t-test were used to evaluate differences in sociodemographic and clinical characteristics between the cohorts. Multivariable logistic regression was used to assess differences in reoperation rates between groups as well as to identify potential risk factors for reoperation.

Results A total of 763 patients were analyzed. The mean age of patients in the overall cohort was 63.6 (standard deviation: 11.5) years. Most patients were white (62.7%). Overall, no statistically significant difference was evidenced between cohorts in terms of immediate postoperative outcomes. Similarly, reoperation rates were similar between groups (p > 0.05). Dependent functional status (p = 0.021) and postoperative infection (p < 0.001) were found to be risk factors for reoperation after holding other factors constant.

Conclusion HN flap reconstruction can be performed safely during the COVID-19 era. Standardized protocols for patient selection must be strictly followed to avoid disease progression and optimize surgical outcomes. Further studies assessing long-term outcomes during the pandemic are of utmost importance to elucidate the true impact of the COVID-19 pandemic on this population.

Keywords

reconstruction - microsurgery - head and neck - COVID-19

• References

• 1 Kang J-Y, Michels A, Lyu F. et al. Rapidly measuring spatial accessibility of COVID-19 healthcare resources: a case study of Illinois, USA. Int J Health Geogr 2020; 19 (01) 36
• 2 Moynihan R, Sanders S, Michaleff ZA. et al. Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review. BMJ Open 2021; 11 (03) e045343
• 3 Chi D, Chen AD, Dorante MI, Lee BT, Sacks JM. Plastic surgery in the time of COVID-19. J Reconstr Microsurg 2021; 37 (02) 124-131
• 4 Elmer NA, Bustos VP, Veeramani A. et al. Trends of autologous free-flap breast reconstruction and safety during the coronavirus disease 2019 pandemic. J Reconstr Microsurg 2023; 39 (09) 715-726
• 5 Wong S, Payton JI, Lombana NF. et al. A protocol for safe head and neck reconstructive surgery in the COVID-19 pandemic. Plast Reconstr Surg Glob Open 2020; 8 (11) e3258
• 6 Jain S, Gupta S, Singh TP. et al. Short term outcomes of head and neck oncology surgery during Covid-19 pandemic: experience from a tertiary cancer care centre in North India. Indian J Otolaryngol Head Neck Surg 2022; 74 (Suppl 2): 2822-2826
• 7 Thione A, Sánchez-García A, Pérez-García A, García-Vilariño E, Salmerón-González E, Balaguer-Cambra J. A protocol for performing reconstructive microsurgery on patients with COVID-19. Plast Surg Nurs 2021; 41 (01) 36-39
• 8 Thacoor A, Sofos SS, Miranda BH. et al. Outcomes of major head and neck reconstruction during the COVID-19 pandemic: the St. Andrew's centre experience. J Plast Reconstr Aesthet Surg 2021; 74 (09) 2133-2140
• 9 Wai KC, Xu MJ, Lee RH. et al. Head and neck surgery during the coronavirus-19 pandemic: the University of California San Francisco experience. Head Neck 2021; 43 (02) 622-629
• 10 ACS National Surgical Quality Improvement Program. Accessed June 28, 2021 at: https://www.facs.org/quality-programs/acs-nsqip
• 11 Shiloach M, Frencher Jr SK, Steeger JE. et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 2010; 210 (01) 6-16
• 12 Henderson WG, Daley J. Design and statistical methodology of the National Surgical Quality Improvement Program: why is it what it is?. Am J Surg 2009; 198 (05) S19-S27
• 13 Piccirillo JF. Otolaryngology-head and neck surgery and COVID-19. JAMA 2020; 324 (12) 1145-1146
• 14 See A, Go LK, Teo CEH, Teo NWY, Toh ST. Adaptations of a tertiary otorhinolaryngology Head and Neck Surgery Department in Singapore during the COVID-19 outbreak. Ann Otol Rhinol Laryngol 2021; 130 (02) 177-181
• 15 Givi B, Schiff BA, Chinn SB. et al. Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic. JAMA Otolaryngol Head Neck Surg 2020; 146 (06) 579-584
• 16 Cho RHW, Yeung ZWC, Ho OYM. et al. Pearls of experience for safe and efficient hospital practices in otorhinolaryngology-head and neck surgery in Hong Kong during the 2019 novel coronavirus disease (COVID-19) pandemic. J Otolaryngol Head Neck Surg 2020; 49 (01) 30
• 17 Liu Z, Zhang L. At the center of the COVID-19 pandemic: lessons learned for otolaryngology-head and neck surgery in China. Int Forum Allergy Rhinol 2020; 10 (05) 584-586
• 18 Kowalski LP, Sanabria A, Ridge JA. et al. COVID-19 pandemic: effects and evidence-based recommendations for otolaryngology and head and neck surgery practice. Head Neck 2020; 42 (06) 1259-1267
• 19 Khariwala SS, Weinreich HM, McCoul ED. et al. Leveraging COVID-19-inspired changes to advance otolaryngology-here to stay. JAMA Otolaryngol Head Neck Surg 2020; 146 (07) 605-607
• 20 Colosimo C, Kelly J, Coker J. et al. Unscreened: urgent and emergent surgical outcomes in the early COVID-19 pandemic. Cureus 2020; 12 (12) e11878
• 21 Bustos SS, Bustos VP, Nguyen MT. Elective surgery in asymptomatic patients with undetected SARS-CoV-2 infection: lessons learned from the global operating room. Br J Surg 2020; 107 (10) e399-e400
• 22 Mohanka MR, Mahan LD, Joerns J. et al. Clinical characteristics, management practices, and outcomes among lung transplant patients with COVID-19. J Heart Lung Transplant 2021; 40 (09) 936-947
• 23 Osorio J, Madrazo Z, Videla S. et al; COVID-CIR Collaborative Group Members of the COVID-CIR Collaborative Group. Analysis of outcomes of emergency general and gastrointestinal surgery during the COVID-19 pandemic. Br J Surg 2021; 108 (12) 1438-1447
• 24 Galloway TJ, Kowalski LP, Matos LL, Junior GC, Ridge JA. Head and neck surgery recommendations during the COVID-19 pandemic. Lancet Oncol 2020; 21 (09) e416
• 25 Krajewska Wojciechowska J, Krajewski W, Zub K, Zatoński T. Krajewska (Wojciechowska) J. Review of practical recommendations for otolaryngologists and head and neck surgeons during the COVID-19 pandemic. Auris Nasus Larynx 2020; 47 (04) 544-558
• 26 Han AY, Miller JE, Long JL, St John MA. Time for a paradigm shift in head and neck cancer management during the COVID-19 pandemic. Otolaryngol Head Neck Surg 2020; 163 (03) 447-454
• 27 Wunsch A, Pitak-Arnnop P. Strategic planning for maxillofacial trauma and head and neck cancers during COVID-19 pandemic- December 2020 updated from Germany. Am J Otolaryngol 2021; 42 (04) 102932
• 28 Ferrari M, Paderno A, Giannini L. et al. COVID-19 screening protocols for preoperative assessment of head and neck cancer patients candidate for elective surgery in the midst of the pandemic: a narrative review with comparison between two Italian institutions. Oral Oncol 2021; 112: 105043
• 29 Brar S, Ofo E, Hyde N. et al. Outcomes of elective head and neck confirmed or suspected cancer surgery during the COVID-19 pandemic. Eur Arch Otorhinolaryngol 2021; 278 (04) 1277-1282
• 30 Ito A, Kobayashi K, Shiotsuka M. et al. Uniform infection screening allowed safe head and neck surgery during the coronavirus disease 2019 pandemic in Japan. Jpn J Clin Oncol 2021; 51 (03) 400-407
• 31 Chen J, Chow A, Lee E. et al. Reintroducing flap reconstruction: one institution's safe return to flap surgery during the COVID-19 pandemic. J Reconstr Microsurg 2023; 39 (01) 59-69
• 32 Kiong KL, Diaz EM, Gross ND, Diaz Jr EM, Hanna EY. The impact of COVID-19 on head and neck cancer diagnosis and disease extent. Head Neck 2021; 43 (06) 1890-1897
• 33 Tevetoğlu F, Kara S, Aliyeva C, Yıldırım R, Yener HM. Delayed presentation of head and neck cancer patients during COVID-19 pandemic. Eur Arch Otorhinolaryngol 2021; 278 (12) 5081-5085
• 34 De Luca P, Bisogno A, Colacurcio V. et al. Diagnosis and treatment delay of head and neck cancers during COVID-19 era in a tertiary care academic hospital: what should we expect?. Eur Arch Otorhinolaryngol 2022; 279 (02) 961-965
• 35 Rygalski CJ, Zhao S, Eskander A. et al. Time to surgery and survival in head and neck cancer. Ann Surg Oncol 2021; 28 (02) 877-885
• 36 Dermody SM, Shuman AG. Psychosocial implications of COVID-19 on head and neck cancer. Curr Oncol 2022; 29 (02) 1062-1068
• 37 Sangal NR, Nishimori K, Zhao E, Siddiqui SH, Baredes S, Chan Woo Park R. Understanding risk factors associated with unplanned reoperation in major head and neck surgery. JAMA Otolaryngol Head Neck Surg 2018; 144 (11) 1044-1051