Lessons Learned during COVID-19: Safety of Vascularized Omental Lymphatic Transfer in the Outpatient Setting.

The coronavirus disease 2019 (COVID-19) pandemic has exacerbated the constant struggle that healthcare systems face due to a lack of resources necessary to provide adequate patient care to all. In particular, the impact of COVID-19 on surgical practice is multifarious, with issues including staffing, procedural prioritization, and surgical education bearing the brunt of suffering.[1] Further, constraints on hospital and bed capacity have exacerbated the problem and drastically impeded surgeons’ abilities to provide necessary intervention. Efforts to mitigate this, including an acuity scale developed by Dorfman et al[2] to simplify surgical decision-making regarding canceling and postponing plastic surgery cases, have been made. Part of the challenge, particularly for plastic surgeons, is the heterogenous nature of cases performed and disagreement on acuity levels.

One example of this is the surgical treatment of lymphedema. Most guidelines, including Dorfman’s, stratify lymphedema as low acuity (ie, Tier 1).[2] The implication is that these procedures can safely be postponed without undue harm to patients. Indeed, lymphedema is generally considered to be a slowly progressive disease process, often requiring years to reach the most severe stages. Specifically, stasis of lymph within affected tissue leads to a localized inflammatory process, resulting in progressive fibrosis, adipose tissue differentiation, and subsequent tissue enlargement. Although it is agreed that lymphedema is not usually an acute surgical emergency, its classification as a condition that can be postponed with minimal harm is incorrect. In contrast, our experience and the experience of others suggest that treatment delay by even a few weeks or months could lead to irreversible injury.[3]

Our general approach to lymphedema management includes vascularized omental lymphatic transfer (VOLT) in appropriate patients.[4] Patients are typically admitted overnight to ensure appropriate bowel function and pain control. In the height of COVID-19-related capacity issues, however, overnight admission precluded our ability to offer lymphatic procedures. In light of recent research demonstrating the safety of same-day discharge for other procedures which historically required overnight admission,[5] we applied similar principles to selected patients undergoing VOLT. Patients were made aware of this change to our practice, and most of them strongly preferred undergoing surgical intervention as an outpatient rather than waiting for clearance. To date, four patients (57% of total) were managed this way. None experienced significant complications or required readmission; however, a larger sample size with longer follow-up is currently under review.

Two important conclusions stem from this viewpoint. First, same-day discharge after VOLT is safe and effective in appropriately selected patients (Table 1) and following additional precautions (Table 2). Ongoing prospective investigations using a larger sample size will better characterize indications, advantages, and disadvantages of this approach. Second, the COVID-19 pandemic has forced the medical community to adapt long-standing processes. Occasionally, change in this manner can serendipitously lead to positive results. Moving forward, during COVID-19 and after, surgeons must continue to adapt and innovate in ways that optimize patient outcomes, reduce capacity and cost issues, and improve access.

Table 1.

Criteria to Consider for Appropriate Patient Selection in Same-day Discharge

Criterion
Good functional status (ie, >4 METs)
BMI < 35
<2 medical comorbidities (eg, DM, COPD, CAD, CHF)
ASA score ≤3
Patient well informed and in agreement with plan
Competent adult with patient during first 24 hours after discharge
Minimal significant prior abdominal morbidity
No anesthesia-related contraindications to early discharge (eg, severe obstructive sleep apnea)

ASA score, American Society of Anesthesiologists Physical Status Classification System—a subjective assessment of a patient’s overall health based on five classes; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus.

Table 2.

Strategies to Optimize Same-day VOLT

Strategy	Rationale
Proper patient selection	To minimize the risk of a poor outcome or readmission due to complications
Obtain appropriate informed consent	To educate patients on potential consequences of their treatment decisions
Confirm understanding of postoperative care	To reduce presentation to ED for nonemergent issues that may arise in the normal postoperative course while also emphasizing indications for urgent readmission
Schedule the surgery early in the day	To allow more time for pain control and resumption of normal bowel function
Ensure bed availability	If complications were to occur, readmission may be necessary

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.