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Enhanced Recovery After Surgery Pathway for Microsurgical Breast Reconstruction: a Systematic Review and Meta-Analysis
Mohamad E. Sebai, MBBS, Charalampos Siotos, MD, Rachael Payne, BS, Stella M. Seal, MLS, Mehran Habibi, MD, Kristen Broderick, MD, Michele M. Manahan, MD, Gedge D. Rosson, MD.
Johns Hopkins, Baltimore, MD, USA.

PURPOSE: Enhanced Recovery After Surgery pathway (ERAS) was introduced in 1997 as a multimodal approach to improve postoperative outcomes. ERAS pathways have become increasingly accepted and implemented for many procedures in several surgical specialties, which successfully improved postoperative pain control, reduced length of stay (LOS), and reduced costs. However, there is yet no widely accepted ERAS for microsurgical breast reconstruction. The purpose of this study is to conduct a systematic review of the current literature on ERAS for microsurgical breast reconstruction and to do a meta-analysis to determine whether the use of ERAS in microsurgical breast reconstruction cases is associated with any changes in LOS, or postoperative morbidity.
METHODS: We searched PubMed, Embase, Cochrane, Scopus and Web of Science for all randomized control trials, case-control, retrospective cohort, and prospective cohort studies published prior to June 2016 that contain original data investigating ERAS in microsurgical breast reconstruction in relation to postoperative LOS and morbidity. Studies found were screened using eligibility criteria previously agreed upon by the authors. Meta-analysis, odds ratio(OR) and 95% confidence interval (CI) were used to pool acquired data.
RESULTS: The initial search identified 87 studies. Two independent screeners identified four original articles, with a pooled population of 676 patients that met the inclusion criteria. Of those, there were three retrospective studies and one prospective study. While LOS data was not homogenous enough to do a meta-analysis, ERAS LOS was reported in three studies to be lower when compared to the previous protocols, from 6.6 to 3.9 days (p < 0.001), 7.4 to 6.2 days (p< 0.001), and 6.2 to 3.1 days (p< 0.001). Two studies were pooled for the meta-analysis of postoperative morbidity, which suggested that ERAS was not associated with changes in 30 days postoperative morbidity; partial flap loss p=0.44 (OR 1.80, 95% CI: 0.41-7.95), total flap loss p=0.91 (OR 1.07, 95% CI: 0.35-3.23), breast hematoma p=0.69 (OR 1.15, 95% CI: 0.59-2.21), donor site infection p=0.53 (OR 1.29, 95% CI: 0.58-2.86), urinary tract infection p=0 .29 (OR 0.37, 95% CI: 0.06-2.29), and pneumonia p=0.42 (OR 1.81, 95% CI: 0.43-7.66).
CONCLUSION: Our review suggests that ERAS in microsurgical breast reconstruction is associated with lower LOS. Meta-analysis suggests that ERAS is not associated with increased postoperative morbidity. The results of this review are limited by the low number of prospective and randomized controlled trials, the small number of patients and studies included, and the moderate heterogeneity of the groups evaluated within the included studies.


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