Perioperative Optimization of Autologous Breast Reconstruction

Intraoperative Methadone: A New Enhanced Recovery After Surgery Pathway for Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

Inadequate postoperative pain relief places patients at risk for increased morbidity, including surgical complications and chronic postoperative pain. Previous studies have shown that just one dose of methadone can achieve better analgesia than multiple doses of short-acting opioids. This study aims to evaluate the effectiveness of our Enhanced Recovery After Surgery (ERAS) protocol for deep inferior epigastric perforator flap breast reconstruction centered around a single weight-based intraoperative dose of methadone.

METHODS

The authors retrospectively reviewed patients from October 2020 to March 2021 to establish a historical control cohort (n = 29). The ERAS protocol was implemented in April 2021, and patients were prospectively enrolled in the ERAS cohort from April 2021 to January 2022 (n = 54). Primary outcomes compared between the ERAS and historical cohorts using univariate analysis were length of stay, postoperative opioid consumption, pain scores, heart rates, and incidence of tachycardia.

RESULTS

There was no difference in the length of stay between our ERAS and non-ERAS cohorts (P = 0.68). Patients in the ERAS pathway had significantly less opioid consumption at 12 hours postoperatively (P < 0.001), 24 hours postoperatively (P < 0.001), and throughout the entire admission (P = 0.002). Pain scores were significantly lower in the ERAS cohort at 24 hours postoperatively (P = 0.021) and throughout admission (P = 0.0051). The ERAS cohort had significantly lower heart rates at 12 hours postoperatively (P = 0.0014), 24 hours postoperatively (P < 0.001), and throughout admission (P < 0.001). The incidence of tachycardia was also significantly lower in the ERAS cohort (P = 0.029).

CONCLUSIONS

This preliminary data after newly instituting our ERAS protocol with a single dose of intraoperative methadone significantly reduced postoperative opioid analgesic usage, pain scores, heart rates, and incidence of tachycardia. This pilot study demonstrates that methadone has the potential to be used for patients undergoing plastic surgery procedures, both inpatient and ambulatory, to decrease postoperative pain, opioid use, and increase overall patient comfort and satisfaction.

Reduced length of stay and less systemic complications, implementation of the optimized DIEP recovery pathway

BACKGROUND AND AIMS

The present study aimed to compare patients who underwent deep inferior epigastric perforator (DIEP) flap reconstruction with and without the implementation of the new optimized surgical recovery pathway. The new protocol aims to standardize and optimize perioperative management, shorten hospital stays, and lower complication rates for patients undergoing major surgical procedures.

METHODS

Consecutive patients who underwent immediate or delayed DIEP flap breast reconstruction were included in this study. Data regarding patient demographics, timing, laterality of reconstruction, hospital length of stay (LOS), and drain management were collected and compared for the pre-protocol group and the post-protocol group.

RESULTS

The pre-protocol group consisted of 65 patients, while the post-protocol group consisted of 68 patients. The two groups had similar total complication rates (pre-protocol 43.1% versus post-protocol 32.4%, p = 0.20). Between the two groups, there was a significantly lower rate of major surgical complications in the post-protocol group (pre-protocol 32.3% versus post-protocol 14.7%, p = 0.016). There were no significant differences between the groups regarding minor surgical complications (pre-protocol 7.7% versus post-protocol 17.6%, p = 0.086). In the pre-protocol group, the mean LOS was 6.1 days (range = 4-10, median = 6); in the post-protocol group, the mean LOS was 3.6 days (range = 3-10, median = 3; p < 0.00001). Majority of the post-protocol patients were discharged on postoperative day 3 (n = 47, 69.1%).

CONCLUSION

Patients undergoing DIEP flap reconstruction can be discharged earlier without risking their safety by following the new protocol.

Post-mastectomy radiation therapy after breast reconstruction: from historic dogmas to practical expert agreements based on a large literature review of surgical and radiation therapy considerations

Breast reconstruction (BR) after mastectomy is important to consider for a woman's body image enhancement and psychological well-being. Although post-mastectomy radiation (PMRT) significantly improves the outcome of patients with high-risk breast cancer (BC), PMRT after BR may affect cosmetic outcomes and may compromise the original goal of improving quality of life (QoL). With the lack of practical guidelines, it seems essential to work on a consensus and provide some "expert agreements" to offer patients the best option for PMRT after BR. We report a global "expert agreement" that results from a critical review of the literature on BR and PMRT during the 6th international multidisciplinary breast conference in March 2023.

Enhanced recovery after surgery pathways for deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis

BACKGROUND

Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach.

METHODS

Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4).

RESULTS

A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant.

CONCLUSIONS

The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol.

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction

Background

Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center.

Methods

The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls.

Results

The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant.

Conclusion

Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.

Trends and Innovations in Autologous Breast Reconstruction

More than 40 years have passed since the description of the first "free abdominoplasty flap" for breast reconstruction by Holmström. In the meantime, surgical advances and technological innovations have resulted in the widespread adoption of autologous breast reconstruction to recreate the female breast after mastectomy. While concepts and techniques are continuing to evolve, maintaining an overview is challenging. This article provides a review of current trends and recent innovations in autologous breast reconstruction.

Outcomes and Economic Evaluation in Delayed Two-Stage Breast Reconstruction in Romania: The Influence of Radiotherapy

The current paper is a retrospective cohort study conducted on sixty-seven patients who underwent two-stage breast reconstruction over a 5-year period (2015-2020). Forty-one (61.2%) patients received radiotherapy (RT group), and twenty-six (38.8%) did not (non-RT group). Data regarding patients, oncological therapies, type of reconstruction, time of hospitalization, complications, and costs were collected. The statistical analysis was performed using IBM SPSS Statistics 25. General complications were noted for 18 patients (43.9%) in the RT group and for 7 patients (26.9%) in the non-RT group. Major complications were observed only in the first group (five patients-12.2%). The mean time of hospitalization in the RT group was 14.83 days for patients with complications versus 9.83 days for those without complications and 15.5 days versus 8.63 days, respectively, in the non-RT group. The mean cost for patients without complications was 235.64 euros, whereas the cost for patients with complications was 330.24 euros (p = 0.001). Radiation therapy can affect the overall outcome by increasing the risk of complications and increasing costs; however, our paper shows that the association of alloplastic reconstruction in patients with radiotherapy can be performed safely and with low costs in carefully selected patients.

Enhanced recovery after microvascular reconstruction in head and neck cancer – A prospective study

Objectives

Patients undergoing microvascular reconstruction after head and neck cancer typically have several comorbidities, and the procedures are often followed by complications and prolonged hospitalization. Consequently, the application of enhanced recovery after surgery (ERAS) for these patients undergoing microvascular reconstruction has gained attention in recent years. ERAS is a peri- and postoperative care concept that has repeatedly shown beneficial results for a wide variety of surgical procedures, including microvascular reconstruction. This study presents the results after the introduction of our ERAS protocol for head and neck cancer reconstruction.

Methods

We prospectively treated 30 consecutive patients according to our ERAS protocol from June 2019 to December 2020 and compared the results of the treated patients with those of patients treated with our traditional recovery after surgery (TRAS) protocol. We are based on our ERAS protocol on the following core elements of recovery: improved patient information, goal-directed fluid therapy, minimally invasive surgery, opioid-sparing multimodal analgesia, early ambulation, and pre-defined functional discharge criteria.

Results

The baseline characteristics of the groups were comparable. The ERAS group had a significantly shorter length of stay (13.1 vs. 20.3 days, p < 0.001), significantly shorter time to ambulation (3.0 days vs. 6.4 days, p < 0.001), shorter time to removal of nasogastric tube (13.3 days vs. 22.7 days, p = 0.05), and fewer tracheostomies performed (10% vs. 90%, p < 0.001). There were no differences in complications, flap survival, or 30-day re-admissions between the two groups.

Conclusion

The introduction of ERAS in patients with head and neck cancer undergoing microvascular reconstruction seems safe and results in improved recovery.

Level of evidence

3

Implementing the Robotic deep inferior epigastric perforator Flap in daily practice: A series of 10 cases

The deep inferior epigastric perforator (DIEP) flap is the workhorse in microvascular breast reconstruction. Rectus muscle sacrifice or denervation and inappropriate rectus sheath closure are the main causes of abdominal wall morbidity. Robotic vessel dissection may limit fascial incision length below the arcuate line and rectus denervation. This study describes and focuses on the implementation and feasibility of this technique in daily surgical practice. A retrospective data collection of all robotic DIEP flap reconstructions between August 2020 and October 2021 was conducted at our university hospital. Primary outcome variables were flap success and intraoperative complications. Secondary variables included timing of the different robot-assisted stages, total operating time, and postoperative complications within 6 weeks. In total, 10 robotic DIEPs were performed using a multiport robotic system through the transabdominal preperitoneal approach. Nine short intramuscular (SIM) and 1 subfascial (SF) perforators were selected based on the preoperative imaging. There were no perioperative intra-abdominal complications or flap losses. Robotic installation ranges from 16 to 40 min. Mean robot-assisted operating time was 86 min, and mean operative time was 479 min. We present the largest case series of robotic DIEP flap reconstructions for delayed and immediate autologous breast reconstruction through a transabdominal preperitoneal approach. This technique is safe, reproducible, and feasible in a daily hospital setting. We have observed a steep learning curve associated with robotic vessel dissection. Future research may optimize surgical technique, assess possible benefit on abdominal wall morbidity, and evaluate cost-effectiveness.

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction

At our institution, multimodal opiate-sparing pain management is the cornerstone of our enhanced recovery program for autologous breast reconstruction. The purpose of this study was to compare postoperative outcomes and pain control metrics following implementation of an enhanced recovery program with two different regional analgesia approaches.

National Trends in Length of Stay for Microvascular Breast Reconstruction: An Evaluation of 10,465 Cases Using the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Decreasing length of stay benefits patients and hospital systems alike. This should be accomplished safely without negatively impacting patient outcomes. The authors hypothesize that in the United States, the average length of stay for patients undergoing microsurgical breast reconstruction has decreased since 2012 without a concurrent increase in complication and readmission rates.

METHODS

The authors identified female patients who underwent microvascular breast reconstruction (CPT 19364) from the 2012 to 2018 National Surgical Quality Improvement Program database. Trends in complication and readmission rates and length of stay were examined over 7 years. Multivariable logistic regression models and Mann-Kendall trend tests were used to evaluate associations between length of stay and complication and readmission rates.

RESULTS

A total of 10,465 cases were identified. The number of autologous microvascular breast reconstruction procedures performed increased annually between 2012 and 2018. Length of stay decreased significantly from 2012 to 2018 (from 4.47 days to 3.90 days) (p < 0.01). Minor and major complication rates remained constant, although major complications showed a decreasing trend (from 27 percent to 21 percent) (p = 0.07). Thirty-day readmission, surgical-site infection, and wound dehiscence rates remained consistent over the study period, whereas rates of blood transfusion or bleeding decreased (p = 0.02).

CONCLUSIONS

Using a national sample from 2012 to 2018, the authors observed a significant decrease in length of stay for patients undergoing microvascular breast reconstruction without a concurrent increase in complication and readmission rates. Current efforts to reduce length of stay have been successful without increasing complication or readmission rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Breast reconstruction using the profunda artery perforator (PAP) flap: Technical refinements and evolution, outcomes, and patient satisfaction based on 116 consecutive flaps

INTRODUCTION

When a deep inferior epigastric artery flap is not suitable, the profunda artery perforator (PAP) flap can be a good alternative for autologous breast reconstruction. Popularity of the PAP flap is expanding, but it is still only slowly being adopted worldwide. We report our experience with 116 consecutive PAP flaps showing refinements and evolution of the technique towards improvement in outcomes and patients' satisfaction.

METHODS

We prospectively collected data from consecutive PAP flap breast reconstructions performed from 2016 to 2019. Patients' demographics, pre-, intra-, postoperative data, and revision procedures were analyzed. The BREAST-Q and a specific questionnaire investigating outcomes at the donor site were completed preoperatively and 12 months postoperatively.

RESULTS

One-hundred and sixteen PAP flaps were performed in 86 patients, 64 unilateral and 22 bilateral breast reconstructions. Mean body mass index was 24.72 kg/m² (range 18.9-29.2) and mean flap weight was 251.30 g (range 152-455 g). Complications included donor site hematoma (1.7%), seroma (2.6%), fat necrosis (1.7%), and wound dehiscence (2.6%). No arterial/venous thrombosis nor flap losses were recorded. Patients reported high satisfaction in all BREAST-Q domains, with mean postoperative scores being higher than preoperative ones, suggesting a positive effect in quality of life and satisfaction. Scores were significant in the satisfaction with breast domain (p = 0.0016).

CONCLUSIONS

Breast reconstruction with PAP flap yields a high success, low complications, and excellent cosmetic outcomes in the breast and donor sites. It improves patients' satisfaction and quality of life; hence, it can be considered an excellent option for autologous breast reconstruction.

Long-term results of a standardized enhanced recovery protocol in unilateral, secondary autologous breast reconstructions using an abdominal free flap

BACKGROUND

In 2015, we published one of the first reports using an enhanced recovery protocol (ERP) in microsurgery¹, and in 2016, our final ERP setup in autologous breast reconstruction (ABR) using free abdominal flaps². We showed that by adhering to a few simple, easy to measure, functional discharge criteria, it was possible to safely discharge the patients by the third postoperative day (POD). However, one of the challenges of interpreting studies using ERP in ABR is the often heterogenous patient populations and the need to clearly distinguish between primary and secondary and unilateral and bilateral reconstructions.

MATERIALS AND METHODS

In the 5-year period from 2016-2020, the same surgical team, performed 147 unilateral, delayed breast reconstructions (135 DIEP, 9 MS-TRAM-2, and 3 SIEA flaps) according to our previous analgesic protocol and surgical strategy. Data were collected prospectively.

RESULTS

Three flaps were lost (2%) and 82% of the patients(n=128) were discharged to home by POD 2 (n=8%) or 3 (74%). The remaining 18% (n=26) were discharged by POD 4 (12.5%) or 5 (5.5%). Ten patients (7%) were reoperated, and 17 patients (12%) had minor complications within POD 30 (infection, seroma, etc.) that did not necessitate hospital admission.

CONCLUSION

Using our ERP, unproblematic discharge directly to home is possible on POD 3 in more than 80% of patients after ABR. ERP is no longer a research tool but considered standard of care in microsurgical breast reconstruction.

Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery

BACKGROUND

Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications.

OBJECTIVES

To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery.

SEARCH METHODS

The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials.

SELECTION CRITERIA

We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes.

MAIN RESULTS

We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I² = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I² = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I² = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I² = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I² = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I² = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I² = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I² = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I² = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.

Enhanced Recovery With Paravertebral and Transversus Abdominis Plane Blocks in Microvascular Breast Reconstruction

Purpose:

We have shown previously that a preoperative paravertebral nerve block is associated with improved postoperative recovery in microvascular breast reconstruction. The purpose of this study was to compare the outcomes of a complete enhanced recovery after surgery (ERAS) protocol with complete regional anesthesia coverage to our traditional care with paravertebral block.

Patients and methods:

This was a retrospective cohort study of 83 patients who underwent autologous breast reconstruction by T.M.M. between May 2014 and February 2018 at a tertiary academic center. Patients in the ERAS group were additionally administered acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, a transversus abdominis plane block (liposomal or plain bupivacaine), and primarily oral opioids postoperatively. The patients were mobilized earlier with more rapid diet progression. All patients received a preoperative paravertebral block.

Results:

Forty-four patients in the ERAS cohort were compared with 39 retrospective controls. The 2 groups were similar with respect to demographics and comorbidities. The ERAS cohort required significantly less opioids (291 vs 707 mg oral morphine equivalent, P < .0001) with unchanged postoperative pain scores and a shorter time to oral only opioid use (16.0 vs 78.2 hours, P < .0001). Median length of stay (3.20 vs 4.62, P < .0001) and time to independent ambulation (1.86 vs 2.88, P < .0001) were also significantly decreased in the ERAS cohort. Liposomal bupivacaine use did not significantly affect the results (P ⩾ .2).

Conclusions:

Implementation of a robust enhanced recovery protocol with complete regional anesthesia coverage was associated with significantly decreased opioid use despite unchanged pain scores, with improved markers of recovery including length of stay, time to oral only narcotics, and time to independent ambulation.

Microvascular reconstruction in head and neck cancer - basis for the development of an enhanced recovery protocol

Introduction

Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. Postoperative complications are common, which often leads to prolonged hospital stay. Enhanced recovery after surgery (ERAS) is a peri- and postoperative care concept with the aim of achieving pain- and risk-free surgery. It has been previously established as superior to conventional care for a wide variety of procedures, including microsurgical procedures such as reconstructions of the breast. Several ERAS protocols for microvascular head and neck cancer reconstructions have been proposed, although most of these are based on extrapolated evidence from different surgical specialties. Results from the implementation of ERAS for these procedures are inconsistent.

Methods

The current study investigates our clinical experience of head and neck cancer reconstruction for the period of 2014-2016 with the aim of establishing a list of functional discharge criteria. By combining these with the current published knowledge on the subject, we developed an ERAS protocol.

Results

We performed 89 microvascular procedures in the study period, of which 58 were in the oral cavity/sinuses and 31 were laryngopharyngeal. Most cases were squamous cell carcinoma (89%). The average LOS was 20.3 days in both groups. Postoperative complications included infection (37%), 30-days re-operations (19%), and re-admissions (17%). Furthermore, we identified the following discharge criteria: adequate pain relief, ambulation, sufficient nutritional intake, normal infection-related blood parameter results and absence of fever, bowel function, and closure of tracheostomy.

Conclusion

Based on our retrospective analysis and identified discharge criteria, we present an approach to develop an ERAS protocol for microvascular reconstruction after head and neck cancer.

Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols utilize multi-modal approaches to decrease morbidity, narcotic usage, and length of stay. In 2013, we made several changes to our perioperative approach to children undergoing complex craniofacial procedures. The goal of this study was to analyze our protocol for children undergoing fronto-orbital advancement (FOA) for craniosynostosis.

METHODS

A retrospective chart review was performed after IRB approval, for children who underwent fronto-orbital advancement for craniosynostosis from 2010 to 2018. The ERAS protocol, initiated in December 2013, involves hemoglobin optimization, cell-saver technology, tranexamic acid, specific postoperative fluid titration, and a transfusion algorithm. The analgesic regimen focuses on narcotic reduction through the utilization of scheduled acetaminophen, ibuprofen, or ketorolac, and a dexmedetomidine infusion with opioids only for breakthrough pain.

RESULTS

Fifty-five ERAS protocol children and 23 control children were analyzed. ERAS children had a decreased rate (13/53 versus 23/23, P < 0.0001) and volume of intraoperative transfusion (183.4 mL versus 339.8 mL, P = 0.05). Fewer ERAS children required morphine/dilaudid (12/55 versus 22/23 P < 0.0001) and for children who required morphine, fewer doses were required (2.8 versus 11, P = 0.02). For ERAS protocol children who required PO narcotics, fewer doses were required (3.2 versus 5.3, P = 0.02). ERAS children had a decreased length of stay (2.3 versus 3.6 nights, P < 0.0001). No patients were re-admitted due to poor oral intake, pain, hemodynamic, or pulmonary concerns.

CONCLUSIONS

Our ERAS protocol demonstrated a reduction in the overall and intraoperative allogenic blood transfusion rate, narcotic use, and hospital length of stay. This is a safe and effective multimodal approach to managing complex craniofacial surgical recovery.

Comparative Effectiveness of Transversus Abdominis Plane Blocks in Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The abdomen is the most common donor site in autologous microvascular free flap breast reconstruction and contributes significantly to postoperative pain, resulting in increased opioid use, length of stay, and hospital costs. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated multiple clinical benefits, but these protocols are widely heterogeneous. Transversus abdominis plane (TAP) blocks have been reported to improve pain control and may be a key driver of the benefits seen with ERAS pathways.

METHODS

A systematic review and meta-analysis of studies reporting TAP blocks for abdominally based breast reconstruction were performed. Studies were extracted from 6 public databases before February 2019 and pooled in accordance with the PROSPERO registry. Total opioid use, postoperative pain, length of stay, hospital cost, and complications were analyzed using a random effects model.

RESULTS

The initial search yielded 420 studies, ultimately narrowed to 12 studies representing 1107 total patients. Total hospital length of stay (mean difference, -1.00 days; P < 0.00001; I = 81%) and opioid requirement (mean difference, -133.80 mg of oral morphine equivalent; P < 0.00001; I = 97%) were decreased for patients receiving TAP blocks. Transversus abdominis plane blocks were not associated with any significant differences in postoperative complications (P = 0.66), hospital cost (P = 0.22), and postoperative pain (P = 0.86).

CONCLUSIONS

Optimizing postoperative pain management after abdominally based microsurgical breast reconstruction is invaluable for patient recovery. Transversus abdominis plane blocks are associated with a reduction in length of stay and opioid use, representing a safe and reasonable strategy for decreasing postoperative pain.

Venous Thromboembolism following Microsurgical Breast Reconstruction: A Longitudinal Analysis of 12,778 Patients

BACKGROUND

Venous thromboembolism is a dreaded complication following microsurgical breast reconstruction. Although the high-risk nature of the procedure is well known, a thorough analysis of modifiable risk factors has not been performed. The purpose of this study was to analyze the association of such factors with the postoperative occurrence of venous thromboembolism longitudinally.

METHODS

Using the Truven MarketScan Database, a retrospective cohort study of women who underwent microsurgical breast reconstruction from 2007 to 2015 and who developed postoperative venous thromboembolism within 90 days of reconstruction was performed. Predictor variables included age, timing of reconstruction, body mass index, history of radiation therapy, history of venous thromboembolism, Elixhauser Comorbidity Index, and length of stay. Univariate analyses were performed, in addition to logistic and zero-inflated Poisson regressions, to evaluate predictors of venous thromboembolism and changes in venous thromboembolism over the study period, respectively.

RESULTS

Twelve thousand seven hundred seventy-eight women were identified, of which 167 (1.3 percent) developed venous thromboembolism. The majority of venous thromboembolisms (67.1 percent) occurred following discharge, with no significant change from 2007 to 2015. Significant predictors of venous thromboembolism included Elixhauser score (p < 0.01), history of venous thromboembolism (p < 0.03), and length of stay (p < 0.001). Compared to patients who developed a venous thromboembolism during the inpatient stay, patients who developed a postdischarge venous thromboembolism had a lower mean Elixhauser score (p < 0.001).

CONCLUSIONS

Postoperative venous thromboembolism continues to be an inadequately addressed problem, as evidenced by a stable incidence over the study period. Identification of modifiable risk factors, such as length of stay, provides potential avenues for intervention. As the majority of venous thromboembolisms occur following discharge, future studies are warranted to investigate the role for an intervention in this period.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The Power of Patient Norms: Postoperative Pathway Associated With Shorter Hospital Stay After Free Autologous Breast Reconstruction

INTRODUCTION

Enhanced recovery after surgery pathways designed to optimize postoperative care have become increasingly popular across multiple surgical specialties with proven benefits. In this retrospective cohort study, we present a comparative evaluation of the impact of protocol-based postoperative care on free autologous breast reconstruction patients.

METHODS

With institutional review board approval, we performed a chart review of patients who underwent breast reconstruction with free autologous tissue transfer by a single surgeon from 2006 to 2017. Patients were managed according to a postoperative protocol since 2006 that initially called for discharge home on postoperative day (POD) 4 for unilateral cases and POD 5 for bilateral cases. In May 2015, the protocol was revised to discharge home on POD 3 for all cases. Patients who underwent reconstruction before (2006 to April 2015) and after (May 2015 to 2017) the change in postoperative protocol were compared.

RESULTS

A total of 432 patients (647 breasts) underwent free autologous breast reconstruction during the study period. Flaps were predominantly muscle-sparing transverse rectus abdominis myocutaneous (56.3%) or deep inferior epigastric perforator (30.3%) flaps. Average patient age was 51.6 years (range, 29.7-80.3 years). Unilateral reconstructions were performed for 167 patients before and 50 patients after the protocol change; average hospital length of stay (LOS) was 4.5 and 3.4 days, respectively (P < 0.001). Bilateral reconstructions were performed for 153 patients before and 62 patients after the protocol change; average hospital LOS was 5.1 and 3.5 days, respectively (P < 0.001). There was no significant increase in patients with major or minor complications.

CONCLUSIONS

Revising our postoperative protocol to reduce expected LOS was associated with an overall faster time to discharge without negative consequences in patients who underwent unilateral and bilateral free autologous breast reconstruction. Use of protocols to guide behavior not only can improve the patient experience by promoting a quicker return home, but may also have the added benefit of decreasing healthcare expenditures through reduced inpatient utilization.

A simple method to secure data-driven improvement of perioperative care

Background:

Enhanced recovery after surgery (ERAS) programmes have been adopted to a varying degree by most surgical departments, not only in Denmark, but worldwide.

Aims:

To report the process from a local ERAS unit in a tertiary university hospital to accelerate implementation of ERAS programmes in all surgical specialties.

Methods:

All surgical departments receive twice-yearly procedure-specific data on length of stay (LOS), readmission rates and death within 30 days, based on surgical codes and the Danish National Patient Register. The ERAS unit and clinical experts review data followed by a clinical audit where appropriate.

Findings:

Setting up data presentation for clinical and nurse leaders has documented progress in implementing ERAS. The combination of outcome data, together with audits have been essential.

Conclusion:

The local ERAS unit has been shown to accelerate implementation of ERAS programmes in all surgical specialties, facilitated by procedure-specific LOS and re-admission data, combined with audit data.

Fast-Track Approach for Breast Reconstructive Surgery in Patients With Breast Cancer

Aim:

The aim of this study was to develop and implement the concept of fast-track surgery (FTS) for reconstructive breast surgery in patients with breast cancer (BC) to improve early and long-term results of treatment.

Materials and methods:

The study includes 749 patients with stage 1 to 3 BC. A total of 253 patients with BC got treatment according to FTS program and were included to the core group. Other 496 patients with BC (control group) were not included to the FTS program. Patients were treated from December 2010 to December 2014. All age groups were covered (18-70 years old).

Results:

There was a significant difference in the average length of hospital stay (LOS) which was 14.27 ± 7.00 days in the core group and 20.11 ± 7.70 days in the control group (P < .001). In advanced BC cases in the core group, LOS was >8 days lower comparing with the control group on average. The LOS in patients who underwent adjuvant chemotherapy was 2.7 times lower in the FTS group comparing with the control group.

Conclusions:

The study results allow us to recommend the concept of FTS for implementation in broad medical practice for breast reconstructive surgery in patients with BC. The FTS program was shown to be effective in all types of breast surgery, including immediate oncoplastic and reconstructive surgeries. The gradual reduction of LOS increased the number of surgeries in our department by 75% from 2008 till 2018.

Gabapentin Decreases Narcotic Usage: Enhanced Recovery after Surgery Pathway in Free Autologous Breast Reconstruction

The opioid crisis is public health emergency, in part due to physician prescribing practices. As a result, there is an increased interest in reducing narcotic use in the postsurgical setting.

A structured pathway for accelerated postoperative recovery reduces hospital stay and cost of care following microvascular breast reconstruction without increased complications

INTRODUCTION

Accelerated recovery protocols have proved effective in many surgical procedures but are infrequently applied in breast reconstruction. In this study, we evaluate the impact of a structured pathway for accelerated postoperative recovery in patients undergoing microvascular breast reconstruction at a high-volume center.

METHODS

We describe our care pathway for patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our center. We compared length of stay (LOS), complication rates, readmission rates, and cost of inpatient care before (pre-protocol (Pre-P)) and after (post-protocol (Post-P)) the implementation of the protocol.

RESULTS

Patients in the Post-P group (n = 198) had a significant reduction in mean LOS as compared to those in the Pre-P (n = 183) group (3.6 +/- 0.85 vs. 4.7 +/-1.04 days, p = 0.006). There was no significant difference in the rates of major (Pre-P 16.9% vs. Post-P 14.7%, p = 0.71) or minor (Pre-P 21.3% vs. 17.1%, p = 0.22) postoperative complications between groups. The readmission rates were also similar (Pre-P 6.5% vs. Post-P 4.5, p = 0.69). Implementation of the protocol resulted in a significant reduction in the mean cost of in-patient care.

CONCLUSION

A simple protocol for accelerated and streamlined postoperative recovery effectively reduces LOS and patient care costs following DIEP flap breast reconstruction without compromising patient safety.

Enhanced Recovery after Surgery Pathway for Microsurgical Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

The enhanced recovery after surgery pathway was introduced in 1997 as a multimodal approach to reduce preventable postoperative harm and shorten hospital length of stay. However, there is yet no widely accepted enhanced recovery after surgery protocol for microsurgical breast reconstruction. The authors conducted a systematic review and meta-analysis of the current literature on enhanced recovery after surgery for microsurgical breast reconstruction with regard to postoperative length of stay and morbidity.

METHODS

The PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for all studies published before June of 2016 containing original data on enhanced recovery after surgery in microsurgical breast reconstruction in relation to postoperative length of stay and morbidity. Studies were screened using eligibility criteria. Meta-analysis, odds ratio, and 95 percent confidence interval were used to pool acquired data.

RESULTS

The initial search identified 86 studies. Two independent screeners identified four original articles with a total of 676 patients. Length of stay was significantly shorter for patients on an enhanced recovery after surgery pathway (mean difference, -1.23; 95 percent CI, -1.50 to -0.96; p < 0.001; I = 0 percent; random effects model). Enhanced recovery was not associated with changes in 30-day postoperative morbidity; specifically, no significant difference was observed in rates of partial flap loss (p = 0.44), total flap loss (p = 0.91), breast hematoma (p = 0.69), donor-site infection (p = 0.53), urinary tract infection (p = 0.29), and pneumonia (p = 0.42).

CONCLUSION

The authors' review suggests that enhanced recovery after surgery in microsurgical breast reconstruction is associated with a reduced length of stay, and is not associated with increased postoperative morbidity.

Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature

PURPOSE

Enhanced recovery after surgery (ERAS) pathways are increasingly promoted in post-mastectomy reconstruction, with several articles reporting their benefits and safety. This meta-analysis appraises the evidence for ERAS pathways in breast reconstruction.

METHODS

A systematic search of Medline, EMBASE, and Cochrane databases was performed to identify reports of ERAS protocols in post-mastectomy breast reconstruction. Two reviewers screened studies using predetermined inclusion criteria. Studies evaluated at least one of the following end-points of interest: length of stay (LOS), opioid use, or major complications. Risk of bias was assessed for each study. Meta-analysis was performed via a mixed-effects model to compare outcomes for ERAS versus traditional standard of care. Surgical techniques were assessed through subgroup analysis.

RESULTS

A total of 260 articles were identified; 9 (3.46%) met inclusion criteria with a total of 1191 patients. Most studies had "fair" methodological quality and incomplete implementation of ERAS society recommendations was noted. Autologous flaps comprised the majority of cases. In autologous breast reconstruction, ERAS significantly reduces opioid use [Mean difference (MD) = - 183.96, 95% CI - 340.27 to 27.64, p = 0.02) and LOS (MD) = - 1.58, 95% CI - 1.99 to 1.18, p < 0.00001] versus traditional care. There is no significant difference in the incidence of complications (major complications, readmission, hematoma, and infection).

CONCLUSION

ERAS pathways significantly reduce opioid use and length of hospital stay following autologous breast reconstruction without increasing complication rates. This is salient given the current US healthcare climate of rising expenditures and an opioid crisis.

Improved patient outcomes using the enhanced recovery pathway in breast microsurgical reconstruction: a UK experience

Introduction

The enhanced recovery after surgery (ERAS) pathway is a protocol aimed at optimizing patient care by reducing the physiological alterations caused by surgery, thus reducing recovery time, surgical morbidities and length of stay. This study assessed the impact of ERAS on patients undergoing microsurgical breast reconstruction.

Methods

Patients undergoing microsurgical breast reconstruction over an eight-month period were retrospectively examined. LOS, complication rates and perioperative outcomes were analysed. Results were compared between patients admitted on the traditional recovery after surgery (TRAS) and the ERAS pathways.

Results

One hundred and thirty-eight patients were included. Seventy-two patients were admitted on the TRAS pathway and 66 patients on the ERAS pathway. There was no difference in median LOS (4 days) between the two groups, p = 0.48. We noted a significant reduction in the total number of major complications (ERAS 11%, TRAS 24% p = 0.04) as well as significant differences in time to catheter removal, time to independent mobilisation, total opioid usage and time to removal of PCA, all in favour of the ERAS group. There was a non-significant reduction in return to theatre and readmission rate in the ERAS group (11% versus 21% p = 0.1 and 6% versus 11% p = 0.29 respectively). Obesity and complications were predictors of a prolonged LOS.

Conclusion

The ERAS pathway reduced overall and major complication rates in a tertiary centre using an already streamlined service. Adoption of ERAS pathways to reduce surgical morbidities and improve patient care is encouraged. Further work is required to optimise enhanced recovery in breast microsurgical reconstruction.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

Enhanced Recovery Pathway in Microvascular Autologous Tissue-Based Breast Reconstruction: Should It Become the Standard of Care?

BACKGROUND

Enhanced recovery pathway programs have demonstrated improved perioperative care and shorter length of hospital stay in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue-based breast reconstruction before and after the implementation of an enhanced recovery pathway program.

METHODS

The authors retrospectively reviewed consecutive patients who underwent autologous tissue-based breast reconstruction performed by two surgeons before and after the implementation of the enhanced recovery pathway at a university center over a 3-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-enhanced recovery pathway) and enhanced recovery pathway patients. Multivariate logistic regression was performed to identify risk factors for length of hospital stay. Cost analysis was performed.

RESULTS

Between April of 2014 and January of 2017, 100 consecutive women were identified, with 50 women in each group. Both groups had similar demographics, comorbidities, and reconstruction types. Postoperatively, the enhanced recovery pathway cohort used significantly less opiate and more acetaminophen compared with the traditional standard of care cohort. Median length of stay was shorter in the enhanced recovery pathway cohort, which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342. Participation in an enhanced recovery pathway program and lower total morphine-equivalent use were independent predictors for decreased length of hospital stay. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were similar between the two groups.

CONCLUSION

Enhanced recovery pathway program implementation should be considered as the standard approach for perioperative care in autologous tissue-based breast reconstruction because it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased length of hospital stay, leading to downstream health care cost savings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

An Enhanced Recovery after Surgery Pathway for Microvascular Breast Reconstruction Is Safe and Effective

Supplemental Digital Content is available in the text.

Background:

The aim of this study was to develop, implement, and evaluate a standardized perioperative enhanced recovery after surgery (ERAS) clinical care pathway in microsurgical abdominal-based breast reconstruction.

Methods:

Development of a clinical care pathway was informed by the latest ERAS guideline for breast reconstruction. Key features included shortened preoperative fasting, judicious fluids, multimodal analgesics, early oral nutrition, early Foley catheter removal, and early ambulation. There were 3 groups of women in this cohort study: (1) traditional historical control; (2) transition group with partial implementation; and (3) ERAS. Narcotic use, patient-reported pain scores, antiemetic use, time to regular diet, time to first walk, hospital length of stay, and 30-day postoperative complications were compared between the groups.

Results:

After implementation of the pathway, the use of parenteral narcotics was reduced by 88% (traditional, 112 mg; transition, 58 mg; ERAS, 13 mg; P < 0.0001), with no consequent increase in patient-reported pain. Patients in the ERAS cohort used less antiemetics (7.0, 5.3, 2.2 doses, P < 0.0001), returned to normal diet 19 hours earlier (46, 39, 27 hours, P < 0.0001), and walked 25 hours sooner (75, 70, 50 hours, P < 0.0001). Overall, hospital length of stay was reduced by 2 days in the ERAS cohort (6.6, 5.6, 4.8 days, P < 0.0001), without an increase in rates of major complications (9.5%, 10.1%, 8.3%, P = 0.9).

Conclusions:

A clinical care pathway in microsurgical breast reconstruction using the ERAS Society guideline promotes successful early recovery.

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

BACKGROUND

At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center.

METHODS

A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption.

RESULTS

In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre-enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre-enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6).

CONCLUSION

The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Cyclooxygenase-2 inhibitors and free flap complications after autologous breast reconstruction: A retrospective cohort study

BACKGROUND

A key component of modern analgesics is the use of multimodal opioid-sparing analgesia (MOSA). In the past, our analgesic regime after autologous breast reconstruction (ABR) included either NSAID or a selective cyclooxygenase-2 (COX-2) inhibitor. COX-2 inhibitors are superior to NSAIDs because of the well-known side effects of NSAID treatment (bleeding/gastrointestinal ulcers). However, COX-2 inhibitors have been suggested to increase flap failure rates. We report our experience in using COX-2 inhibitors as part of our post-operative MOSA after ABR using free flaps.

MATERIALS AND METHODS

A total of 132 unilateral secondary ABR were performed (DIEP or MS-TRAM) in the NSAID period (2007-2011) and 128 in the COX-2 inhibitor period (2006, 2012-2014). The same surgical team operated all patients. Data were collected prospectively and reviewed to compare the two periods, with special focus on reoperations due to bleeding/haematomas and flap thrombosis/failure. Comparisons between the COX-2 inhibitor and NSAID were made.

RESULTS

Median age, ischaemia time, blood loss and operating time were similar in the two periods. Significantly, more patients were re-operated because of post-operative haematoma in the NSAID group (n = 13/132, 9.8%) than in the COX-2 inhibitor group (n = 4/128, 3.1%) (p = 0.02). We found no difference in flap loss rates between the NSAID (n = 2/132, 1.5%) and the COX-2 inhibitor groups (n = 3/128, 2.3%) (p = 0.63). No patients suffered from thromboembolic complications or gastrointestinal bleeding.

CONCLUSIONS

Multimodal analgesia using a COX-2 inhibitor is safe in ABR with free flaps and does not increase flap failure. COX-2 inhibitors seem superior to NSAID with reduced risk of post-operative haematomas.