Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Tissue Expander-based Breast Reconstruction

Background

Enhanced recovery after surgery (ERAS) protocols have demonstrated success in reducing hospital stay and opioid consumption, but are less well studied in patients undergoing tissue expander-based breast reconstruction (TEBR). This study evaluates the effectiveness of an ERAS postoperative protocol for TEBR at a high-volume center.

Methods

All patients undergoing immediate tissue expander reconstruction after the introduction of ERAS were prospectively included from April 2019 to June 2023. An equivalent number of similar patients were retrospectively reviewed before this date as the non-ERAS control. Data included demographics, operative details, postoperative length of stay, inpatient and discharge narcotic quantities, inpatient pain assessments, postoperative radiation, and complications within 90 days.

Results

There were 201 patients in each cohort with statistically similar demographics. Patients in the ERAS cohort were more likely to undergo prepectoral reconstruction (83.1% versus 4.5%, P < 0.001), be discharged by day 1 (96.5% versus 70.2%, P < 0.001) and consume lower inpatient milligram morphine equivalent (MME) median (79.8 versus 151.8, P < 0.001). Seroma rates (17.4% versus 3.5%, P < 0.001) and hematoma incidence (4.5% versus 0%, P = 0.004) were higher in the ERAS cohort. Adjusting for implant location, ERAS was associated with a 60.7 MME reduction (β=-60.7, P < 0.001) and a shorter inpatient duration by 0.4 days (β =-0.4, P < 0.001). Additionally, prepectoral reconstruction significantly decreased MME (β=-30.9, P = 0.015) and was the sole predictor of seroma development (odds ratio = 5.2, P = 0.009).

Conclusions

ERAS protocols significantly reduce opioid use and hospital stay after TEBR.

Enhanced Recovery After Surgery Protocols in Craniofacial Surgery

Enhanced Recovery after Surgery (ERAS) refers to a patient centered, multidisciplinary team developed pathway aimed at reducing the surgical stress response and facilitating expedited patient postoperative recovery. These protocols have been largely developed in the general surgery literature and have led to vast improvements in the patient experience. ERAS protocols are generally substantiated on 3 phases along the continuum of surgical care: preadmission optimization, intraoperative treatment, and postoperative management. In this article, the evidence for ERAS development in craniomaxillofacial surgery will be reviewed, and recommendations from prior studies for enhanced recovery will be outlined.

Optimizing Blood Loss and Management in Craniosynostosis Surgery: A Systematic Review of Outcomes Over the Last 40 Years

Surgical correction of craniosynostosis can involve significant blood loss. Rates of allogenic blood transfusion have been reported to approach 100%. Multiple interventions have been described to reduce blood loss and transfusion requirements. The aim of this study was to analyze various approaches over the last 4 decades to optimize blood loss and management during craniosynostosis surgery.

PRISMA guidelines for systematic reviews were followed. PubMed and Cochrane database searches identified studies analyzing approaches to minimizing blood loss or transfusion rate in craniosynostosis surgery.

Primary outcomes included rate or amount of allogenic or autologous blood transfusion, estimated blood loss (EBL), postoperative hemoglobin (Hg), or hematocrit (Hct) levels. Secondary outcomes were examined when reported.

Fifty-two studies met inclusion criteria. There was marked heterogeneity regarding design, inclusion criteria, surgical intervention, and endpoints. The majority of the studies were nonrandomized and noncomparative. Four studies analyzed erythropoietin (EPO), 6 analyzed various cell-saver (CS) technologies, 18 analyzed antifibrinolytics (tranexamic acid [TXA], aminocaproic acid [ACA], and aprotinin [APO]), 8 analyzed various alternatives, and 16 analyzed multimodal pathways & protocols. Some studies analyzed multiple approaches.

Although the majority of studies reviewed represent level III/IV evidence, several high-quality level I studies were identified and included. Level I evidence supported an improvement in blood outcomes by utilizing EPO, CS, and TXA, individually or in concert with one another. Thus, this review suggests that a multi-prong approach may be the most effective means to optimize blood loss and transfusion outcomes in craniosynostosis surgery.

The management of perioperative pain in craniosynostosis repair: a systematic literature review of the current practices and guidelines for the future

Background

Craniosynostosis is a condition characterized by a premature fusion of one or more cranial sutures. The surgical repair of craniosynostosis causes significant pain for the child. A key focus of craniosynostosis repair is developing effective strategies to manage perioperative pain. This study aimed to review perioperative pain control strategies for craniosynostosis repair systematically.

Methods

Guidelines for reporting systematic reviews and meta-analyses were used in the design of this review. In May 2022, the following databases were used to conduct the literature search: MEDLINE, Cochrane, EMBASE, and Google Scholar. A search was performed using MeSH terms “craniosynostosis,” “pain management,” and “cranioplasty.”

Results

The literature review yielded 718 publications. After applying our inclusion criteria, 17 articles were included, accounting for a total of 893 patients. During the postoperative period, most studies used multimodal analgesia, primarily opioids, and acetaminophen. In the postoperative period, oral ibuprofen was the most commonly used NSAID, rectal codeine, and acetaminophen were the most commonly used weak opioids, and continuous remifentanil infusion was the most commonly used potent opioid.

Conclusion

The authors determined the best pain management options for pediatric patients undergoing cranioplasty by analyzing the most commonly used analgesics. A high-quality clinical trial comparing different types of analgesic combinations would be a valuable addition to the present literature.

Enhanced Recovery after Surgery (ERAS) protocols in craniomaxillofacial surgery: an evidence-based review

PURPOSE OF REVIEW

Enhanced Recovery after Surgery (ERAS) refers to a patient centered, multidisciplinary team developed pathway aimed at reducing the surgical stress response and facilitating expedited patient postoperative recovery. These protocols have been largely developed in the general surgery literature and have led to vast improvements in the patient experience. With a growing shortage of hospital resources during the height of the COVID-19 pandemic there has been a growing push to apply these principles to a wide variety of specialties.

RECENT FINDINGS

ERAS protocols are generally substantiated on three phases along the continuum of surgical care: preadmission optimization, intraoperative treatment, and postoperative management. In this article, the evidence for ERAS development in craniomaxillofacial surgery will be reviewed, and recommendations from prior studies for enhanced recovery will be outlined.

SUMMARY

ERAS protocols have been proven effective in many surgical arenas, however, modification is needed for the craniomaxillofacial population. The implications for widespread implementation of ERAS protocols during these procedures are a potentially shortened length of stay, expedited early return to function, reduction in narcotic dependence, and reduction in postdischarge complications necessitating additional intervention.

Geographic Financial Analysis of Craniosynostosis Surgery in the United States

BACKGROUND

The purpose of this study was to investigate the financial implications of demographic and socioeconomic factors upon the cost of surgical procedures for craniosynostosis.

METHODS

A retrospective cohort study was conducted of admissions for craniosynostosis surgery in the United States from 2015 through 2020 using the Pediatric Health Information System. Patient demographics, case volume, and surgical approach were analyzed in context of hospital charges.

RESULTS

During the study interval, 3869 patients were admitted for surgery for craniosynostosis. In multivariate regression accounting for demographic and socioeconomic factors, hospital admission charges were significantly higher in patients with longer hospital length of stay (P < 0.001), longer ICU length of stay (P < 0.001), living in an underserved area (P = 0.046), preoperative risk factors (P = 0.016), and those undergoing open procedures (P < 0.001); hospital admission charges were significantly lower in patients with White race (P = 0.020) and those treated at high-volume centers (P < 0.001). In multivariate regression, ICU length of stay was significantly higher in patients with preoperative risk factors (P < 0.001), undergoing open procedures (P < 0.001), government insurance (P = 0.018), and not treated at high-volume centers (P = 0.005). There were significant differences in admission charges (P < 0.001), charge-to-cost ratios (P < 0.001), and likelihood of being treated at high-volume craniofacial centers (P < 0.001) across geographic regions of the country.

CONCLUSIONS

In the United States, there is significant sociodemographic variability in charges for craniosynostosis care, with increased hospital charges independently associated with non-White race, preoperative risk factors, and living in an underserved area.

Systematic Review of Enhanced Recovery After Surgery in Patients Undergoing Cranial Surgery

BACKGROUND

Enhanced Recovery after Surgery (ERAS) pathways are increasingly being integrated in neurosurgical patient management. The full extent of ERAS in cranial surgery is not well studied. We performed a systematic review examining ERAS in cranial surgery patients to 1) identify the extent to which ERAS is integrated in cranial neurosurgical procedures and 2) assess effectiveness of ERAS interventions for patients undergoing these procedures.

METHODS

A systematic review of MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Scopus, PsychInfo, and Google Scholar was conducted according to PRISMA guidelines (CRD42020197187). Studies eligible for inclusion assessed patients undergoing any cranial surgical procedure using an ERAS or ERAS-like pathway, defined by ≥2 ERAS protocol elements per the ERAS Society's RECOvER Checklist and the recommendations of Hagan et al. 2016 (not including patient education, criteria for discharge, or tracking of postdischarge outcomes).

RESULTS

Nine studies were included in qualitative synthesis, 2 of which were randomized controlled trials. All studies showed a moderate risk of bias. The most common ERAS elements used were screening and/or optimization and formal discharge criteria. The least common ERAS elements used were fasting/carbohydrate loading and antithrombotic prophylaxis. Complication rates were similar in studies comparing ERAS with non-ERAS groups. ERAS interventions were associated with reduced length of stay, with comparable and/or improved patient satisfaction.

CONCLUSIONS

ERAS is a safe and potentially favorable perioperative pathway for select patients undergoing cranial surgery. Future studies of ERAS in cranial surgery patients should emphasize postoperative optimizations and patient-reported outcome measures as key features.