Enhanced Recovery after Surgery (ERAS) in DIEP-Flap Breast Reconstructions-A Comparison of Two Reconstructive Centers with and without ERAS-Protocol

Efficacy of the enhanced recovery after surgery protocol on reducing surgical disparities related to overweight/obesity in deep inferior epigastric perforator flap breast reconstruction

BACKGROUND

When choosing a method of deep inferior epigastric perforator (DIEP) flap for breast reconstruction, concerns regarding the potentially detrimental effects of obesity on postoperative recovery remain. Enhanced recovery after surgery (ERAS) is known to facilitate rapid postoperative recovery. This study aimed to examine the effect of the ERAS protocol on the disparity between normal/underweight and overweight/obese patients after DIEP flap breast reconstruction.

METHODS

A retrospective review of consecutive patients who underwent DIEP flap breast reconstruction between January 2015 and November 2022 was conducted. The patients were categorized into two groups: pre-ERAS and post-ERAS. In each group, associations between overweight/obese patients (BMI ≥25 kg/m2 ) and postoperative course were evaluated.

RESULTS

In total, 217 patients in the pre-ERAS group (including 71 overweight/obese) and 165 in the post-ERAS group (including 58 overweight/obese) were analyzed. The post-ERAS group had shorter length of stay (LOS) (8.0 versus 7.0 days, p-value <.001) and lower postoperative pain scores (5.0 versus 3.0 at postoperative day (POD) 1, p-value <.001) than the pre-ERAS group. The complication profiles did not differ according to ERAS adoption. In the pre-ERAS group, overweight/obese patients showed a significantly longer LOS (8.0 versus 9.0 days, p-value = .017) and a higher postoperative pain score (3.0 versus 4.0 at POD 2, p-value = .018) than normal/underweight patients; however, these differences disappeared in the post-ERAS group, showing similar LOS, pain scores, and analgesic consumption.

CONCLUSIONS

Implementation of the ERAS protocol in DIEP free-flap breast reconstruction may reduce overweight/obesity-related disparities in postoperative recovery.

Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction

Background and Objective

After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway.

Methods

All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed.

Key Content and Findings

Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions.

Conclusions

Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.

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.

The clinical impact of pectoral nerve block in an 'enhanced recovery after surgery' program in breast surgery

Background: Pectoral nerve block (PECS) is increasingly performed in breast surgery. Aim: The study evaluated the clinical impact of these blocks in the postoperative course. Patients & methods: In this case-control study, patients undergoing breast surgery with 'enhanced recovery after surgery' pathways were divided into group 1 (57 patients) in whom PECS was performed before general anesthesia, and group 2 (57 patients) in whom only general anesthesia was effected. Results: Postoperative opioid consumption (p < 0.002), pain at 32 h after surgery (p < 0.005) and the length of stay (p < 0.003) were significantly lower in group 1. Conclusion: Reducing opioid consumption and pain after surgery, PECS could favor a faster recovery with a reduction in length of stay, ensuring a higher turnover of patients undergoing breast surgery.

The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization

BACKGROUND

Patients undergoing primary palatoplasty rely on narcotics for pain control, but narcotics can lead to sedation and respiratory depression. Recent research into Enhanced Recovery After Surgery (ERAS) pathways utilizing multimodal pain therapy has yielded promising results for patients undergoing palatoplasty in terms of decreased hospital length of stay (LOS), increased oral intake, and decreased narcotic usage. Despite the potential benefit of ketorolac after palatoplasty, there is a paucity of data regarding its use.

METHODS

A single-center cohort study of patients undergoing primary palatoplasty was performed using 2 cohorts: a retrospective cohort treated with our institution's prior ERAS protocol from 2016 to 2018 and a prospective group of patients who also received ketorolac (ERAS+K) postoperatively from 2020 to 2022.

RESULTS

A total of 85 patients (57 ERAS and 28 ERAS+K) were included. Compared with the ERAS group, the ERAS+K cohort had significantly decreased LOS (31.8 versus 55 h, P =0.02), decreased morphine milligram equivalents administered at 24 hours (1.5 versus 2.5, P =0.003), 48 hours (0 versus 1.5, P <0.001), and total inpatient morphine milligram equivalents (1.9 versus 3.8, P =0.001). The ERAS+K group also had a significant decrease in the prescribed narcotic rate (32.1% versus 61.4%, P =0.006). No bleeding issues, blood transfusions, or reoperations were noted in either cohort.

CONCLUSIONS

This study illustrates many potential benefits of using ketorolac as a pain management adjunct in combination with a multimodal pain regimen. Our results demonstrated favorable outcomes, including decreased narcotic usage and LOS as well as increased hourly oral intake, without increasing bleeding complications.

A Single-center Comparison of Unipedicled and Bipedicled Diep Flap Early Outcomes in 98 Patients

The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One or two pedicles may be used. Our study is the first to compare unipedicled and bipedicled DIEP flaps on donor and recipient site outcomes in the same patient cohort.

Methods

This is a retrospective cohort study comparing DIEP flap outcomes between 2019 and 2022.

Results

There were 98 patients, categorized differently for recipient or donor site. The recipient groups were unilateral unipedicled (N = 52), bilateral unipedicled (N = 15), and unilateral bipedicled (N = 31), and donor site groups were unipedicled (N = 52) and bipedicled (N = 46, including bilateral unipedicled and unilateral bipedicled). Bipedicled DIEP flaps had 1.15 times greater odds of donor site complication (95% CI, 0.52-2.55). Adjusting for operative time that was longer in bipedicled DIEP flaps (P < 0.001), odds ratio decreased, and there was a lower probability of donor site complication for bipedicled flaps (OR, 0.84; 95% CI, 0.31-2.29). Odds of recipient area complication was not significantly different between groups. Unilateral unipedicled DIEP flaps had significantly higher rates of revisional elective surgery than unilateral bipedicled DIEP flaps (40.4% versus 12.9%; P = 0.029).

Conclusions

We demonstrate no significant difference in donor site morbidity between unipedicled and bipedicled DIEP flaps. Bipedicled DIEP flaps do have slightly higher rates of donor site morbidity, which can be partly explained by longer operative times. There is no significant difference in recipient site complications, and bipedicled DIEP flaps can reduce rates of further elective surgery.

The Scarless Neo-Umbilicus in DIEP-Flap Breast Reconstruction

While the DIEP (deep inferior epigastric perforator) flap has become the gold standard in autologous breast reconstruction due to its favourable tissue characteristics and preserved abdominal wall function, a constant attempt is done to improve the outcome of the donor site. Even if just a small detail, the umbilicus has a big impact on the overall aesthetic outcome of the donor site. As an already established technique in abdominoplasties, we introduced the neo-umbilicus as the standard procedure for DIEP donor site closure. The aim of this study was to assess the aesthetic outcome of this neo-umbilicoplasty technique in DIEP-flaps. This is a single-center cohort study. A total of 30 consecutive breast cancer patients were treated during a period of 9 months with a mastectomy and an immediate reconstruction with a DIEP-flap. In all patients, the reconstruction of the umbilicus was done by an immediate neo-umbilicoplasty technique, consisting of a cylindrical fat resection at the new loco typico and fixation of the dermis directly to the rectus fascia. All patients were photographed in a standardised setting. Subjective patient satisfaction was assessed with a survey consisting of three questions and aesthetic outcome was evaluated by an independent professional panel consisting of three plastic surgeons. The results were compared to a previous cohort of conventional umbilicoplasties in DIEP-flap patients. Twenty-six patients participated in the follow-up study. There were no wound complications associated with the neo-umbilicus. Questionnaire results demonstrated high but not statistically significant different patient satisfaction. The panel scores were statistically significant (p < 0.05) better for the neo-umbilicus reconstructions. The aesthetic outcome was rated higher in patients with a higher BMI compared to those in patients with a low BMI. The creation of a neo-umbilicus at the donor site after DIEP-flap breast reconstruction is a quick and safe technique and leads to a superior aesthetic donor site result.

Comparing complications and perioperative teams in microsurgical breast reconstruction: retrospective cohort study

Background

Subspecialization with dedicated perioperative teams has become common practice in some surgical disciplines. While surgeon experience, the number of surgeons involved, and enhanced recovery after surgery (ERAS) pathways are known factors affecting the outcome after microsurgical breast reconstruction, the impact of the perioperative team has not been studied.

Methods

We conducted a retrospective cohort study consisting of a chart review of all patients who underwent microsurgical breast reconstruction from January 2019-April 2020. Surgery was performed by three microsurgeons at two institutions with different perioperative teams-one being a small clinic [private clinic (PC), 33 beds] and the other being a larger hospital [corporate hospital (CH), 335 beds]. Patients were grouped into two cohorts according to the institution where surgery was performed. The primary outcomes studied were frequency of revision surgery, flap loss and patient length-of-stay (LOS).

Results

One hundred and fifty microsurgical breast reconstructions were performed in 125 patients. Demographic data [age, body mass index (BMI), current tobacco use, donor site] was found statistically comparable between both cohorts. In the PC cohort with fewer perioperative care providers, lower rates of revision surgery and flap loss were observed (P value =0.009 and 0.04, respectively). LOS was not significantly different between the two cohorts (P value =0.44).

Conclusions

The outcome of microsurgical breast reconstruction depends on multiple factors. In this study, fewer flap complications occurred at the small clinic. One reason among others might be the lower number of perioperative care providers involved and hence higher likelihood of sharing microsurgical cases, which facilitates routine and ensures less variability in care. The value of perioperative team subspecialization in microsurgical breast reconstruction needs to be assessed in prospective studies.

Autologous Breast Reconstruction with Free Nipple–Areola Graft after Circumareolar (Skin Reducing) Mastectomy

Introduction of skin-sparing mastectomy (SSM) led to a paradigm shift in breast reconstruction. Primary reconstructions have become the therapy of choice. At the same time, immediate autologous reconstructions are oncologically safe and aesthetically pleasing. Our preferred SSM incision is the circumareolar with removal of nipple and areola (NAC). Adjustment of the skin envelope is well accomplished in mild-to-moderate ptotic breasts. We describe our technique consisting of circumareolar incision in SSM, keeping the NAC as a free graft, and immediate autologous reconstruction and immediate free NAC grafting on the flap. Aesthetic indications are slight asymmetries, ptotic breasts, large breasts where the reconstructed breast will be smaller than the original breast and where a Wise pattern is not indicated. Oncologic indications are risk-reducing mastectomies and tumors close to the NAC where resection would compromise the vitality of the NAC. We evaluated the healing of the NAC and the NAC position with regard to the breast shape. From 2019–2022, 296 autologous flaps were used for breast reconstruction. In 36 flaps, this technique was applied. Eighteen flaps were bilateral (nine patients). In total, we performed 15 inner thigh flaps and 21 DIEP flaps. No flap or NAC loss occurred. There was no wound healing complication at the breast, and no adjuvant chemotherapy or radiation therapy needed to be postponed. The advantages of this technique are (1) scar reduction with only one periareolar scar on the breast, which is also well concealed; (2) oncological safety in relation to the nipple and optimal visibility of the mastectomy cavity, which allows a meticulous mastectomy, especially important in risk-reducing mastectomies; (3) generally, fewer wound healing problems, especially fewer than with Wise pattern incision; (4) primary adjustment of the skin envelope and positioning of the NAC are easier to perform than in a secondary procedure; and (5) that the NAC is spared, and no secondary reconstruction is necessary. Disadvantages are that (1) the NAC must heal as a free graft and (2) that the sensitivity of the NAC is lower than in pedicled NAC transposition.