Each year, healthcare experts and patient advocates gather in San Antonio to present the latest research findings and updates on clinical trials at the San Antonio Breast Cancer Symposium. This year, PRMA was honored to present our research finding from our Enhanced Recovery After Surgery (ERAS) protocol. Thanks to our ERAS protocol, our patients experience less pain, take little to no narcotics and are able to leave the hospital sooner after breast reconstruction surgery.

Here is the overview of our poster presentation on our ERAS study:

Background

As microsurgical breast reconstruction continues to become more popular, there has been an increased focus on implementing enhanced recovery after surgery (ERAS) pathways to improve outcomes. Enhanced recovery pathways have showed benefits in many surgical populations including cardiac, colorectal, urology and general surgery by aiming to accelerate recovery and reduce post-operative morbidity. ERAS pathways strive to minimize surgical stress and restore normal physiological function through standardized and streamlined peri-operative care protocols. Consensus guidelines from the ERAS society have been published for a variety of these procedures to allow for shorter recovery times and decreased hospital length of stay.

Extension of these general principles to patients undergoing microsurgical breast reconstruction including preoperative counseling, optimization of nutrition and fluid management, multimodal analgesia and early mobilization are relatively recent, but have shoed promising results. However, adoption of these principles is slow and there is still considerable variation in consensus of elements of ERAS in microsurgical breast reconstruction. Uniquely, this study is the first to look at adoption of ERAS pathways in a private practice microsurgical breast reconstruction model.

Objectives

The purpose of this study is to assess the effectiveness of an ERAS pathway for microsurgical breast reconstruction in the private practice setting. Our hypothesis is that execution of an ERAS pathway will result in decreased opioid usage and shorter length of stay without significant increase in complications.

Methods

A retrospective analysis of consecutive patients undergoing DIEP flap breast reconstruction from November of 2015 to April of 2018 was performed. Study populations were defined relative to uniform implementation of an ERAS pathways, which included preoperative counseling, optimization of nutrition, perioperative fluid management, early mobilization and multimodal analgesia. Patient age, medical comorbidities, and BMI were recorded preoperatively. Procedural characteristics and immediate postoperative morbidity were recorded along with length of hospitalization. Utilization of narcotics was standardized for the entire hospitalization by determining morphine milligram equivalents. 

Results

During the study period, 409 patients met inclusion criteria. The pre-ERAS group was comprised of 205 patients, while 204 patients were managed via ERAS pathway. Step wise multivariate regression analysis, decreased LOS was associated (p< 0.001) with ERAS protocol implementation, decreased OR time and patient age. Decreased narcotic usage was associated (p < 0.05) with ERAS protocol implementation, decreased OR time, patient age and BMI.

Conclusions

In conclusion, our study examined the effect of enhanced pathway in microsurgical breast reconstruction in a large private practice. Benefits observed included less postoperative opioid usage and decreased length of stay without increase in complications.

You can learn more about our ERAS protocol HERE.

Author: Dr. Oscar Ochoa and Courtney Floyd