Perioperative Optimization of Autologous Breast Reconstruction

Bonde, Christian; Khorasani, Hoda; Elberg, Jens Jørgen; Kehlet, Henrik

doi:10.1097/01.prs.0000475749.40838.85

Cited by 43 publications

(47 citation statements)

References 29 publications

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“…They continued to improve on their fast-track protocol with the identification of specific factors that prolonged hospital stay. A more recent paper by the same group (22) demonstrated a dramatic reduction in mean LOS, to 3.1 days, among 16 consecutive patients. These patients mostly underwent delayed, unilateral DIEP procedures; their outcomes continued to improve as the ERP implementation efforts continued.…”

Section: Discussionmentioning

confidence: 89%

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

Afonso

Oskar

Tan

et al. 2017

Plastic &Amp; Reconstructive Surgery

107

146

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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.

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Section: Discussionmentioning

confidence: 89%

“…However, to date, only a few ERPs have been described in the plastic surgery literature (3–5, 21, 22). Batdorf et al initially described a comprehensive ERP for microsurgical breast reconstruction (3).…”

Section: Discussionmentioning

confidence: 99%

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

Afonso

Oskar

Tan

et al. 2017

Plastic &Amp; Reconstructive Surgery

107

146

View full text Add to dashboard Cite

show abstract

“…Seven studies investigated the utilization of enhanced recovery after surgery (ERAS) pathways in providing pain control after autologous breast reconstruction. 31, [33][34][35][36][37][38][39][40] Pathways varied markedly in regard to pre, intra, and postoperative interventions. All studies demonstrated a reduction in opioid utilization with ERAS approaches.…”

Section: Enhanced Recovery Pathwaysmentioning

confidence: 99%

Optimizing Postoperative Pain Control in Autologous Breast Reconstruction: A Systematic Review

Knackstedt

Oliver

Gatherwright

2020

J Reconstr Microsurg

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Background Pain management approaches in autologous breast reconstruction have become a topic of great interest in the era of enhanced recovery after surgery protocols, as well as the opioid epidemic. The management of postoperative pain is of critical importance for women undergoing breast reconstruction; however, these protocols have yet to be synthesized and compared in the primary literature. Herein, we present a systematic review of approaches to provide optimal pain control while minimizing narcotic use and its associated potential negative sequelae in autologous breast reconstruction. Methods A comprehensive systematic review of the published literature was conducted using Ovid Medline/PubMed database without timeframe limitations, in compliance with the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria were selected for studies reporting objective outcomes of pain modulation in autologous breast reconstruction. Articles for inclusion were stratified based on intervention. Results A total of 101 articles were identified on initial search query. After full-text review and final screening of all articles and review of included studies’ references, 28 studies met the inclusion criteria and were analyzed. Conclusion There continues to be a substantial need for evidence-based guidelines in the plastic surgery literature. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Given the increasing popularity of and access to autologous approaches to breast reconstruction, we hope this area of study continues to be a top priority for plastic surgeons to allow for optimized postoperative care.

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“…Studies were performed between 2011 and 2018 and comprised 11 cohort studies, 3 of which included a single cohort of ERAS patients, whereas 8 included a traditional pathway control cohort. [9][10][11][12][13][14][15][16][17][18][19] The traditional cohort was collected through retrospective chart review of recent patients who underwent breast reconstruction with the perioperative standard of care. 11,12,[14][15][16][17][18][19] Significant differences between cohorts in terms of patient and surgical characteristics were rare, as shown in individual tables present in each manuscript.…”

Section: Study Detailsmentioning

confidence: 99%

“…The majority of autologous patients underwent free abdominally based reconstruction (403, 75.0%), followed by pedicled abdominally based reconstruction (118, 22.0%), and pedicled latissimus reconstruction (13, 2.42%). [9][10][11][12][13][14][15][16] The majority of autologous cases were unilateral (385, 71.7%), and delayed (405, 83.0% reported by patient; 57, 64.0% reported by flap). All alloplastic studies involved reconstruction in the subpectoral plane with tissue expanders or direct-to-implant reconstruction.…”

Section: Patient Characteristicsmentioning

confidence: 99%

Enhanced Recovery after Surgery in Breast Reconstruction: A Systematic Review

Soteropulos

Tang

Poore

2019

J reconstr Microsurg

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Background Enhanced Recovery after Surgery (ERAS) principles have received focused attention in breast reconstruction. Many protocols have been described in the literature for both autologous and alloplastic reconstruction. This systematic review serves to better characterize successful ERAS protocols described in the literature for potential ease of adoption at institutions desiring implementation. Methods A systematic review of ERAS protocols for autologous and alloplastic breast reconstruction was conducted using Medline, the Cochrane Database, and Web of Science. Results Eleven cohort studies evaluating ERAS protocols for autologous (n = 8) and alloplastic (n = 3) breast reconstruction were included for review. The majority compared with a retrospective cohort of traditional perioperative care. All studies described the full spectrum of implemented ERAS protocols including preoperative, intraoperative, and postoperative phases of care. Most frequently reported significant outcomes were reduced length of stay and opioid use with ERAS implementation. No significant change in major complication or readmission rate was demonstrated. Conclusion Based on this systematic review, several core elements that make up a successful perioperative enhanced recovery protocol for breast reconstruction have been identified. Elements include patient counseling and education, limited preoperative fasting, appropriate thromboprophylaxis and antibiotic prophylaxis dependent on reconstructive method, preoperative antiemetics, multimodal analgesia and use of local anesthetic, goal-directed intravenous fluid management, prompt removal of drains and catheters, early diet advancement, and encouragement of ambulation postoperatively. Implementation of ERAS protocols in both autologous and alloplastic breast reconstruction can positively enhance patient experience and improve outcomes by reducing length of stay and opioid use, without compromising successful reconstructive outcomes.

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Perioperative Optimization of Autologous Breast Reconstruction

Abstract: Therapeutic, IV.

Cited by 43 publications

References 29 publications

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

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

Optimizing Postoperative Pain Control in Autologous Breast Reconstruction: A Systematic Review

Enhanced Recovery after Surgery in Breast Reconstruction: A Systematic Review

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