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Comparison of Outcomes for Patients Undergoing Free Flap Autologous Breast Reconstruction Utilizing a Multimodal Enhanced Recovery Pathway Versus Traditional Care
Niles J. Batdorf, M.D., Ronnie Mubang, M.D., Goede Whitney, Pharm.D., R.Ph., Karla Ballman, Ph.D., Jenna Lovely, Pharm.D., R.Ph., Pamela Grubbs, R.N., C.N.S., Bungum Lisa, R.N., Andria Hinckley, R.N., C.N.P., Valerie Lemaine, M.D., Michel Saint-Cyr, M.D..
Mayo Clinic, Rochester, MN, USA.
Purpose: Enhanced recovery after surgery pathways (ERAS) have been utilized in other surgical specialties and been shown to reduce length of hospital stay after surgery, but they have not been described for patients undergoing free flap breast reconstruction. The purpose of this study was to develop an ERAS pathway specific to plastic surgery free flap breast reconstruction.
Methods: An enhanced recovery after surgery pathway (ERAS) was developed through multidisciplinary collaboration between a plastic surgeon, anesthesiologists, pharmacists, and nursing staff. The ERAS pathway included preoperative analgesia, use of intraoperative liposomal bupivacaine in the surgical site, avoidance of postoperative opioids, pre-emptive nausea and vomiting treatment, avoidance of routine intensive care unit monitoring, immediate resumption of diet, and early ambulation. All patients were treated using the ERAS pathway once it was instituted. Postoperative outcomes were retrospectively analyzed and compared to a historical cohort of patients treated in a traditional care after surgery (TRAS), non-pathway manner. All patients in the study were operated on and under the care of a single staff surgeon within a 12 month period. Patients were excluded from the study if they had a pre-operatively diagnosed coagulopathy or a chronic pain syndrome.
Results: A total of 48 patients were analyzed, 17 treated with TRAS, and 31 patients with ERAS. The total number of flaps in the cohort was 83. Flaps were either deep inferior epigastric perforator flaps (n=71), muscle sparing transverse rectus abdominis flaps (n=7), or transverse upper gracilis flaps (n=5). The hospital stay averaged 4.4 days with TRAS, but decreased to 3.0 days with ERAS (p=0.0007). None of the ERAS patients were admitted to the ICU post-operatively. Total inpatient postoperative opioid usage for the first three days, calculated in oral morphine equivalents, was 321.3 mg for TRAS, but decreased to 142.3 mg with ERAS (p=0.005). Pain goal and scores (from 1-10) were analyzed for the first 3 days at 8 time points. At 24 hours postoperatively, pain scores in the ERAS cohort were significantly better than TRAS (p=0.014), however, this was the only time point with a statistically significant difference. The observed 30 day complication rate between ERAS and TRAS cohorts was not statisitically significant (p=0.28).
Conclusions: The initiation of an Enhanced Recovery After Surgery pathway for breast free flap reconstruction significantly reduced hospital stay in our study. The pathway also significantly decreased the amount of opioids used post-operatively by more than 50% without a consequent increase in patient reported pain score. A free flap breast reconstruction ERAS pathway is a powerful tool to deliver high-value, quality care and decrease costs.
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