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Thakur I, Shepherd H, Soliman B. The first 150 consecutive DIEP free flaps: Lessons learnt and a guide to efficiency for the junior plastic surgeon. JPRAS Open 2024; 41:336-346. [PMID: 39188657 PMCID: PMC11345896 DOI: 10.1016/j.jpra.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/27/2024] [Indexed: 08/28/2024] Open
Abstract
Introduction The deep inferior epigastric artery perforator (DIEP) free flap is the gold-standard for breast reconstruction but is technically demanding, resource intensive and time-consuming, making it a daunting task for the junior surgeon. Aim To report the lessons learnt from the experience of a single surgeon performing their first 150 DIEP reconstructions as a guide for junior surgeons. Methods Data regarding patient demographics and surgical outcomes from April 2021 to October 2022 were collected retrospectively from medical records. Surgical outcomes were analysed using Microsoft Excel. Results Over 17 months, 150 flaps were completed in 97 patients by the senior author (BS). Operative duration was negatively correlated with case number for unilateral DIEPs (r = -0.73, p < 0.05) and for bilateral DIEPs (r = -0.67, p = 0.14). Raise time and ischaemic time were also negatively correlated with case number (r = -0.82, p < 0.05 and r = -0.79, p < 0.05, respectively). There were 10 complications and no flap losses. Discussion The data demonstrate an expected improvement in surgical efficiency with increased experience. We describe the key factors contributing to efficiency in our series, such as preoperative CT angiography, surgical markings prior to the day of surgery, a two-team approach with three diathermy sets, flap raise using monopolar diathermy, preference towards choosing a single dominant perforator and early commitment to perforator choice. This case series acts as a guide for the junior plastic surgeon in achieving safe, aesthetic and efficient results when completing free DIEP flap breast reconstructions.
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Affiliation(s)
- Ishaan Thakur
- Westmead Hospital Plastic Surgery Department, Cnr Hawkesbury Road and Darcy Rd, Westmead, NSW, 2145
| | - Henry Shepherd
- Westmead Hospital Plastic Surgery Department, Cnr Hawkesbury Road and Darcy Rd, Westmead, NSW, 2145
| | - Bish Soliman
- Westmead Hospital Plastic Surgery Department, Cnr Hawkesbury Road and Darcy Rd, Westmead, NSW, 2145
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Etemad SA, Poh MM. Enhanced Recovery After Gender-Affirming Surgery. Aesthet Surg J 2024; 44:S3-S14. [PMID: 39147383 DOI: 10.1093/asj/sjae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024] Open
Abstract
The adoption of enhanced recovery after surgery (ERAS) protocols in multiple surgical disciplines has revolutionized perioperative care, demonstrating reduced complications and shorter hospital stays across surgical specialties. ERAS protocols have increasingly been incorporated in plastic surgery, yet a notable gap in the literature on ERAS for gender-affirming surgery (GAS) still exists. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies on ERAS protocols in GAS. The aim of this review was to assess the current status of ERAS adoption in GAS, evaluate its impact on perioperative care, and provide recommendations for future research and clinical practice. While there is an overall scarcity of evidence-based ERAS protocols across GAS, published studies on the application of ERAS in GAS have demonstrated promising early outcomes and illustrate an area for further investigation and innovation in plastic surgery. LEVEL OF EVIDENCE: 5
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Muetterties CE, Taylor JM, Kaeding DE, Rosales Morales R, Nguyen AV, Kwan L, Tseng CY, Delong MR, Festekjian JH. Impact of Gabapentin on Postoperative Hypotension in Enhanced Recovery after Surgery Protocols for Microvascular Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5732. [PMID: 38623445 PMCID: PMC11018206 DOI: 10.1097/gox.0000000000005732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/20/2024] [Indexed: 04/17/2024]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have been associated with hypotensive episodes after autologous breast reconstruction. Gabapentin (Gaba), a nonopioid analgesic used in ERAS, has been shown to attenuate postoperative hemodynamic responses. This study assesses ERAS's impact, with and without Gaba, on postoperative hypotension after microvascular breast reconstruction. Methods Three cohorts were studied: traditional pathway, ERAS + Gaba, and ERAS no-Gaba. We evaluated length of stay, inpatient narcotic use [morphine milligram equivalents (MME)], mean systolic blood pressure, hypotension incidence, and complications. The traditional cohort was retrospectively reviewed, whereas the ERAS groups were enrolled prospectively after the initiation of the protocol in April 2019 (inclusive of Gaba until October 2022). Results In total, 441 patients were analyzed. The three cohorts, in the order mentioned above, were similar in age and bilateral reconstruction rates (57% versus 61% versus 60%). The ERAS cohorts, both with and without Gaba, had shorter stays (P < 0.01). Inpatient MME was significantly less in the ERAS + Gaba cohort than the traditional or ERAS no-Gaba cohorts (medians: 112 versus 178 versus 158 MME, P < 0.01). ERAS + Gaba significantly increased postoperative hypotensive events on postoperative day (POD) 1 and 2, with notable reduction after Gaba removal (P < 0.05). Across PODs 0-2, mean systolic blood pressure was highest in the traditional cohort, followed by ERAS no-Gaba, then the ERAS + Gaba cohort (P < 0.05). Complication rates were similar across all cohorts. Conclusions Postmicrovascular breast reconstruction, ERAS + Gaba reduced overall inpatient narcotic usage, but increased hypotension incidence. Gaba removal from the ERAS protocol reduced postoperative hypotension incidence while maintaining similar stay lengths and complication rates.
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Affiliation(s)
- Corbin E. Muetterties
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jeremiah M. Taylor
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Diana E. Kaeding
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Ricardo Rosales Morales
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Anissa V. Nguyen
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Lorna Kwan
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Charles Y. Tseng
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Michael R. Delong
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jaco H. Festekjian
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
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Hatchell A, Osman M, Bielesch J, Temple-Oberle C. Acceptance of outpatient enhanced recovery after surgery (ERAS©) protocols for implant-based breast reconstruction nudged on by the COVID-19 pandemic. Breast 2024; 74:103689. [PMID: 38368765 PMCID: PMC10884541 DOI: 10.1016/j.breast.2024.103689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/20/2024] Open
Abstract
We retrospectively identified 295 women undergoing outpatient implant breast reconstruction (IBR) who received standardized ERAS care pre-pandemic (PP; April 2018-March 2020) and during the pandemic (DP; April 2020-March 2022). The majority of IBR was completed as outpatient surgeries DP versus PP (73% versus 38%, p < 0.001). Immediate IBR increased DP versus PP (p < 0.001). Preoperative ERAS© order sets were used 54% of the time. Lack of ERAS© order set use was associated with unplanned admissions (55.3% versus 44.7%, p = 0.02). COVID-19 changed health care and nudged IBR to outpatient procedures. With ERAS© recommendations, IBR can be safely and effectively transitioned to outpatient settings.
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Affiliation(s)
- Alexandra Hatchell
- Section of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
| | - Mariam Osman
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jody Bielesch
- ERASAlberta Team, Surgery Strategic Clinical Network (SSCN™), Calgary, Alberta, Canada
| | - Claire Temple-Oberle
- Section of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Perez K, Teotia SS, Haddock NT. To Ablate or Not to Ablate: Does Umbilectomy Decrease Donor-Site Complications in DIEP Flap Breast Reconstruction? Plast Reconstr Surg 2024; 153:305-314. [PMID: 37166049 DOI: 10.1097/prs.0000000000010617] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Improving outcomes for deep inferior epigastric perforator (DIEP) flap breast reconstruction is an evolving area of interest. The aim of this study was to evaluate the effect of umbilectomy in abdominally based breast reconstruction. METHODS This retrospective study evaluated postoperative outcomes of patients who underwent autologous DIEP flap breast reconstruction at an academic center between January of 2015 and December of 2021 performed by one of two reconstructive surgeons. The primary outcome variable was abdominal donor-site complications. A secondary outcome variable was treatment outcomes for complications. Covariates included demographic information, comorbidities, cancer treatment, and smoking. RESULTS A total of 408 patients underwent DIEP flap breast reconstruction, with 194 (47.5%) undergoing umbilectomy. Umbilectomy resulted in decreased number of total wounds per patient (0.35 ± 0.795) compared with umbilical preservation (0.75 ± 1.322; P < 0.001), as well as decreased associated risk of any reported wounds (OR, 0.530; P = 0.009). Associations that trended toward significance occurred between umbilectomy and minor wound separation and partial necrosis, with both showing decreased risk. A significant association was noted between umbilectomy and donor-site seroma [χ 2 (1) = 6.348; P = 0.016], showing an increased risk (OR, 5.761). CONCLUSIONS Umbilectomy should be discussed with patients and considered as a part of DIEP flap breast reconstruction given the reduction in the risk of abdominal donor-site wounds. Although umbilectomy decreases the rate of wounds, it can increase the risk of seroma; therefore, other interventions, such as progressive tension sutures, may be explored to aid in reducing seroma and improving wound healing. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Kevin Perez
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center
| | - Sumeet S Teotia
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center
| | - Nicholas T Haddock
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center
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Clark RC, Alving-Trinh A, Becker M, Leach GA, Gosman A, Reid CM. Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:414. [PMID: 38213812 PMCID: PMC10777219 DOI: 10.21037/atm-23-1509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/07/2023] [Indexed: 01/13/2024]
Abstract
Background and Objective After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway. Methods All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed. Key Content and Findings Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions. Conclusions Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.
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Affiliation(s)
- Robert Craig Clark
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | | | - Miriam Becker
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Garrison A Leach
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Amanda Gosman
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Chris M Reid
- Division of Plastic Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
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Brown OH, Danko D, Muret-Wagstaff SL, Emefiele J, Argüello-Angarita M, Baker NF, Losken A, Carlson G, Cheng A, Walsh M, Muralidharan VJ, Thompson PW. Close the GAPS: A Standardized Perioperative Protocol Reduces Breast Reconstruction Implant Infections. Plast Reconstr Surg 2023; 152:1175-1184. [PMID: 37010468 DOI: 10.1097/prs.0000000000010491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is a complex process with significant practice variability. Infections after IBBR are associated with higher rates of readmission, reoperation, and reconstructive failure. To reduce process variability and postoperative infections, the authors implemented an evidence-based, standardized protocol for IBBR. METHODS The protocol was applied to all patients undergoing IBBR at a single institution from December of 2019 to February of 2021. Intraoperative protocol adherence was recorded, and infection events were considered minor (managed with outpatient antibiotics) or major (managed with readmission or reoperation). A historic control group was retrospectively analyzed for comparison. RESULTS Sixty-nine patients (120 breasts) in the protocol group were compared with 159 patients (269 breasts) in the retrospective group. No differences were found in demographic characteristics, comorbidities, or type of reconstruction (expander versus implant). Intraoperative protocol adherence was 80.5% (SD, 13.9%). Overall infection rate was significantly lower in the protocol group versus controls (8.7% versus 17.0%; P < 0.05). When dichotomized, protocol patients had a lower rate of both minor (2.9% versus 5.7%; P = 0.99) and major (5.8% versus 11.3%; P = 0.09) infections, although this was not statistically significant. Rate of reconstructive failure secondary to infection was significantly lower in the protocol group (4.4% versus 8.8%; P < 0.05). Among protocol patients, those without infection had higher protocol adherence (81.5% versus 72.2%; P < 0.06), which neared statistical significance. CONCLUSION A standardized perioperative protocol for IBBR reduces process variability and significantly decreases rate of overall infections and reconstructive failure secondary to infection. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Owen H Brown
- From the Division of Plastic and Reconstructive Surgery
| | | | | | | | | | | | - Albert Losken
- From the Division of Plastic and Reconstructive Surgery
| | - Grant Carlson
- From the Division of Plastic and Reconstructive Surgery
| | - Angela Cheng
- From the Division of Plastic and Reconstructive Surgery
| | - Mark Walsh
- From the Division of Plastic and Reconstructive Surgery
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Muetterties CE, Taylor JM, Kaeding DE, Morales RR, Nguyen AV, Kwan L, Tseng CY, Delong MR, Festekjian JH. Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5444. [PMID: 38098953 PMCID: PMC10721129 DOI: 10.1097/gox.0000000000005444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/11/2023] [Indexed: 12/17/2023]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center. Methods The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls. Results The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant. Conclusion Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.
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Affiliation(s)
- Corbin E. Muetterties
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jeremiah M. Taylor
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Diana E. Kaeding
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Ricardo R. Morales
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Anissa V. Nguyen
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Lorna Kwan
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
- Department of Urology, University of California Los Angeles, Los Angeles, Calif
| | - Charles Y. Tseng
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Michael R. Delong
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jaco H. Festekjian
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
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Araya S, Webster TK, Egleston B, Amadio GM, Panichella JC, Elmer NA, Patel SA. Significant Reduction in Length of Stay in Deep Inferior Epigastric Perforator Flap Breast Reconstruction With Implementation of Multimodal ERAS Protocol. Ann Plast Surg 2023; 91:90-95. [PMID: 37450866 PMCID: PMC10575614 DOI: 10.1097/sap.0000000000003578] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) implementation achieves earlier recovery, reduced hospital length of stay (LOS) and improved outcomes in patients undergoing deep inferior epigastric perforator (DIEP) free flaps. We sought to review our ERAS protocols and their impact on our patients' LOS compared with the literature. METHODS This was a retrospective review of a single surgeon's experience from 2017 to 2021 of patients undergoing DIEP free-flap breast reconstruction with LOS as the primary outcome. Complication rates and patient demographics are described as secondary outcomes. RESULTS One hundred twenty-one patients underwent DIEP free-flap breast reconstruction. After adapting ERAS protocols, there has been a 0.98 [SD, 0.17; confidence interval [CI], -1.3 to -0.64; P < 0.001) day decrease in length of stay comparing pre-ERAS to post-ERAS implementation. Length of stay has routinely decreased from an average discharge on day 4.17 (SD, 1.1; range, 3-8 days) in 2017 to discharge on day 2.91 (SD, 1.1; range, 1-5 days) in 2021. Seventy-five percent of patients in 2021 were hospitalized for 3 or fewer days compared with 75% of patients in 2017 hospitalized for 4 or more days. One patient experienced a flap failure. Our study supports successful discharge on postoperative days 2-3 compared with postoperative days 3-4 in the current literature. CONCLUSIONS The implementation of our ERAS protocol for DIEP free-flap breast reconstruction has resulted in a shorter LOS compared with contemporary literature. The ERAS protocols can be efficiently adopted in microsurgical DIEP breast reconstruction to achieve a shorter LOS without jeopardizing patient outcomes.
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Affiliation(s)
- Sthefano Araya
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA
| | | | - Brian Egleston
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - Grace M. Amadio
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | | | | | - Sameer A. Patel
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA
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Tapp MW, Duet ML, Steele TN, Gallagher RJ, Kogan S, Calder BW, Robinson JM. Postoperative Day 1 Discharge in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5064. [PMID: 37325370 PMCID: PMC10266520 DOI: 10.1097/gox.0000000000005064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/24/2023] [Indexed: 06/17/2023]
Abstract
With high success rates of autologous breast reconstruction, the focus has shifted from flap survival to improved patient outcomes. Historically, a criticism of autologous breast reconstruction has been the length of hospital stay. Our institution has progressively shortened the length of stay after deep inferior epigastric artery perforator (DIEP) flap reconstruction and began discharging select patients on postoperative day 1 (POD1). The purpose of this study was to document our experience with POD1 discharges and to identify preoperative and intraoperative factors that may identify patients as candidates for earlier discharge. Methods An institutional review board-approved, retrospective chart review of patients undergoing DIEP flap breast reconstruction from January 2019 to March 2022 at Atrium Health was completed, consisting of 510 patients and 846 DIEP flaps. Patient demographics, medical history, operative course, and postoperative complications were collected. Results Twenty-three patients totaling 33 DIEP flaps were discharged on POD1. The POD1 group and the group of all other patients (POD2+) had no difference in age, ASA score, or comorbidities. BMI was significantly lower in the POD1 group (P = 0.039). Overall operative time was significantly lower in the POD1 group, and this remained true when differentiating into unilateral operations (P = 0.023) and bilateral operations (P = 0.01). No major complications occurred in those discharged on POD1. Conclusions POD1 discharge after DIEP flap breast reconstruction is safe for select patients. Lower BMI and shorter operative times may be predictive in identifying patients as candidates for earlier discharge.
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Enhanced Recovery After Surgery Protocol Allows Safe Same-Day Discharge in Expander Based and Oncoplastic Breast Reconstruction. Ann Plast Surg 2023:00000637-990000000-00190. [PMID: 36880790 DOI: 10.1097/sap.0000000000003492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
PURPOSE Data after enhanced recovery after surgery (ERAS) with same-day discharge in breast reconstruction is limited. This study evaluates early postoperative outcomes after same-day discharge in tissue-expander immediate breast reconstruction (TE-IBR) and oncoplastic breast reconstruction. METHODS A single-institution retrospective review of TE-IBR patients from 2017 to 2022 and oncoplastic breast reconstruction patients from 2014 to 2022 was performed. Patients were divided by procedure and recovery pathway: group 1 (TE-IBR, overnight admission), group 2 (TE-IBR, ERAS), group 3 (oncoplastic, overnight admission), and group 4 (oncoplastic, ERAS). Groups 1 and 2 were subdivided by implant location: groups 1a (prepectoral) and 1b (subpectoral), and groups 2a (prepectoral) and 2b (subpectoral). Demographics, comorbidities, complications, and reoperations were analyzed. RESULTS A total of 160 TE-IBR patients (group 1, 91; group 2, 69) and 60 oncoplastic breast reconstruction patients (group 3, 8; group 4, 52) were included. Of the 160 TE-IBR patients, 73 underwent prepectoral reconstruction (group 1a, 25; group 2a, 48), and 87 underwent subpectoral reconstruction (group 1b, 66; group 2b, 21). There were no differences in demographics and comorbidities between groups 1 and 2. Group 3 had a higher average body mass index than group 4 (37.6 vs 32.2, P = 0.022). There was no significant difference between groups 1a and 2a or between groups 1b and 2b in rates of for rates of infection, hematoma, skin necrosis, wound dehiscence, fat necrosis, implant loss, or reoperations. Group 3 and group 4 showed no significant difference in any complications or in reoperations. Notably, no patients in same-day discharge groups required unplanned hospital admission. CONCLUSIONS Many surgical subspecialities have successfully adopted ERAS protocols into their patient care and have shown both its safety and feasibility. Our research shows that same-day discharge in both TE-IBR and oncoplastic breast reconstruction does not increase risk for major complications or reoperations.
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Daniel Pereira D, Market MR, Bell SA, Malic CC. Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review. J Plast Reconstr Aesthet Surg 2023; 79:101-110. [PMID: 36907019 DOI: 10.1016/j.bjps.2023.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/07/2023] [Accepted: 01/29/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND There has been a recent increase in the number and complexity of quality improvement studies in plastic surgery. To assist with the development of thorough quality improvement reporting practices, with the goal of improving the transferability of these initiatives, we conducted a systematic review of studies describing the implementation of quality improvement initiatives in plastic surgery. We used the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guideline to appraise the quality of reporting of these initiatives. METHODS English-language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of quality improvement initiatives in plastic surgery were included. The primary endpoint of interest in this review was the distribution of studies per SQUIRE 2.0 criteria scores in proportions. Abstract screening, full-text screening, and data extraction were completed independently and in duplicate by the review team. RESULTS We screened 7046 studies, of which 103 full texts were assessed, and 50 met inclusion criteria. In our assessment, only 7 studies (14%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and specific aims. The lowest SQUIRE 2.0 scores appeared in funding, conclusion, and interpretation criteria. CONCLUSIONS Improvements in QI reporting in plastic surgery, especially in the realm of funding, costs, strategic trade-offs, project sustainability, and potential for spread to other contexts, will further advance the transferability of QI initiatives, which could lead to significant strides in improving patient care.
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Affiliation(s)
- D Daniel Pereira
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada.
| | - Marisa R Market
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephanie A Bell
- Department of Plastic Surgery, Children's Hospital of Eastern Ontario, Canada
| | - Claudia C Malic
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada; Department of Plastic Surgery, Children's Hospital of Eastern Ontario, Canada
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Donato D, Veith J, Holoyda K, Magno-Padron D, Simpson A, King B, Agarwal J. Associations of discharge destination and length of stay in lower extremity free flap reconstruction. J Plast Surg Hand Surg 2023; 57:279-284. [PMID: 35848882 DOI: 10.1080/2000656x.2022.2070175] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Patients with lower extremity defects requiring free flap reconstruction often have difficult postoperative courses with prolonged length of stay and need for transfer to a post-acute care facility. The primary aim of this study was to determine associations of preoperative and perioperative variables with length of stay and discharge destination in patients undergoing lower extremity free flap reconstruction. The secondary aim was to determine associations of various complications with their discharge destination. The 2011- 2017 NSQIP database was queried for CPT codes for free flap procedures and ICD-9/ICD-10 codes for lower extremities. Univariate and multivariate analyses were used to determine associations of preoperative and perioperative variables with length of stay and discharge destination in patients undergoing lower extremity free flap reconstruction and associations of complications with their discharge destination. A total of 420 patients were identified who underwent lower extremity reconstruction in 2011-2017. Of 79.8% were discharged home and 21.2% were discharged to destinations other than home. On multivariate analysis, female gender, age > 55, ASA class > 2 and dependent functional status were found to have independent associations with discharge to post-acute care facilities. ASA classification greater than 2, active smoking, and discharge to a post-acute care facility all were independently associated with prolonged length of stay. Increased length of stay and discharge to post-acute care facility are closely associated. Understanding variables that influence length of stay and need for discharge to post-acute care facilities can help identify patients that may be triaged through appropriate interventions and expectation management.
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Affiliation(s)
- Daniel Donato
- Department of Surgery, Division of Plastic Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Jacob Veith
- Department of Surgery, Division of Plastic Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kathleen Holoyda
- Department of Surgery, Division of Plastic Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - David Magno-Padron
- Department of Surgery, Division of Plastic Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Andrew Simpson
- Department of Surgery, Division of Plastic Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Brody King
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jayant Agarwal
- Department of Surgery, Division of Plastic Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
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14
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Bonapace-Potvin M, Govshievich A, Tessier L, Karunanayake M, Tremblay D, Chollet A. Canadian Trends in Free Flap Management for Microsurgical Lower Limb Reconstruction. Plast Surg (Oakv) 2023; 31:70-77. [PMID: 36755829 PMCID: PMC9900030 DOI: 10.1177/22925503211019602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Free tissue transfers have become a mainstay in lower limb salvage, allowing safe and reliable reconstruction after trauma, tumor extirpation, and complex wounds. The optimal perioperative (PO) management of these flaps remains controversial. This study aims to assess the current state of practice among Canadian microsurgeons. Methods: Sixty-four Canadian microsurgeons were approached to complete an online questionnaire regarding their PO management of fasciocutaneous free flaps used for lower limb reconstruction. Trends in dangling timing and duration, use of venous couplers, compressive garments, thromboprophylaxis, and surgeons' satisfaction with their protocol were assessed. Results: Twenty-eight surgeons responded. Fifty-seven percent did not have a specific mobilization protocol. Dangling was mainly initiated on postoperative days 5 to 6 (44%). The most common protocol duration was 5 to 6 days (43%). The concern for prolonged venous pooling was the main reason for delay of dangling (71%). Compressive garments were placed routinely by 12 surgeons (43%) with 20% starting before dangling, 46% with dangling, and 33% after dangling. Venous couplers were routinely used by 24 surgeons (85.7%). Trends in management were influenced by previous training in 53.6% of cases (vs evidence-based medicine 7.1%). Although 89.3% were satisfied with their approach, 92.8% would consider changing practice if higher-level evidence was available. Conclusions: The majority of Canadian microsurgeons initiate dangling early and utilize venous couplers. However, the use of compressive garments is limited. Trends in management are largely based on personal experience. Nearly all surgeons would consider changing their practice if higher-level evidence was available.
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Affiliation(s)
| | | | - Laurent Tessier
- Université de Montréal Plastic Surgery Program,
Montréal, Quebec, Canada
| | | | - Dominique Tremblay
- Université de Montréal Plastic Surgery Program,
Montréal, Quebec, Canada
| | - André Chollet
- Université de Montréal Plastic Surgery Program,
Montréal, Quebec, Canada
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15
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Castellanos CX, Paoletti M, Ulloa R, Kim C, Fong M, Xepoleas M, Sinha U, Kokot N, Swanson MS. Opioid Sparing Multimodal Analgesia for Transoral Robotic Surgery: Improved Analgesia and Narcotic Use Reduction. OTO Open 2023; 7:e17. [PMID: 36998552 PMCID: PMC10046737 DOI: 10.1002/oto2.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/23/2022] [Indexed: 03/15/2023] Open
Abstract
Objective To compare postoperative pain scores and opioid consumption in patients after transoral robotic surgery (TORS). Study Design Single institution retrospective cohort study. Setting TORS was performed at a single academic tertiary care center. Methods This study compared traditional opioid-based and opioid-sparing multimodal analgesia (MMA) regimens in patients with oropharyngeal and supraglottic malignancy after TORS. Data were obtained from the electronic health records from August 2016 to December 2021. The average postoperative pain scores and total opioid consumption in morphine milligram equivalents were calculated for postoperative days (PODs) 0 to 3. The secondary objectives were to quantify and characterize opioid prescriptions upon hospital discharge. Results A total of 114 patients were identified for this study, 58 patients in the non-MMA cohort and 56 in the MMA cohort. Postoperative pain levels in the MMA cohort were statistically lower on POD 0 (p = 0.001), POD 1 (p = 0.001), and POD 3 (p = 0.004). Postoperative opioid consumption decreased significantly in the MMA cohort from 37.7 to 10.8 mg on POD 0 (p = 0.002), 65.9 to 19.9 mg on POD 1 (p < 0.001), 36.0 to 19.3 mg on POD 2 (p = 0.02), and 45.4 to 13.8 mg on POD 3 (p = 0.02). The number of patients discharged from the hospital with a prescription for narcotics was significantly lower in the MMA cohort (71.4%) compared with the non-MMA cohort (98.3%) (p < 0.001). Conclusion Implementation of our MMA pain protocol reduced pain levels and narcotic consumption in the immediate postoperative period.
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Affiliation(s)
- Carlos X. Castellanos
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Marcus Paoletti
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Ruben Ulloa
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Celeste Kim
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Michelle Fong
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Meredith Xepoleas
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Uttam Sinha
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Niels Kokot
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Mark S. Swanson
- Caruso Department of Otolaryngology‐Head & Neck SurgeryKeck Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
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16
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Ruccia F, Savage JA, Sorooshian P, Lees M, Fesatidou V, Zoccali G. Hyponatremia after Autologous Breast Reconstruction: A Cohort Study Comparing Two Fluid Management Protocols. J Reconstr Microsurg 2023; 39:35-42. [PMID: 36075382 DOI: 10.1055/a-1939-5874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Perioperative fluid management is an important component of enhanced recovery pathways for microsurgical breast reconstruction. Historically, fluid management has been liberal. Little attention has been paid to the biochemical effects of different protocols. This study aims to reduce the risk of postoperative hyponatremia by introducing a new fluid management protocol. METHODS A single-institution cohort study comparing a prospective series of patients was managed using a new "modestly restrictive" fluid postoperative fluid management protocol to a control group managed with a "liberal" fluid management protocol. RESULTS One-hundred thirty patients undergoing microsurgical breast reconstruction, at a single institution during 2021, are reported. Hyponatremia is demonstrated to be a significant risk with the original liberal fluid management protocol. At the end of the first postoperative day, mean fluid balance was +2,838 mL (± 1,630 mL). Twenty-four patients of sixty-five (36%) patients had low blood sodium level, 14% classified as moderate-to-severe hyponatremia. Introducing a new, "modestly-restrictive" protocol reduced mean fluid balance on day 1 to +844 mL (±700) (p ≤ 0.0001). Incidence of hyponatremia reduced from 36 to 14% (p = 0.0005). No episodes of moderate or severe hyponatremia were detected. Fluid intake, predominantly oral water, between 8am and 8pm on the first postoperative day is identified as the main risk factor for developing hyponatremia (odds ratio [OR]: 7; p = 0.019). Modest fluid restriction, as guided by the new protocol, protects patients from low sodium level (OR: 0.25; confidence interval: 95%; 0.11-1.61; p = 0.0014). CONCLUSION The original "liberal" fluid management protocol encouraged unrestricted postoperative oral intake of water. Patients were often advised to consume in excess of 5 L in the first 24 hours. This unintentionally, but frequently, was associated with moderate-to-severe hyponatremia. We present a new protocol characterized by early cessation of intravenous fluid and an oral fluid limit of 2,100 mL/day associated with a significant reduction in the incidence of hyponatremia and fluid overload.
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Affiliation(s)
- Francesca Ruccia
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Jessica Anne Savage
- Plastic and Reconstructive Surgery Department, Salisbury District Hospital, Salisbury, United Kingdom
| | - Parviz Sorooshian
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Matthew Lees
- Department of Anaesthesia and Critical care, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Vasiliki Fesatidou
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Giovanni Zoccali
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
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17
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Marxen T, Shauly O, Losken A. The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4448. [PMID: 35924002 PMCID: PMC9298472 DOI: 10.1097/gox.0000000000004448] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/02/2022] [Indexed: 11/25/2022]
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18
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Echeverria-Villalobos M, Fiorda-Diaz J, Uribe A, Bergese SD. Postoperative Nausea and Vomiting in Female Patients Undergoing Breast and Gynecological Surgery: A Narrative Review of Risk Factors and Prophylaxis. Front Med (Lausanne) 2022; 9:909982. [PMID: 35847822 PMCID: PMC9283686 DOI: 10.3389/fmed.2022.909982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/13/2022] [Indexed: 11/25/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) have been widely studied as a multifactorial entity, being of female gender the strongest risk factor. Reported PONV incidence in female surgical populations is extremely variable among randomized clinical trials. In this narrative review, we intend to summarize the incidence, independent predictors, pharmacological and non-pharmacological interventions for PONV reported in recently published clinical trials carried out in female patients undergoing breast and gynecologic surgery, as well as the implications of the anesthetic agents on the incidence of PONV. A literature search of manuscripts describing PONV management in female surgical populations (breast surgery and gynecologic surgery) was carried out in PubMed, MEDLINE, and Embase databases. Postoperative nausea and vomiting incidence were highly variable in patients receiving placebo or no prophylaxis among RCTs whereas consistent results were observed in patients receiving 1 or 2 prophylactic interventions for PONV. Despite efforts made, a considerable number of female patients still experienced significant PONV. It is critical for the anesthesia provider to be aware that the coexistence of independent risk factors such as the level of sex hormones (pre- and postmenopausal), preoperative anxiety or depression, pharmacogenomic pleomorphisms, and ethnicity further enhances the probability of experiencing PONV in female patients. Future RCTs should closely assess the overall risk of PONV in female patients considering patient- and surgery-related factors, and the level of compliance with current guidelines for prevention and management of PONV.
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Affiliation(s)
- Marco Echeverria-Villalobos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- *Correspondence: Marco Echeverria-Villalobos
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alberto Uribe
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Sergio D. Bergese
- Department of Anesthesiology, Health Sciences Center, School of Medicine, Stony Brook University, New York, NY, United States
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19
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Enhanced Recovery Pathway Reduces Hospital Stay and Opioid Use in Microsurgical Breast Reconstruction: A Single-Center, Private Practice Experience. Plast Reconstr Surg 2022; 150:13e-21e. [PMID: 35500278 DOI: 10.1097/prs.0000000000009179] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care resource utilization. METHODS A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol. RESULTS Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar ( p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar ( p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly ( p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly ( p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements ( p < 0.001) and length of stay ( p < 0.001). CONCLUSIONS ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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20
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Rodnoi P, Dickey RM, Teotia SS, Haddock NT. Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety. J Reconstr Microsurg 2022; 38:742-748. [PMID: 35714625 DOI: 10.1055/s-0042-1749595] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS) protocols have decreased postoperative opioid consumption and hospital length of stay in deep inferior epigastric perforator (DIEP) flap breast reconstruction. We aim to evaluate whether there needs to be further adjustments to best improve outcomes specifically in patients with a preexisting psychiatric condition. METHODS A retrospective review was performed of all patients that underwent DIEP flap breast reconstruction between October 2018 and September 2020. This includes all patients with the most recent ERAS protocol implementation of intraoperative transverse abdominal plane blocks with liposomal bupivacaine. We looked at patients with a psychiatric diagnosis at the time of surgery. Specifically, forms of depression and anxiety were the psychiatric diagnoses for these patients. We divided these patients into three groups: those with no diagnoses, those with a single diagnosis, and those with both diagnoses. Primary outcomes observed were postoperative opioid consumption and length of stay. A one-way analysis of variance determined whether there was a difference between the three groups and a Tukey post hoc analysis made pairwise comparisons. A p-value of < 0.05 was significant. RESULTS A total of 176 patients were analyzed in this study: 59 (33.5%) of our study population had a diagnosis of either depression, anxiety, or both. Postoperative opioid consumption was higher in patients with a psychiatric diagnosis compared with those without (123.8 to 91.5; p < 0.0005). A multiple regression model consisting of operating time, hospital length of stay, whether the patient has a psychiatric diagnosis, and history of chemotherapy statistically significantly predicted opioid consumption (p < 0.0005). CONCLUSION With similar hospital length of stay postoperatively, it is notable that patients with a psychiatric diagnosis had significantly higher amounts of postoperative opioid consumption. This study highlights the need to further improve multidisciplinary integrated care for patients with psychiatric comorbidities to improve pain management postoperatively.
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Affiliation(s)
- Pope Rodnoi
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan M Dickey
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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21
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The Role of Maximal Locoregional Block in Autologous Breast Reconstruction. Ann Plast Surg 2022; 88:612-616. [PMID: 35276709 DOI: 10.1097/sap.0000000000003134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has become the standard of care in microsurgical breast reconstruction. The current literature provides overwhelming evidence of the benefit of ERAS pathways in improving quality of recovery, decreasing length of hospital stay, and minimizing the amount of postoperative narcotic use in these patients. However, there are limited data on the role of using maximal locoregional anesthetic blocks targeting both the abdomen and chest as an integral part of an ERAS protocol in abdominally based autologous breast reconstruction. The aim of this study is to compare the outcomes of implementing a comprehensive ERAS protocol with and without maximal locoregional nerve blocks to determine any added benefit of these blocks to the standard ERAS pathway. METHODS Forty consecutive patients who underwent abdominally based autologous breast reconstruction in the period between July 2017 and February 2020 were included in this retrospective institutional review board-approved study. The goal was to compare patients who received combined abdominal and thoracic wall locoregional blocks as part of their ERAS pathway (study group) with those who had only transversus abdominis plane blocks. The primary end points were total hospital length of stay, overall opioids consumption, and overall postoperative complications. RESULTS The use of supplemental thoracic wall block resulted in a shorter hospital length of stay in the study group of 3.2 days compared with 4.2 days for the control group (P < 0.01). Postoperative total morphine equivalent consumption was lower at 38 mg in the study group compared with 51 mg in the control group (P < 0.01). Complications occurred in 6 cases (15%) in the control group versus one minor complication in the thoracic block group. There was no difference between the 2 groups in demographics, comorbidities, and type of reconstruction. CONCLUSION The maximal locoregional nerve block including a complete chest wall block confers added benefits to the standard ERAS protocol in microvascular breast reconstruction.
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22
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Broyles JM, Balk EM, Adam GP, Cao W, Bhuma MR, Mehta S, Dominici LS, Pusic AL, Saldanha IJ. Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4180. [PMID: 35291333 PMCID: PMC8916208 DOI: 10.1097/gox.0000000000004180] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/13/2022] [Indexed: 01/29/2023]
Abstract
For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer. Methods We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods. Results We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4-8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1-10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5-4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions. Conclusions Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.
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Affiliation(s)
- Justin M. Broyles
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Harvard Medical School, Boston, Mass
| | - Ethan M. Balk
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Gaelen P. Adam
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Wangnan Cao
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Monika Reddy Bhuma
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Shivani Mehta
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Laura S. Dominici
- Department of Surgery, Division of Breast Surgery, Harvard Medical School, Boston, Mass
| | - Andrea L. Pusic
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Harvard Medical School, Boston, Mass
| | - Ian J. Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
- Department of Epidemiology, Brown University School of Public Health, Providence, R.I
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23
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Faulkner HR, Coopey SB, Sisodia R, Kelly BN, Maurer LR, Ellis D. Does An ERAS Protocol Reduce Postoperative Opiate Prescribing in Plastic Surgery? JPRAS Open 2021; 31:22-28. [PMID: 34869817 PMCID: PMC8626793 DOI: 10.1016/j.jpra.2021.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocols are effective at reducing inpatient opiate use. There is a paucity of studies on the effects of an ERAS protocol on outpatient opiate prescriptions. The aim of this study was to determine whether an ERAS protocol for plastic and reconstructive surgery would reduce opiate use in the outpatient postoperative setting. Methods A statewide (Massachusetts, USA) controlled substance prescription monitoring database was retrospectively reviewed to assess the prescribing patterns of a single academic plastic surgeon performing common plastic surgical outpatient operations. The time period prior to implementation of the ERAS protocol was then compared with the time period following protocol implementation. An additional three months of post-implementation data were then compared with those of each of the previous time periods to investigate whether the results were sustained. Results A comparison of opiate prescriptions in pre-ERAS, immediate post-ERAS procedures, and follow-up ERAS implementation procedures revealed a statistically significant decrease in opiate prescriptions after ERAS protocol implementation. This decrease in the quantity of opiates prescribed was sustained over time. Conclusions ERAS protocols are effective at reducing outpatient opiate prescriptions after a variety of plastic surgery operations. Appropriate patient and physician education is paramount for success.
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Affiliation(s)
- Heather R Faulkner
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suzanne B Coopey
- Division of Surgical Oncology, Allegheny Health Network, Wexford, Pennsylvania, USA
| | - Rachel Sisodia
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget N Kelly
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Dan Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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24
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Haddock NT, Garza R, Boyle CE, Teotia SS. Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction. J Reconstr Microsurg 2021; 38:506-510. [PMID: 34820799 DOI: 10.1055/s-0041-1740125] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ricardo Garza
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carolyn E Boyle
- Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Bonde CT, Højvig JB, Jensen LT, Wolthers M, Sarmady FN, Andersen KG, Kehlet H. Long-term results of a standardized enhanced recovery protocol in unilateral, secondary autologous breast reconstructions using an abdominal free flap. J Plast Reconstr Aesthet Surg 2021; 75:1117-1122. [PMID: 34895856 DOI: 10.1016/j.bjps.2021.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 10/24/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND In 2015, we published one of the first reports using an enhanced recovery protocol (ERP) in microsurgery1, and in 2016, our final ERP setup in autologous breast reconstruction (ABR) using free abdominal flaps2. We showed that by adhering to a few simple, easy to measure, functional discharge criteria, it was possible to safely discharge the patients by the third postoperative day (POD). However, one of the challenges of interpreting studies using ERP in ABR is the often heterogenous patient populations and the need to clearly distinguish between primary and secondary and unilateral and bilateral reconstructions. MATERIALS AND METHODS In the 5-year period from 2016-2020, the same surgical team, performed 147 unilateral, delayed breast reconstructions (135 DIEP, 9 MS-TRAM-2, and 3 SIEA flaps) according to our previous analgesic protocol and surgical strategy. Data were collected prospectively. RESULTS Three flaps were lost (2%) and 82% of the patients(n=128) were discharged to home by POD 2 (n=8%) or 3 (74%). The remaining 18% (n=26) were discharged by POD 4 (12.5%) or 5 (5.5%). Ten patients (7%) were reoperated, and 17 patients (12%) had minor complications within POD 30 (infection, seroma, etc.) that did not necessitate hospital admission. CONCLUSION Using our ERP, unproblematic discharge directly to home is possible on POD 3 in more than 80% of patients after ABR. ERP is no longer a research tool but considered standard of care in microsurgical breast reconstruction.
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Affiliation(s)
- Christian T Bonde
- Department of Plastic Surgery, Breast Surgery, and Burns, Section 7034 Rigshospitalet, Copenhagen University Hospital, Denmark.
| | - Jens B Højvig
- Department of Plastic Surgery, Breast Surgery, and Burns, Section 7034 Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Lisa T Jensen
- Department of Plastic Surgery, Breast Surgery, and Burns, Section 7034 Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Mette Wolthers
- Department of Plastic Surgery, Breast Surgery, and Burns, Section 7034 Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Faranak N Sarmady
- Department of Plastic Surgery, Breast Surgery, and Burns, Section 7034 Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Kenneth G Andersen
- Department of Plastic Surgery, Breast Surgery, and Burns, Section 7034 Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Henrik Kehlet
- The Section of Surgical Patho-physiology, Rigshospitalet, Copenhagen University Hospital, Denmark
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Defining Enhanced Recovery Pathway with or without Liposomal Bupivacaine in DIEP Flap Breast Reconstruction. Plast Reconstr Surg 2021; 148:948-957. [PMID: 34705768 DOI: 10.1097/prs.0000000000008409] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Parrish AJ, Markov NP, Michael Johnson R, Fox JP. Hospital length of stay and hospital readmission after immediate breast reconstruction in the United States: Implications for quality measurement. J Plast Reconstr Aesthet Surg 2021; 75:439-488. [PMID: 34742659 DOI: 10.1016/j.bjps.2021.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 04/08/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew J Parrish
- Wright State Boonshoft School of Medicine, Department of Orthopaedic and Plastic Surgery, 30 E. Apple St., Suite 2200, Dayton, OH 45409 USA.
| | - Nickolay P Markov
- Plastic Surgery Element, Surgical Operations Squadron, 88th Medical Group, Wright Patterson Medical Center, Wright Patterson Air Force Base, Ohio USA
| | - R Michael Johnson
- Wright State Boonshoft School of Medicine, Department of Orthopaedic and Plastic Surgery, 30 E. Apple St., Suite 2200, Dayton, OH 45409 USA; Plastic Surgery Element, Surgical Operations Squadron, 88th Medical Group, Wright Patterson Medical Center, Wright Patterson Air Force Base, Ohio USA
| | - Justin P Fox
- Wright State Boonshoft School of Medicine, Department of Orthopaedic and Plastic Surgery, 30 E. Apple St., Suite 2200, Dayton, OH 45409 USA; Plastic Surgery Element, Surgical Operations Squadron, 88th Medical Group, Wright Patterson Medical Center, Wright Patterson Air Force Base, Ohio USA
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Tan YY, Liaw F, Warner R, Myers S, Ghanem A. Enhanced Recovery Pathways for Flap-Based Reconstruction: Systematic Review and Meta-Analysis. Aesthetic Plast Surg 2021; 45:2096-2115. [PMID: 33821314 DOI: 10.1007/s00266-021-02233-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/11/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways are known to improve patient outcomes after surgery. In recent years, there have been growing interest in ERAS for reconstructive surgery. OBJECTIVES To systematically review and summarise literature on the key components and outcomes of ERAS pathways for autologous flap-based reconstruction. DATA SOURCES Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Controlled Trials, World Health Organization International Clinical Trials Registry Platform and reference lists of relevant studies. INCLUSION CRITERIA All primary studies of ERAS pathways for free and pedicled flap-based reconstructions reported in the English language. OUTCOME MEASURES The primary outcome measure was length of stay. Secondary outcomes were complication rates including total flap loss, partial flap loss, unplanned reoperation within 30 days, readmission to hospital within 30 days, surgical site infections and medical complications. RESULTS Sixteen studies were included. Eleven studies describe ERAS pathways for autologous breast reconstructions and five for autologous head and neck reconstructions. Length of stay was lower in ERAS groups compared to control groups (mean reduction, 1.57 days; 95% CI, - 2.15 to - 0.99). Total flap loss, partial flap loss, unplanned reoperations, readmissions, surgical site infections and medical complication rates were similar between both groups. Compliance rates were poorly reported. CONCLUSION ERAS pathways for flap-based reconstruction reduce length of stay without increasing complication rates. ERAS pathways should be adapted to each institution according to their needs, resources and caseload. There is potential for the development of ERAS pathways for chest wall, perineum and lower limb reconstruction. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3830. [PMID: 34549012 PMCID: PMC8447987 DOI: 10.1097/gox.0000000000003830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/28/2021] [Indexed: 11/27/2022]
Abstract
Background: The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions. Methods: This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay. Results: Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome. Conclusions: The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.
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Cho MJ, Garza R, Teotia SS, Haddock NT. Utility of ERAS Pathway in Nonabdominal-Based Microsurgical Breast Reconstruction: Efficacy in PAP Flap Reconstruction? J Reconstr Microsurg 2021; 38:371-377. [PMID: 34454407 DOI: 10.1055/s-0041-1733993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction. METHODS Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected. RESULTS A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption. CONCLUSION Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.
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Affiliation(s)
- Min-Jeong Cho
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ricardo Garza
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Gort N, van Gaal BGI, Tielemans HJP, Ulrich DJO, Hummelink S. Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction. Breast 2021; 60:53-57. [PMID: 34464847 PMCID: PMC8406354 DOI: 10.1016/j.breast.2021.08.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction. MATERIALS EN METHODS The effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications. RESULTS 152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028). CONCLUSION An enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.
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Affiliation(s)
- N Gort
- Radboud University Medical Center, Dept. of Plastic Surgery, Nijmegen, the Netherlands.
| | - B G I van Gaal
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, the Netherlands; Radboud University Medical Center, Radboud Institute for Health Science, IQ Healthcare, Nijmegen, the Netherlands
| | - H J P Tielemans
- Radboud University Medical Center, Dept. of Plastic Surgery, Nijmegen, the Netherlands
| | - D J O Ulrich
- Radboud University Medical Center, Dept. of Plastic Surgery, Nijmegen, the Netherlands
| | - S Hummelink
- Radboud University Medical Center, Dept. of Plastic Surgery, Nijmegen, the Netherlands
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Safran T, Dionisopoulos T. Enhanced Recovery Protocol in Prepectoral Direct-to-Implant Reconstruction. Plast Reconstr Surg 2021; 148:332e-334e. [PMID: 34233339 DOI: 10.1097/prs.0000000000008148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tyler Safran
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Quebec, Canada
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Straughan DM, Lindsey JT, McCarthy M, Legendre D, Lindsey JT. Enhanced Recovery After Surgery Protocol With Ultrasound-Guided Regional Blocks in Outpatient Plastic Surgery Patients Leads to Decreased Opioid Prescriptions and Consumption. Aesthet Surg J 2021; 41:NP1105-NP1114. [PMID: 33730152 DOI: 10.1093/asj/sjab137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Opioids are a mainstay of pain management. To limit the use of opioids, enhanced recovery after surgery (ERAS) protocols implement multimodal approaches to treat postoperative pain. OBJECTIVES The aim of this paper was to be the first to assess the efficacy of an ERAS protocol for plastic surgery outpatients that includes ultrasound-guided, surgeon-led regional blocks. METHODS A retrospective review of patients undergoing outpatient plastic surgery on an ERAS protocol was performed. These patients were compared to a well-matched group not on an ERAS protocol (pre-ERAS). Endpoints included the amounts of opioid, antinausea, and antispasmodic medication prescribed. ERAS patients were given a postoperative questionnaire to assess both pain levels (0-10) and opioid consumption. ERAS patients anticipated to have higher levels of pain received ultrasound-guided anesthetic blocks. RESULTS There were 157 patients in the pre-ERAS group and 202 patients in the ERAS group. Patients in the pre-ERAS group were prescribed more opioid (332.3 vs 100.3 morphine milligram equivalents (MME)/patient; P < 0.001), antinausea (664 vs 16.3 mg of promethazine/patient; P < 0.001), and antispasmodic (401.3 vs 31.2 mg of cyclobenzaprine/patient; P < 0.001) medication. Patients on the ERAS protocol consumed an average total of 22.7 MME/patient postoperatively. Average pain scores in this group peaked at 5.32 on postoperative day 1 and then decreased significantly daily. CONCLUSIONS Implementation of an ERAS protocol for plastic surgery outpatients with utilization of ultrasound-guided regional anesthetic blocks is feasible and efficacious. The ability to significantly decrease prescribed opioids in this unique patient population is noteworthy. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- David M Straughan
- Dr Straughan is a fellow, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - John T Lindsey
- Mr Lindsey Jr is a medical student, Louisiana State University Medical School, New Orleans, LA, USA
| | | | - Davey Legendre
- Dr Legendre is a doctor of pharmacy, Comprehensive Pharmacy Services, Woodstock, GA, USA
| | - John T Lindsey
- Dr Lindsey Sr is an associate clinical professor of surgery, Tulane University, New Orleans, LA, USA
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Engel O, Haikin Herzberger E, Yagur Y, Hershko Klement A, Fishman A, Constantini N, Biron Shental T. Walking to a better future? Postoperative ambulation after cesarean delivery and complications: A prospective study. Int J Gynaecol Obstet 2021; 157:391-396. [PMID: 34214190 DOI: 10.1002/ijgo.13815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/29/2021] [Accepted: 07/01/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the correlation between maternal mobility after cesarean delivery and postoperative morbidity. METHODS A prospective study was conducted in a tertiary hospital among patients after cesarean delivery. The women were recruited after surgery and before ambulation. Each participant received an accelerometer and routine instructions for mobilization. The patients were asked to wear the accelerometer constantly. It was collected at discharge. Electronic files were reviewed and patients' outcomes were analyzed. The Mann-Whitney U test was used to compare groups and a receiver operating characteristic curve was calculated for the threshold of number of steps. RESULTS Data were analyzed for 199 patients, among which 107 (54.4%) deliveries were urgent and 90 (45.6%) were elective. The median number of steps was higher for multiparous women compared to nulliparous women (P = 0.035). Patients who developed complications after discharge walked significantly less during their hospitalization compared to those who did not. There was a trend toward increased risk for in-hospitalization complications among patients who walked less while hospitalized. A threshold of more than 9716 steps per hospitalization was found to be associated with fewer post-discharge complications. CONCLUSION There is a significant correlation between the extent of ambulation after cesarean delivery and fewer postoperative complications.
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Affiliation(s)
- Offra Engel
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einat Haikin Herzberger
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Yagur
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Hershko Klement
- Hadassah Hospital Mt. Scopus, The Hebrew University of Jerusalem and the Hebrew University Medical School, Jerusalem, Israel
| | - Ami Fishman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Constantini
- Heidi Rothberg Sports Medicine Center, Shaare Zedek Medical Center, Jerusalem, Israel.,Israel Ministry of Health, Exercise Medicine Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tal Biron Shental
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Nelson JA, Polanco TO, Shamsunder MG, Coriddi M, Matros E, Hicks MEV, Disa JJ, Mehrara BJ, Allen RJ, Dayan JH, Afonso A. Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes. Ann Surg Oncol 2021; 28:7823-7833. [PMID: 33959829 DOI: 10.1245/s10434-021-10023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/26/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction. METHODS We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q. RESULTS Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores. CONCLUSION System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.
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Affiliation(s)
- Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Thais O Polanco
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meghana G Shamsunder
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Joseph J Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph H Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Bamba R, Wiebe JE, Ingersol CA, Dawson S, Sinha M, Cohen AC, Hartman BC, Lester ME, Hassanein AH. Do Patient Expectations of Discharge Affect Length of Stay after Deep Inferior Epigastric Perforator Flap for Breast Reconstruction? J Reconstr Microsurg 2021; 38:34-40. [PMID: 33853122 DOI: 10.1055/s-0041-1727201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Deep inferior epigastric artery perforator (DIEP) flap is a common method of breast reconstruction. Enhanced recovery after surgery (ERAS) postoperative protocols have been used to optimize patient outcomes and facilitate shorter hospital stays. The effect of patient expectations on length of stay (LOS) after DIEP has not been evaluated. The purpose of this study was to investigate whether patient expectations affect LOS. METHODS A retrospective chart review was performed for patients undergoing DIEP flaps for breast reconstruction from 2017 to 2020. All patients were managed with the same ERAS protocol. Patients were divided in Group I (early expectations) and Group II (standard expectations). Group I patients had expectations set for discharge postoperative day (POD) 2 for unilateral DIEP and POD 3 for bilateral DIEP. Group II patients were given expectations for POD 3 to 4 for unilateral DIEP and POD 4 to 5 for bilateral. The primary outcome variable was LOS. RESULTS The study included 215 DIEP flaps (45 unilateral and 85 bilateral). The average age was 49.8 years old, and the average body mass index (BMI) was 31.4. Group I (early expectations) included 56 patients (24 unilateral DIEPs, 32 bilateral). Group II (standard expectations) had 74 patients (21 unilateral, 53 bilateral). LOS for unilateral DIEP was 2.9 days for Group I compared with 3.7 days for Group II (p = 0.004). Group I bilateral DIEP patients had LOS of 3.5 days compared with 3.9 days for Group II (p = 0.02). Immediate timing of DIEP (Group I 42.9 vs. Group II 52.7%) and BMI (Group I 32.1 vs. Group II 30.8) were similar (p = 0.25). CONCLUSION Our study found significantly shorter hospital stay after DIEP flap for patients who expected an earlier discharge date despite similar patient characteristics and uniform ERAS protocol. Patient expectations should be considered during patient counseling and as a confounding variable when analyzing ERAS protocols.
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Affiliation(s)
- Ravinder Bamba
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jordan E Wiebe
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Christopher A Ingersol
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Steven Dawson
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mithun Sinha
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam C Cohen
- Department of Surgery, Community Health Network, Indianapolis, Indiana
| | - Brett C Hartman
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary E Lester
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Harrison CA, Parks RM, Cheung KL. The impact of breast cancer surgery on functional status in older women - A systematic review of the literature. Eur J Surg Oncol 2021; 47:1891-1899. [PMID: 33875285 DOI: 10.1016/j.ejso.2021.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/17/2021] [Accepted: 04/08/2021] [Indexed: 11/18/2022] Open
Abstract
Primary endocrine therapy as treatment of breast cancer is only recommended in older women with limited life expectancy. However, many older women opt for endocrine therapy due to concerns regarding frailty and potential decline in function after surgery. A decline in functional status after surgery is documented in some cancer types, such as colorectal, however, the full impact of breast cancer surgery is less understood. A systematic review was performed to examine the evidence for impact of breast cancer surgery on functional status in older women. PubMed and Embase databases were searched. Studies were eligible if performed within the last 10 years; included patients over the age of 65 years undergoing breast cancer surgery; included stratification of results by age; measured functional status pre-operatively and at least six months following surgery. A total of 11 studies including 12 030 women were appraised. Two studies represented level-II and nine level-IV evidence. Overall, physical activity level was negatively impacted by breast cancer surgery and this was compounded by the extent of surgery. Evidence for impact of breast cancer surgery on quality of life, fatigue and cognition, was conflicting. The possibility of decline in functional status after breast cancer surgery should be discussed in all older women considering surgery. A structured exercise program may improve the negative effects of surgery on physical activity. Further work is required in the areas of quality of life, fatigability and cognition.
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Affiliation(s)
- C A Harrison
- Nottingham Breast Cancer Research Centre, University of Nottingham, UK
| | - R M Parks
- Nottingham Breast Cancer Research Centre, University of Nottingham, UK
| | - K L Cheung
- Nottingham Breast Cancer Research Centre, University of Nottingham, UK.
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Hinther A, Nakoneshny SC, Chandarana SP, Matthews TW, Hart R, Schrag C, Matthews J, McKenzie CD, Fick GH, Dort JC. Efficacy of Multimodal Analgesia for Postoperative Pain Management in Head and Neck Cancer Patients. Cancers (Basel) 2021; 13:cancers13061266. [PMID: 33809273 PMCID: PMC7999688 DOI: 10.3390/cancers13061266] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/03/2021] [Accepted: 03/10/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Chronic opioid use is a serious global health problem and surgery is often the point of initial exposure for many chronic opioid users. Multimodal analgesia (MMA) is an approach designed to reduce or eliminate opioid use in surgical patients, but it has not been studied in patients having major head and neck surgery. This study explores the impact of an MMA protocol on opioid prescribing practices in patients having major head and neck surgery with flap reconstruction. The results of this study will provide evidence to inform and guide pain management practice in this important patient population. The results of this study could also be applied to other areas of otorhinolaryngology. MMA is an important tool in the effort to reduce chronic opioid use. Abstract Postoperative opioid use has been linked to the subsequent development of opioid dependency. Multimodal analgesia (MMA) can reduce the use of opioids in the postoperative period, but MMA has not been well-studied after major head and neck surgery. Our goal is to explore the association between MMA and postoperative opioid use and pain control in patients undergoing major head and neck surgery. We performed a retrospective study in adult (age ≥ 18 years) patients undergoing primary head and neck cancer resection with free-flap reconstruction. All patients were treated using an established care pathway. The baseline group was treated between January 2015–December 2015 (n = 41), prior to the implementation of MMA, and were compared to an MMA-treated cohort treated between December 2017–June 2019 (n = 97). The primary outcome was the proportion of opioids prescribed and oral morphine equivalents (OMEs) consumed during the hospitalization. The secondary outcome was pain control. We found that the post-MMA group consumed fewer opioids in the postoperative period compared to the pre-MMA group. Prior to post-operative day (POD) 6, pain control was better in the post-MMA group; however, the pain control lines intersect on POD 6 and the pre-MMA group appeared to have better pain control from PODs 7–10. In conclusion, our data suggest MMA is an effective method of pain control and opioid reduction in patients undergoing surgery for head and neck cancer with free flap reconstruction. MMA use was associated with a significant decrease in the quantity of opioids consumed postoperatively. The MMA protocol was associated with improved pain management early in the postoperative course. Finally, the MMA protocol is a feasible method of pain control and may reduce the adverse side effects associated with opioid use.
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Affiliation(s)
- Ashley Hinther
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
| | - Steven C. Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - Shamir P. Chandarana
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - T. Wayne Matthews
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - Robert Hart
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - Christiaan Schrag
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (C.S.); (J.M.); (C.D.M.)
| | - Jennifer Matthews
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (C.S.); (J.M.); (C.D.M.)
| | - C. David McKenzie
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (C.S.); (J.M.); (C.D.M.)
| | - Gordon H. Fick
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
| | - Joseph C. Dort
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (A.H.); (S.P.C.); (T.W.M.); (R.H.)
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada;
- Correspondence: ; Tel.: +1-403-220-7268
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Post-mastectomy Breast Reconstruction with Autologous Tissue: Current Methods and Techniques. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3433. [PMID: 33680677 PMCID: PMC7929567 DOI: 10.1097/gox.0000000000003433] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/23/2020] [Indexed: 12/03/2022]
Abstract
Breast reconstruction is an option that should be considered for any patient facing a mastectomy. Autologous breast reconstruction provides the benefits of excellent longterm results, natural appearance, natural feel, and the best opportunity for sensory restoration. These factors lead many patients to choose autologous tissue over implant-based reconstruction. With improved anatomic and technical knowledge, the donor site morbidity previously associated with abdominally based autologous reconstruction has been significantly reduced. Today, the DIEP flap is the preferred autologous method allowing restoration of a “natural,” aesthetic breast with potential for sensation while simultaneously minimizing abdominal donor site morbidity. Alternative flaps and adjunctive procedures provide options when dealing with patients who present with challenging clinical scenarios because of an inadequate abdominal donor site. This paper reviews current methods employed by a high volume breast reconstruction practice to achieve these goals.
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Shin HD, Rodriguez AM, Abraham JT, Cargile JC, Brown CN, Altman AM, Saint-Cyr MH. “Does ERAS benefit higher BMI patients? A single institutional review”. J Plast Reconstr Aesthet Surg 2021; 74:475-479. [DOI: 10.1016/j.bjps.2020.08.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/02/2020] [Accepted: 08/24/2020] [Indexed: 12/22/2022]
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Kiely J, Smith K, Stirrup A, Holmes WJM. Setting up a new microsurgical breast service in a non-tertiary hospital: Is it safe, and do outcomes compare to centres of excellence? J Plast Reconstr Aesthet Surg 2021; 74:2034-2041. [PMID: 33541825 DOI: 10.1016/j.bjps.2020.12.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 12/02/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
AIMS Access to autologous reconstruction continues to be limited in some areas of the United Kingdom. This is, in part, due to the perceived difficulty offering this service outside of a large tertiary centre. We present our experience setting up a new microsurgical breast reconstruction service in a district hospital and compare our results to the published outcomes of large volume centres. METHODS Patient data were collected prospectively from the start of the service to date (July 2018- July 2020) with the capture of demographics, management, and outcomes. The BREAST-Q tool was used preoperatively and at a minimum of 3 months. RESULTS The first 40 patients undergoing DIEP reconstruction were included. Of these, 70% were immediate, mean age was 49 years (27-68) and BMI was 28.1 kg/m2 (22-32.5). In all, 50% had one or more co-morbidities other than breast cancer. Median length of stay was 3 days (2-6) with 75% of patients discharged on day 2 or 3. Ten patients' stay exceeded 3 days - mostly due to social reasons. Flap loss occurred in 1 patient (2.5%). Twenty-one patients developed complications (52%) within 90 days: seven Clavien-Dindo Grade I, two Grade II and ten Grade IIIb. Fat necrosis and mastectomy flap necrosis were the most common complications. Surgical intervention was higher in those needing adjuvant therapy. Patient-reported outcomes showed post-operative improvement across all domains except abdominal physical well-being at median 11.3 months. CONCLUSIONS We present the shortest published length of stay for unilateral DIEP reconstructions. We are the first paper to publish patient-reported outcomes following a breast microsurgical enhanced recovery protocol. We demonstrate how a new microsurgical service, utilising an enhanced recovery protocol and careful patient selection can immediately achieve outcomes comparable to well-established centres. There is no reason why all patients should not have access to microsurgical breast reconstruction locally.
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Affiliation(s)
- J Kiely
- Department of Plastic and Reconstructive Surgery, Pinderfields Hospital, Mid Yorkshire NHS Foundation Trust, UK.
| | - K Smith
- Department of Plastic and Reconstructive Surgery, Pinderfields Hospital, Mid Yorkshire NHS Foundation Trust, UK.
| | - A Stirrup
- Department of Plastic and Reconstructive Surgery, Pinderfields Hospital, Mid Yorkshire NHS Foundation Trust, UK.
| | - W J M Holmes
- Department of Plastic and Reconstructive Surgery, Pinderfields Hospital, Mid Yorkshire NHS Foundation Trust, UK.
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Enhanced Recovery after Abdominoplasty Using Perisurgical Nutritional Supplementation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3314. [PMID: 33425620 PMCID: PMC7787335 DOI: 10.1097/gox.0000000000003314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/24/2020] [Indexed: 11/26/2022]
Abstract
Nutritional supplements are common in other surgical specialties but not widely used in the plastic surgery setting. This study compares the surgical outcomes of patients using our standard ERAS protocol involving arnica and bromelain with an updated ERAS protocol using perisurgical nutritional supplementation using a staged administration of nutraceuticals. Methods In total, 300 female abdominoplasty patients were randomly provided with perioperative supplementation consisting of arnica and bromelain, or a 3-stage nutraceutical regimen containing arginine, citrulline, glutamine, bromelain, and vitamin C. Narcotic use in recovery and post-operative drainage were measured, and both groups completed a self-assessment of bruising coloration, days to independent activity, perceived pain, and documented the quantity of narcotic and non-prescription pain killers they took over a 14-day recovery period. Results There were 130 patients in the nutraceutical group and 80 in the arnica and bromelain group; patients were excluded due to non-compliance or due to incomplete data. Patients taking the nutraceutical regimen reported a shorter duration of pain and had a 41% reduction in narcotic use in recovery and experienced 48% less post-operative drainage. Home use of narcotic pain killers decreased by 25%. There also was a trend toward decreased and earlier clearing/maturation of bruising as well as return to daily activates without assistance. Patients also reported an increase in satisfaction with their surgical experience. Conclusions This study demonstrated that perioperative supplementation with nitric oxide precursors, antioxidants, and proteolytic enzymes in a staged fashion can positively affect post-operative outcomes and is an adjunct to enhanced surgical recovery protocols.
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Enhanced recovery after breast reconstruction with a pedicled Latissimus Dorsi flap-A prospective clinical study. J Plast Reconstr Aesthet Surg 2020; 74:1725-1730. [PMID: 33342743 DOI: 10.1016/j.bjps.2020.11.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/22/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION We have previously implemented and published an enhanced recovery after surgery (ERAS) program for autologous breast reconstruction using DIEP flaps. The latissimus dorsi (LD) flap is another commonly used flap for autologous breast reconstruction (ABR). The aim of the present study was to use our experience from the ERAS program in DIEP flap reconstruction to optimize our LD breast reconstruction program. MATERIAL AND METHODS We examined our data for a 10-year period (n = 135) and compared this with two different surgical team approaches, within the same unit. One team implemented an ERAS program (n = 18), the other did not (n = 12). Data were collected prospectively. In the ERAS group, patient information was revised, multimodal analgesia was introduced, drain handling was optimised and functional discharge criteria was introduced. Fulfilment of functional discharge criteria were assessed twice daily and specified reasons for not allowing discharge registered. RESULTS All patients had a breast reconstruction using a unilateral LD flap. Patient and surgical parameters were comparable. Length of stay was significantly shorter in the ERAS group (3.2 days) compared to the historical (6.9) and non-ERAS (TRAS) group (6.3) (p<0.0001). Drains were removed significantly faster in the ERAS group (day 3.9) vs day 6.3 (historical) and day 7.0 (TRAS) (p<0.0001). Time to drain removal was the main reason for extended LOS. There were no differences in reoperations, readmissions or complications between the three groups. All patients in the ERP group were ambulating, pain free, had abdominal function, were eating and managing personal hygiene on POD 1. CONCLUSIONS LOS was safely reduced to 3 days for LD breast reconstruction in the ERAS group. By discharging patients with drains, it should theoretically be possible to reduce LOS to 1 day, as all other discharge criteria have then been fulfilled.
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Guffey R, Keane G, Ha AY, Parikh R, Odom E, Zhang L, Myckatyn TM. Enhanced Recovery With Paravertebral and Transversus Abdominis Plane Blocks in Microvascular Breast Reconstruction. BREAST CANCER-BASIC AND CLINICAL RESEARCH 2020; 14:1178223420967365. [PMID: 33597807 PMCID: PMC7863148 DOI: 10.1177/1178223420967365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/24/2020] [Indexed: 11/17/2022]
Abstract
Purpose: We have shown previously that a preoperative paravertebral nerve block is associated with improved postoperative recovery in microvascular breast reconstruction. The purpose of this study was to compare the outcomes of a complete enhanced recovery after surgery (ERAS) protocol with complete regional anesthesia coverage to our traditional care with paravertebral block. Patients and methods: This was a retrospective cohort study of 83 patients who underwent autologous breast reconstruction by T.M.M. between May 2014 and February 2018 at a tertiary academic center. Patients in the ERAS group were additionally administered acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, a transversus abdominis plane block (liposomal or plain bupivacaine), and primarily oral opioids postoperatively. The patients were mobilized earlier with more rapid diet progression. All patients received a preoperative paravertebral block. Results: Forty-four patients in the ERAS cohort were compared with 39 retrospective controls. The 2 groups were similar with respect to demographics and comorbidities. The ERAS cohort required significantly less opioids (291 vs 707 mg oral morphine equivalent, P < .0001) with unchanged postoperative pain scores and a shorter time to oral only opioid use (16.0 vs 78.2 hours, P < .0001). Median length of stay (3.20 vs 4.62, P < .0001) and time to independent ambulation (1.86 vs 2.88, P < .0001) were also significantly decreased in the ERAS cohort. Liposomal bupivacaine use did not significantly affect the results (P ⩾ .2). Conclusions: Implementation of a robust enhanced recovery protocol with complete regional anesthesia coverage was associated with significantly decreased opioid use despite unchanged pain scores, with improved markers of recovery including length of stay, time to oral only narcotics, and time to independent ambulation.
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Affiliation(s)
- Ryan Guffey
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Grace Keane
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Austin Y Ha
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Rajiv Parikh
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Elizabeth Odom
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Li Zhang
- Department of Anesthesiology, Wuhan No. 1 Hospital, Wuhan, China
| | - Terence M Myckatyn
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Knackstedt R, Patel N. Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3205. [PMID: 33173704 PMCID: PMC7647619 DOI: 10.1097/gox.0000000000003205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 08/31/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols utilize multi-modal approaches to decrease morbidity, narcotic usage, and length of stay. In 2013, we made several changes to our perioperative approach to children undergoing complex craniofacial procedures. The goal of this study was to analyze our protocol for children undergoing fronto-orbital advancement (FOA) for craniosynostosis. METHODS A retrospective chart review was performed after IRB approval, for children who underwent fronto-orbital advancement for craniosynostosis from 2010 to 2018. The ERAS protocol, initiated in December 2013, involves hemoglobin optimization, cell-saver technology, tranexamic acid, specific postoperative fluid titration, and a transfusion algorithm. The analgesic regimen focuses on narcotic reduction through the utilization of scheduled acetaminophen, ibuprofen, or ketorolac, and a dexmedetomidine infusion with opioids only for breakthrough pain. RESULTS Fifty-five ERAS protocol children and 23 control children were analyzed. ERAS children had a decreased rate (13/53 versus 23/23, P < 0.0001) and volume of intraoperative transfusion (183.4 mL versus 339.8 mL, P = 0.05). Fewer ERAS children required morphine/dilaudid (12/55 versus 22/23 P < 0.0001) and for children who required morphine, fewer doses were required (2.8 versus 11, P = 0.02). For ERAS protocol children who required PO narcotics, fewer doses were required (3.2 versus 5.3, P = 0.02). ERAS children had a decreased length of stay (2.3 versus 3.6 nights, P < 0.0001). No patients were re-admitted due to poor oral intake, pain, hemodynamic, or pulmonary concerns. CONCLUSIONS Our ERAS protocol demonstrated a reduction in the overall and intraoperative allogenic blood transfusion rate, narcotic use, and hospital length of stay. This is a safe and effective multimodal approach to managing complex craniofacial surgical recovery.
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Affiliation(s)
| | - Niyant Patel
- Plastic and Reconstructive Surgery Center, Akron Children’s Hospital, Akron, Ohio
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Early Discontinuation of Breast Free Flap Monitoring: A Strategy Driven by National Data. Plast Reconstr Surg 2020; 146:258e-264e. [PMID: 32842096 DOI: 10.1097/prs.0000000000007052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multiple single-institution studies have revealed that breast free flap compromise usually occurs within the first 48 postoperative hours. However, national studies analyzing the rates and timing of breast free flap compromise are lacking. This study aimed to fill this gap in knowledge to better guide postoperative monitoring. METHODS All women undergoing breast free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2016 database were analyzed to determine the rates and timing of free flap take-back. Take-backs were stratified by postoperative day through the first month. Multivariable modified Poisson regression analysis was used to determine the independent predictors of free flap take-back. RESULTS A total of 6792 breast free flap patients were analyzed. Multivariable analysis revealed that body mass index of 40 kg/m or higher, hypertension, American Society of Anesthesiologists class of 3 or higher, steroid use, and smoking were independent predictors of take-back (p < 0.05). Take-back occurred at the highest rate during postoperative day 1, dropped significantly by postoperative day 2 (p < 0.001), and remained consistently low after postoperative day 2 (<0.6 percent daily). The identified risk factors significantly increased the likelihood of take-back on postoperative day 1 (p < 0.05), with a trend noted on postoperative day 2 (p = 0.06). Fewer than 0.4 percent of patients (n = 27) underwent take-back on postoperative day 2 without having risk factors. CONCLUSIONS This is the first national study specifically analyzing rates, timing, and independent predictors of breast free flap take-back. The data support discontinuing breast free flap monitoring by the end of postoperative day 1 for patients without risk factors, given the very low rate of take-back for such patients during postoperative day 2 (≤0.4 percent). CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Chi D, Chen AD, Ha AY, Yaeger LH, Lee BT. Comparative Effectiveness of Transversus Abdominis Plane Blocks in Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-analysis. Ann Plast Surg 2020; 85:e76-e83. [PMID: 32960515 DOI: 10.1097/sap.0000000000002376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The abdomen is the most common donor site in autologous microvascular free flap breast reconstruction and contributes significantly to postoperative pain, resulting in increased opioid use, length of stay, and hospital costs. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated multiple clinical benefits, but these protocols are widely heterogeneous. Transversus abdominis plane (TAP) blocks have been reported to improve pain control and may be a key driver of the benefits seen with ERAS pathways. METHODS A systematic review and meta-analysis of studies reporting TAP blocks for abdominally based breast reconstruction were performed. Studies were extracted from 6 public databases before February 2019 and pooled in accordance with the PROSPERO registry. Total opioid use, postoperative pain, length of stay, hospital cost, and complications were analyzed using a random effects model. RESULTS The initial search yielded 420 studies, ultimately narrowed to 12 studies representing 1107 total patients. Total hospital length of stay (mean difference, -1.00 days; P < 0.00001; I = 81%) and opioid requirement (mean difference, -133.80 mg of oral morphine equivalent; P < 0.00001; I = 97%) were decreased for patients receiving TAP blocks. Transversus abdominis plane blocks were not associated with any significant differences in postoperative complications (P = 0.66), hospital cost (P = 0.22), and postoperative pain (P = 0.86). CONCLUSIONS Optimizing postoperative pain management after abdominally based microsurgical breast reconstruction is invaluable for patient recovery. Transversus abdominis plane blocks are associated with a reduction in length of stay and opioid use, representing a safe and reasonable strategy for decreasing postoperative pain.
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Affiliation(s)
| | - Austin D Chen
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Austin Y Ha
- From the Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO
| | - Lauren H Yaeger
- From the Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, MA
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Wallner C, Kolbenschlag J, Daigeler A, Stambera P, Andree C, Rieger UM, Behr B, Schaefer DJ, Kneser U, Lehnhardt M. Perioperatives Management in der Mikrochirurgie – Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße. HANDCHIR MIKROCHIR P 2020; 52:310-315. [PMID: 32823366 DOI: 10.1055/a-1205-1309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Perioperative management in microsurgery is a key element of success in reconstructive surgery. There are no uniform concepts for this in the German-speaking countries and individual schemes differ significantly from each other, as ascertained in an expert survey. In the course of the 41st Annual Conference of the German-speaking Working Group for Microsurgery (DAM) held in Munich in November 2019, concepts were evaluated and a survey was carried out and summarised as a position paper in due consideration of the scientific literature.
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Affiliation(s)
- Christoph Wallner
- Universitätsklinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil
| | - Jonas Kolbenschlag
- Universitätsklinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen
| | - Adrien Daigeler
- Universitätsklinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen
| | - Peter Stambera
- Klinik für Plastische und Ästhetische Chirurgie, Sana-Kliniken Düsseldorf, Krankenhaus Gerresheim, Akademisches Lehrkrankenhaus der Heinrich Heine Universität Düsseldorf
| | - Christoph Andree
- Klinik für Plastische und Ästhetische Chirurgie, Sana-Kliniken Düsseldorf, Krankenhaus Gerresheim, Akademisches Lehrkrankenhaus der Heinrich Heine Universität Düsseldorf
| | - Ulrich Michael Rieger
- Klinik & Praxis für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus
| | - Björn Behr
- Universitätsklinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil
| | - Dirk Johannes Schaefer
- Universitätsklinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, BG-Klinik Ludwigshafen, Klinik für Plastische und Handchirurgie an der Universität Heidelberg
| | - Marcus Lehnhardt
- Universitätsklinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil
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Enhanced Recovery After Surgery (ERAS): Protocols in Post-Mastectomy Breast Reconstruction. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00378-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Oliver JD, Knackstedt R, Gatherwright J. Optimizing non-opioid pain control after implant-based breast reconstruction: a review of the literature and proposed pain control algorithm. J Plast Surg Hand Surg 2020; 54:328-336. [PMID: 32734796 DOI: 10.1080/2000656x.2020.1800480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Despite the intense focus on the opioid epidemic and its known association with surgical procedures, there is a paucity of evidence-based literature on pain management in implant-based breast reconstruction (IBR). Herein, we present an updated review of the literature aimed at identifying pain treatment protocols to minimize narcotic use and its associated potential addiction in IBR. A comprehensive review of the published English literature was conducted using Ovid Medline/PubMed Database without timeframe limitations. The inclusion criteria of selected articles presented in this review included studies reporting objective outcomes of pain modulation (preoperatively, intraoperatively and postoperatively) in IBR. Articles for inclusion were stratified based on intervention. A total of 219 articles were identified in the initial search query, with 23 studies meeting the inclusion criteria. Pain optimization interventions in IBR are herein summarized and analyzed based on the reported outcomes of each respective study. There is a substantial need for evidence-based guidelines in the plastic surgery literature for pain optimization without the use of opioids. While this review of studies to date investigates potential solutions, we hope this area of study continues to be a top priority for plastic surgeons to allow for optimized post-operative care for patients following IBR.
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Affiliation(s)
- Jeremie D Oliver
- Department of Biomedical Engineering and School of Dentistry, University of Utah Health, Salt Lake City, UT, USA
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