Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

Abstract

Background Enhanced recovery pathways (ERPs) have been shown to aid in patient recovery and improve outcomes in many surgical settings. At present, there is limited data available regarding the use and feasibility of ERPs for patients undergoing microsurgical breast reconstruction. We sought to assess patient outcomes before and after the introduction of an ERP that was adopted by multiple surgeons at a single cancer center. Methods A multidisciplinary ERP was developed for patients undergoing deep inferior epigastric perforator (DIEP) or muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Core elements of the ERP included substituting intravenous patient-controlled analgesia with a multimodal pain regimen consisting of intravenous ketorolac and transversus abdominis plane blocks with liposomal bupivacaine, as well as the use of intraoperative goal-directed fluid management. Patients who underwent surgery between April and August 2015 using the ERP were compared with a historical control cohort. The primary endpoints were hospital length of stay (LOS) and total postoperative opioid consumption. Results In total, 91 consecutive patients were analyzed (ERP, 42; pre-ERP, 49). Mean hospital LOS was significantly shorter in the ERP group than in the pre-ERP group (4.0 vs. 5.0 days; p<0.0001). Total postoperative morphine equivalent consumption was also lower in the ERP group (46.0 vs. 70.5 mg; p=0.003). There was no difference in the incidence of 30-day complications between the groups (p=0.6). Conclusions The adoption of an ERP for DIEP and TRAM flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced LOS by 1 day.

Postoperative analgesia after microsurgical breast reconstruction using liposomal bupivacaine (Exparel)

“…As demonstrated in this study, 91.3% of patients included in this study did not require any PCA postoperatively. This compares favorably with the results of Afonso et al and Batdorf et al who reported that following implementation of an ERAS pathway only 21% and 20% of their patients used postoperative PCA, respectively …”

“…In addition to the small percentage of patients requiring postoperative PCA and the lower total postoperative OME use when compared to our previous report, median patient‐reported pain scores were lower in the present study, thus, indicating improved postoperative analgesia, not just based on objective (ie, OME) but also subjective data. Adequate postoperative analgesia is, furthermore, reflected by a mean LOS of 3.5 days in our patient cohort, which compares favorably with other reports following successful implementation of ERAS protocols . Of note, a recent study by Jablonka et al reported an even shorter LOS following introduction of TAP blocks with liposomal bupivacaine, namely an average of 2.65 days …”

“…Adequate postoperative analgesia is, furthermore, reflected by a mean LOS of 3.5 days in our patient cohort, which compares favorably with other reports following successful implementation of ERAS protocols. 19,33 Of note, a recent study by Jablonka et al reported an even shorter LOS following introduction of TAP blocks with liposomal bupivacaine, namely an average of 2.65 days. 20 Several limitations of the present study deserve mentioning.…”

“…[26][27][28][29][30][31] The respectively. 19,33 Analysis of the total postoperative OME use demonstrated a mean of 123.2 mg. This by itself compares favorably with our previous report of 40 patients who underwent autologous breast reconstruction with abdominal flaps and TAP blocks with catheter insertion and continuous bupivacaine, ropivacaine, or lidocaine infusion as well as additional boluses as needed; ie, mean total OME of 194.3 mg. 6 The difference becomes even more pronounced, ie, >100 mg OME, when excluding the four patients who required PCA.…”

Enhanced Recovery after Surgery (ERAS) protocols in breast cancer patients undergoing post-mastectomy breast reconstruction with tissue expander

“…Στην Ελλάδα δεν έχει εκδοθεί από κάποιο επίσηµο κρατικό φορέα πρωτόκολλο ERAS για την άµεση αποκατάσταση µε διατατήρες µετά από µαστεκτοµή. Παράλληλα, σε αρκετά ιδιωτικά νοσοκοµεία εφαρµόζονται παρόµοια προγράµµατα για την αποκατάσταση µετά από µαστεκτοµή µε µεγάλη µείωση της συνολικής µέσης διάρκειας νοσηλείας από 3,6 ηµέρες πριν από την εφαρµογή του προγράµµατος ERAS σε 0 (αυθηµερόν εξιτήριο) έως 1,2 ηµέρες (Mertz et al 2013, Dumestre et al 2017, Afonso et al 2017.…”