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Beyond The Abdomen: Extending The Enhanced Recovery After Surgery (eras) Pathway To Thigh-based Microsurgical Breast Reconstruction
David Nash, MD, Nicolas Greige, BS, Katie Weichman.
Montefiore Medical Center, New York, NY, USA.

PURPOSE:
There is mounting evidence to support universal adoption of enhanced recovery after surgery (ERAS) pathways in patients undergoing microsurgical breast reconstruction. Champions of ERAS cite its ability to safely decrease length of hospital stay and opioid requirements. However, this data is entirely based upon patients treated with abdominal-based free flaps and fails to considering the growing popularity of alternative donor sites. The authors sought to examine the outcomes of patients undergoing both thigh and abdominal-based breast reconstruction before and after implementation of ERAS protocols. METHODS:
A retrospective review of all patients that underwent microsurgical breast reconstruction over a two-year period at a single institution was conducted. Patient demographics and perioperative data were compared between those managed utilizing ERAS recommendations or pre-ERAS standards of care. Univariate analyses were performed for group comparisons. RESULTS:
Eighty-two consecutive patients were identified, forty-one in each group. The mean age was 52.08.9 years. There were significantly more thigh-based flaps in the ERAS group than in the pre-ERAS group (22.0% vs. 2.4%, p=0.007). Average length of stay (LOS) was similar between the ERAS and pre-ERAS groups (3.5 vs. 3.6 days, p=0.486). During the immediate 24-hour post-operative period, patients in the ERAS group required significantly less opioids for pain management (24.2 vs. 31.9 mg of oral morphine equivalents, p=0.002), however there was no significant difference in opioid utilization throughout the remainder of the hospital stay (9.7 vs. 13.6 mg/day of oral morphine equivalents, p=0.318). Additionally, patients in the ERAS group had significantly increased post-operative intravenous fluid demands during the length of their hospital stay (40 vs. 31 mL/kg/day, p=0.023). A subgroup analysis comparing patients that underwent thigh-based flaps and abdominally based flaps within the ERAS group revealed no significant difference in LOS (3.3 vs. 3.5 days, p=0.507) or post-operative opioid utilization (9.6 vs. 12.5 mg/day of oral morphine equivalents, p=0.537). CONCLUSION:
Patients undergoing thigh and abdominal-based microsurgical breast reconstruction appear to benefit equally from adoption of ERAS protocols with regards to reducing overall opioid requirements. Our series did not show a difference in length of stay between ERAS and pre-ERAS cohorts, but did identify peri-operative fluid management and multimodal pain control regimen beyond the first 24 hours as areas in which current ERAS protocols may be further improved.


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