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Enhanced recovery after surgery (ERAS) protocols have been shown to improve perioperative care in many different surgical settings. As ERAS protocols become increasingly common in microsurgical breast reconstruction, this practice should be critically evaluated to determine efficacy and safety. The goal of this study was to measure the outcomes of a specific Northwell Health ERAS protocol for breast reconstruction patients, and specifically identify which factors of the protocol most contribute to these outcomes.
Methods
An ERAS protocol was designed for microsurgical breast reconstruction patients. The primary focus of the protocol was to improve patients’ postoperative recovery experience and decrease length of stay without compromising surgical outcomes and patient safety. All consecutive patients treated by a single surgeon (NT) during the first 12 months of ERAS implementation were compared to a control group of patients from the 12 months prior. Demographic data as well as intraoperative and postoperative data were recorded. Complications requiring a return to the operating room or readmission to the hospital within 30 days were recorded. Statistical analysis was performed to determine any significant differences between the two groups. Multivariable linear regression analysis was used to identify any factors predictive of total opioid use, maximum pain scores, and length of stay.
Results
A total of 120 patients were identified, including 74 ERAS and 46 pre-ERAS patients. Patients in the two groups were similar with respect to demographics, reconstruction type, history of neoadjuvant chemotherapy, and history of radiotherapy. ERAS patients had significantly shorter lengths of stay (4.0 vs. 3.1 days; p>.001) and used fewer doses of opioids (91.77 vs. 54.52 morphine equivalents; p=.012). Rates of complications were similar between groups (23.9% vs. 13.5%; p=.145). Linear regression revealed lower pain scores on postoperative day (POD) 1 and 2 and patient being out of bed on POD1 were predictive of decreased total opioid use. Factors predictive of decreased length of stay included patient out of bed on POD1, decreased total opioid use, and participation in the ERAS protocol. Increased total opioid use was predictive of increased pain scores on day of discharge.
Conclusion
For microsurgical breast reconstruction patients, ERAS protocols may significantly improve and expedite the postoperative recovery experience without an increased risk of complications. The statistical models show various aspects of ERAS being predictors of decreased opioid use, decreased pain scores, and decreased length of stay.