Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. METHODS: This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. RESULTS: Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. CONCLUSION: The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

Defining Enhanced Recovery Pathway with or without Liposomal Bupivacaine in DIEP Flap Breast Reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) includes multiple interventions that have yielded positive outcomes in a number of surgical fields. The authors evaluated whether an ERAS protocol and the subsequent addition of liposomal bupivacaine affect patient outcomes specifically in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: All patients treated with DIEP flaps from January of 2016 to December of 2019 were reviewed retrospectively. The ERAS protocol was implemented midway through 2017; halfway through 2018, intraoperative transversus abdominis plane blocks with liposomal bupivacaine were added to the protocol. Such interventions allowed for comparison of three patient groups: before ERAS, during ERAS, and after ERAS plus liposomal bupivacaine. Primary outcomes observed were postoperative opioid consumption and length of stay. The p values were obtained using the Wilcoxon test for pairwise comparisons. RESULTS: After adjusting for ERAS group compliance, 216 patients were analyzed. The pre-ERAS group was composed of 67 patients, the ERAS group was composed of 69 patients, and the ERAS plus liposomal bupivacaine group was composed of 80 patients. Postoperative opioid consumption was reduced when comparing the pre-ERAS and ERAS groups (from 275.7 oral morphine equivalents to 146.7 oral morphine equivalents; p < 0.0001), and also reduced with the addition of liposomal bupivacaine (115.3 oral morphine equivalents; p = 0.016). Furthermore, hospital length of stay was decreased from 3.6 days in the pre-ERAS group to 3.2 days (p = 0.0029) in the ERAS group, and to 2.6 days (p < 0.0001) in the ERAS group plus liposomal bupivacaine groups. CONCLUSIONS: Enhanced recovery after surgery protocols decrease postoperative opioid consumption and hospital length of stay in DIEP flap breast reconstruction. The addition of liposomal bupivacaine further strengthens the impact of the protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Implications of Instituting an Enhanced Recovery after Surgery Pathway in Patients Receiving Chemotherapy in Microsurgical Breast Reconstruction.

BACKGROUND: Neuropathy is a common side effect of chemotherapeutic agents. Manifestations of chemotherapy-induced neuropathy can present in a myriad of fashions, ranging from numbness, tingling, and pain to motor weakness and autonomic dysfunction.1 Given the nature of breast reconstruction, a significant portion of the patients have a history of chemotherapy exposure; its effect on postoperative pain management has not been previously explored. METHODS: This study is a retrospective review of patients who underwent deep inferior epigastric perforator flap breast reconstruction performed by the two senior authors from January of 2016 to September of 2019. The patients were separated into two groups, before and after enhanced recovery after surgery. The primary outcome observed was postoperative opioid consumption, measured as oral morphine equivalents; p values were obtained through univariate linear regression. RESULTS: In total, 256 patients were analyzed, of which 113 had chemotherapy exposure. The difference between opioid consumption in patients in the pre-enhanced recovery after surgery group without and with chemotherapy exposure was statistically significant (211.5 mg versus 278.5 mg; p = 0.0279). There was no difference between opioid consumption with regard to chemotherapy history in the enhanced recovery after surgery group (137.4 mg versus 133.0 mg; p = 0.7251). CONCLUSIONS: Patients with chemotherapy exposure required more opioids to be comfortable. It is unknown whether this difference is secondary to increased pain or less effectiveness of opioids. Further research is necessary to assess whether there are better ways to address pain postoperatively in patients with chemotherapy exposure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.