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AurisNasusLarynxxxx(xxxx)xxx
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Auris
Nasus
Larynx
journal homepage:www.elsevier.com/locate/anl
Letter
to
the
Editor
Reshaping head andneck reconstructionpolicy during the COVID-19pandemic peak:Experience in a front-line institution
To the Editor,
the current outbreak of COVID-19 inLombardy, aregion of Northern Italy,has dramaticallyimpactedthe organization ofhealthcareactivities.Astheinfectionescalates,inthehopes of conservingresources, anumber of hospitalsreduced elec-tivesurgeriesaspartoftheirCOVID-19containmentstrategy. Patientsrequiringoncologicresectionwereofferedthe pos-sibilitytobereferred tothe twoCOVID-19-freeregional on-cologic hubs,both locatedin Milan.
In ourInstitution,all availablebeds inintensive careunits (ICU) were instantaneously saturated by COVID-19 patients
[1] despitethefact thattheoverallICUrecoverycapacityfor adultsincreasedfrom29to57beds.SurgeryatourHeadand Neck Department in Brescia was reduced from 3 operating theatres running5days perweek,to1 theaterrunning 2days per week.
For those refusing to be referred to the aforementioned structures, relevant adjustments in global management were mandatory.Tocopewiththeverylimitedavailabilityof anes-thesiologists, and to avoid waste of precious resources, the surgical strategy was re-discussed in orderto reduce operat-ing times, possiblyminimizingthe risk of complications and postoperative ICUadmission.
Theaimofthedemolitionphaseisradicality,andthus can-cer resectionremainsstandard. Conversely,thereconstructive phase canbe tailoredto bettercope withcurrent constraints. In the first two weeks of March2020, during the striking phaseoftheItalianCOVID-19emergency,3patientsaffected byHN-SCCunderwentsurgeryattheOtolaryngologyUnitof the University of Brescia, Italy.
Patient1,presentingatonguecT3N0 SCC,underwentpull through resection with en-blocselective neck dissectionI-III and temporary tracheostomy. Initially scheduled for a radial forearm freeflap (FF),heunderwent infrahyoidpedicledflap (PF)reconstruction (Fig.1).
Abbreviations: FF, freeflap; ICU,intensive care units;PM, pectoralis myocutaneous;PF,pedicledflap.
Patient 2, presenting a cT4aN0 inferior alveolar ridge tumor, underwent lateral segmental mandibular resection with en-bloc selective neck dissection I-IV, temporary tra-cheostomy,andpectoralismyocutaneous(PM)PF reconstruc-tioninsteadoftheinitiallyplannedosteo-cutaneousfibulaFF. Patient 3 presented a laryngeal SCC rT4aN2c post-chemoradiation (initially cT4aN2c), and underwent total la-ryngectomy extending to the right base of tongue and pir-iform sinus, and to the already existing tracheostoma with surroundingskin, totalthyroidectomy,andbilateralneck dis-sectionII-VI.InitiallyscheduledforananterolateralthighFF, heunderwent reconstruction with aPMPF.
In order to reduce operating times, flap harvesting was performed simultaneously tothe resectionphase inallcases, withthe goalof keeping the operating timeunder 5 h.
Patient 1 and 2 were discharged on postoperative day 7 and9, respectively, without complications.At phone consul-tationspeechintelligibilitywasexcellent,andthepatientshad returnedtonormaldiet.Bothwerescheduledforadjuvant ra-diotherapy.
Forpatient3 theinitial postoperativecoursewas unevent-ful, and the patient’s discharge was scheduled on postopera-tiveday11.However,afistulawasradiologicallyrevealedby video fluoroscopy the day before discharge. The patient re-mainedadmittedandcompressivedressingwasapplieddaily. Thefistulawassolvedafter10daysofconservativetreatment. TheCOVID-19outbreak inLombardy hasposedacritical challenge to the health care system. General recommenda-tionsfor evaluation andsurgeryof the head andneck during theCOVID-19pandemichavebeenrecentlydepictedbyGivi etal.[2],althoughtherehasbeennospecificfocus on recon-structivepolicy todate.
According to previous Institutional policy, all patients of the series were considered SARS-CoV-2 free based on the analysisofpotentialsourcesof contact,the absenceof symp-toms consistent with active infection and the evaluation of preoperative chest radiogram; these requirements to undergo elective surgery were recently implemented by adding a mandatorynegative nasopharyngealswabtest.
Our dedicated anesthesiologists requested that we mini-mizesurgicaltimesinordertobeavailableformanagementof the dramatic challenge represented by the current pandemic. Moreover,no postoperativeICU surveillancewas available.
https://doi.org/10.1016/j.anl.2020.04.008
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Fig. 1.. ClinicalcaseofarightcT3N0-pT3N2bsquamouscellcarcinomaofthetongue(A).Thepatientunderwentpullthroughtumorresection(B)with enblocselectiveneckdissectionI-IIIplustemporarytracheostomy.AninfrahyoidPFwas harvested(C)andtransposedtocovertheoralcavitydefect(D). Operativetimewas3hand35min.
In this scenario, the greater advantage provided by PFis therelevantshorteningofoperativetimes,as reportedby sev-eral seriesinliterature; longer surgicaltime isalso a signifi-cantfactorforthedevelopmentofpostoperativecomplications and prolonged hospitalization [3,4]. Of note, the simultane-ous rising of the flap during cancer resection was possible alsowiththe PM flap.
Although suboptimal inspecificcases(i.e. mandibular re-construction),PF can provide satisfactoryfunctional and es-theticresults,inparticularforlateraldefectsinweakpatients. The only complication experienced in the series was the developmentofapharyngo-cutaneousfistulainPatient3,who wasathighrisk inview ofa poornutritional status and per-sistentsmokehabit.Amulticentricreview[5]showedno dif-ferencesintermsoffistulaformationbetweenFFandPFafter salvagelaryngectomywithpartialpharyngectomy,althoughin ouropinionthe selection of PMflap reconstruction wasalso appropriate because a PF can better withstand conservative managementwithcompressive dressingincaseoffistula[6]. The reshaping of the reconstructive strategy allowed us to save precious resources, without jeopardizing the overall validity of surgery and functionalresults. Our reconstructive viewpoint should be taken into consideration when facing a massivepandemicoutbreaksuch asthat experiencedin Lom-bardy.
Declarationof Competing Interest
The author(s) declared no potential conflicts of interest withrespecttoresearch,authorship,and/orpublicationofthis article.
Funding
The author(s) received no financial support for the re-search, authorship,and/or publication of thisarticle.
References
[1]GrasselliG,ZangrilloA,ZanellaA,AntonelliM,CabriniL,CastelliA, etal.Baselinecharacteristicsandoutcomesof1591patientsinfectedwith SARS-CoV-2 admittedto ICUsof theLombardyRegion, Italy.JAMA 2020.
[2]GiviB,SchiffBA,ChinnSB,ClayburghD,GopalakrishnaIyer N, Jal-isi S,etal.Safetyrecommendations forevaluation and surgeryofthe headandneckduringtheCOVID-19pandemic.JAMAOtolaryngolHead NeckSurg2020.
[3]MahieuR,CollettiG,BonomoP,ParrinelloG,IavaroneA,Dolivet G, etal.Headand neckreconstruction withpedicledflapsinthefreeflap era.ActaOtorhinolaryngolItal2016;36:459–68.
[4]Deganello A, Leemans CR. The infrahyoid flap: a comprehensive review of an often overlooked reconstructive method. Oral Oncol 2014;50:704–10.
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[5]MicrovascularCommitteeoftheAmericanAcademyofOtolaryngology– Head&NeckSurgerySalvagelaryngectomyandlaryngopharyngectomy: multicenterreviewofoutcomesassociatedwithareconstructiveapproach. HeadNeck2019;41:16–29.
[6]BusoniM,DeganelloA,GalloO.Pharyngocutaneousfistulafollowing to-tallaryngectomy:analysisofriskfactors,prognosisandtreatment modal-ities.ActaOtorhinolaryngolItal2015;35:400–5.
Vittorio Rampinelli∗ Davide Mattavelli TommasoGualtieri AlbertoPaderno Stefano Taboni Giulia Berretti Alberto Deganello
UnitofOtorhinolaryngology -Head and Neck Surgery, Department ofMedical and Surgical Specialties,
Radiological Sciences,and Public Health, University of Brescia,ASST SpedaliCivili ofBrescia,25121 Brescia,Italy
∗Correspondingauthor.
E-mailaddress: vittorio.rampinelli@gmail.com
