BACKGROUND: Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach. METHODS: Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4). RESULTS: A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant. CONCLUSIONS: The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol.
Enhanced Recovery After Surgery , Mammaplasty , Perforator Flap , Humans , Mammaplasty/methods , Breast , Perioperative Care
OBJECTIVE: Spinal cord injury (SCI) is responsible for approximately 18,000 trauma cases each year in the United States, often resulting in debilitating motor and autonomic disability. Neuromodulation is a rapidly growing field of interest in the neurosurgical field and has additionally shown promise in the treatment of SCI. This review characterizes all clinical trials to date studying neuromodulation for the treatment of SCI. METHODS: The ClinicalTrials.gov database was queried using the search terms "neuromodulation" and "spinal cord injury" on ClinicalTrials.gov. Trials were excluded if they were not yet recruiting, suspended, terminated early, or of unknown status. RESULTS: In total, 33 clinical trials were included in this study. Of the 33 trials, 8 were completed and 1 had published results. Most trials studied deficits of motor function (60%) and bladder control (37%). Fourteen studies (42.4%) utilized transcutaneous spinal stimulation, 7 (21.2%) utilized epidural electrical stimulation, and 6 (18.2%) utilized tibial nerve stimulation. There was an uptrend of clinical trials studying SCI indexed on PubMed, which was comparable to the increased number of publications indexed overall (Pearson correlation, P < 0.001). Of these, only 1 study regarding home tibial nerve stimulation for neurogenic bladder had published data, which was performed with no adverse events. CONCLUSIONS: Neuromodulation in SCI studies currently assess transcutaneous spinal stimulation, epidural electrical stimulation, and tibial nerve stimulation. There is currently 1 completed study suggesting feasibility of home neuromodulation techniques without adverse events. The results of trials that will be completed in the next few years will help dictate the potential of neuromodulation as a treatment for SCI.
