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

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial

BACKGROUND

Transversus abdominis plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compared pain-related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction.

METHODS

The authors conducted a single-center, single-blinded randomized controlled trial between March of 2021 and December of 2022. Patients undergoing deep inferior epigastric perforator flap breast reconstruction in a standardized enhanced recovery after surgery pathway were randomized to receive intraoperative TAP blocks with either bupivacaine and epinephrine (control group) or liposomal bupivacaine, bupivacaine, and epinephrine (experimental group). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay, and narcotic medication refills.

RESULTS

A total of 117 patients met inclusion criteria (59 control patients and 58 experimental patients). Demographic characteristics, comorbidities, breast pathologic variables, surgery laterality, and immediate versus delayed reconstruction status were equivalent between groups. The control group had significantly higher average pain scores postoperatively (4.3 versus 3.6; P = 0.004). However, there were no significant differences in mean narcotic use (66.9 morphine milligram equivalents versus 60.2 morphine milligram equivalents; P = 0.47). Both length of stay and postoperative narcotic prescription refills were equivalent between groups (2.1 days versus 2.2 days, P = 0.55; 22% versus 17.2%, P = 0.52).

CONCLUSIONS

The addition of liposomal bupivacaine to the standard bupivacaine TAP block mixture in a standardized enhanced recovery after surgery protocol did not demonstrate a significant reduction in postoperative narcotic requirements after deep inferior epigastric perforator flap breast reconstruction compared with standard bupivacaine alone. Patient-reported pain scores, however, were lower among liposomal bupivacaine patients after the initial 24 hours postoperatively and consistent with a longer duration of analgesia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Multi-Flap Microsurgical Autologous Breast Reconstruction

Microsurgical autologous breast reconstruction (MABR) remains the gold standard technique of breast reconstruction, providing a durable, natural, and aesthetically pleasing result. However, some patients may not be candidates for a traditional deep inferior epigastric perforator (DIEP) flap, either due to abdominal tissue paucity, the need for higher-volume reconstruction, or prior surgical procedures. In these patients, alternative flaps must be considered to achieve the optimal result. Such configurations include the conjoined (or double pedicle) DIEP flap, and alternative flaps such as the lumbar artery perforator (LAP) and profunda artery perforator (PAP) flaps, which can be combined in a stacked fashion. By combining multiple flaps in a conjoined or stacked fashion, breast reconstruction can be optimized to fulfill the three critical components of breast reconstruction in restoring the skin envelope, breast footprint, and conus shape. When harvesting multiple flaps, the surgical sequence of events must be meticulously planned to ensure an efficient and successful operation. Preoperative imaging can aid the surgeon in identifying the ideal perforator, assess for side branches for possible intra-flap anastomoses, expedite the operative time, and decrease intraoperative complications. Reconstructive surgeons should be familiar with the variety of configurations with conjoined and/or stacked flaps to address patient-specific reconstructive needs.

Postoperative Magnesium Sulfate Repletion Decreases Narcotic Use in Abdominal-Based Free Flap Breast Reconstruction

BACKGROUND

 Microsurgical breast reconstruction after mastectomy is now the standard of care for breast cancer patients. However, the costs and resources involved in free flap reconstruction can vary across different medical settings. To enhance patient outcomes in a cost-effective manner, we investigated the effect of intravenous magnesium sulfate (IV Mg) on postoperative opioid usage in this context.

METHODS

 A retrospective chart review was performed on all consecutive patients who underwent abdominal-based free flap breast reconstruction in a single institute following an enhanced recovery after surgery (ERAS) protocol. Patients who received IV Mg were compared with those who did not receive supplementation. Serum magnesium levels at different time points, narcotic consumption in units of oral morphine milligram equivalents (MMEs), and other postoperative recovery parameters were compared.

RESULTS

 Eighty-two patients were included. Those who received IV Mg on postoperative day 0 (n = 67) showed significantly lower serum magnesium levels before repletion (1.5 vs. 1.7 mg/dL, p = 0.004) and significantly higher levels on postoperative day 1 after repletion (2.2 vs. 1.7 mg/dL, p = 0.0002) compared to patients who received no magnesium repletion (n = 13). While both groups required a similar amount of narcotics on postoperative day 0 (20.2 vs. 13.2 MMEs, p = 0.2), those who received IV Mg needed significantly fewer narcotics for pain control on postoperative day 1 (12.2 MMEs for IV Mg vs. 19.8 MMEs for No Mg, p = 0.03). Recovery parameters, including maximal pain scores, postoperative mobilization, and length of hospital stay, did not significantly differ between the two groups.

CONCLUSION

 This is the first study to describe the potential analgesic benefits of routine postoperative magnesium repletion in abdominal-based free flap reconstruction. Further research is necessary to fully understand the role of perioperative magnesium supplementation as part of an ERAS protocol.

Multiple intramuscular ropivacaine injections to donor sites reduces pain in deep inferior epigastric artery perforator flap breast reconstruction

INTRODUCTION

Local anesthetic infiltration at the surgical site has been studied in various surgical disciplines; however, its impact on deep inferior epigastric artery perforator (DIEP) flap breast reconstruction has not been previously assessed. This study aimed to evaluate the effects of multiple intramuscular ropivacaine injections on donor site pain during DIEP flap breast reconstruction.

METHODS

The study included 65 patients who received local ropivacaine injections during DIEP reconstructions between March 2022 and February 2023, compared to 55 patients who underwent surgeries without ropivacaine from October 2018 to July 2020. A total of 20 cc of 0.75% ropivacaine solution was evenly administered at 20 sites along the abdominal wall muscles. The effect of intramuscular ropivacaine injection on postoperative visual analog scale (VAS) was evaluated using linear mixed-effect model. Opioid consumption and hospital days were also compared.

RESULTS

The daily median VAS score was lower in the ropivacaine group (all p-values < 0.001). When analyzed using a linear mixed-effects model, those who received ropivacaine had significantly lower VAS scores over the first 5 days postoperatively (p-value < 0.001). The rate of VAS score decline was also faster in the ropivacaine group over the first 24 h postoperative (p-value = 0.045). Although opioid consumption was comparable between the groups, those receiving ropivacaine had significantly shorter hospital stay (p-value = 0.001) and no complications related to the injections were observed.

CONCLUSION

Multiple intramuscular injections of ropivacaine to the donor site may reduce postoperative pain and shorten hospital stays, without increasing opioid consumption.

Enhanced Recovery After Surgery (ERAS) With Exparel in Tissue Expander-based Breast Reconstruction Following Mastectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been widely shown to yield positive outcomes, including in plastic surgery. Our group has previously validated ERAS in our deep inferior epigastric perforator flap breast reconstruction population.

OBJECTIVES

We evaluated whether the ERAS protocol and addition of liposomal bupivacaine affected patient outcomes at the time of mastectomy and first-stage tissue expander reconstruction.

METHODS

All patients treated between July 2021 and May 2022 were reviewed retrospectively. The ERAS protocol was implemented in December 2021. Two patient groups were compared: pre-ERAS and ERAS. The ERAS protocol included use of liposomal bupivacaine in the pectoralis nerve block 1/2 planes. Primary outcomes were observed with postoperative length of stay and hospital narcotic use.

RESULTS

Eighty-one patients were analyzed in this cohort. The pre-ERAS group was composed of 41 patients, the ERAS group was composed of 83 patients. Postoperative length of stay was significantly reduced in the ERAS group (1.7 pre-ERAS vs 1.1 ERAS, P = .0004). When looking at morphine equivalents during the hospital stay, the degree of narcotics in the recovery room was relatively similar. Average PACU pain morphine equivalents were 6.1 pre-ERAS vs 7.1 ERAS (P = .406). However, total hospital morphine equivalents were significantly lower in the ERAS group (65.0 pre-ERAS vs 26.2 ERAS, P = <.001).

CONCLUSIONS

The introduction of an enhanced recovery after surgery protocol with liposomal bupivacaine pectoralis 1/2 nerve blocks decreased postoperative opioid consumption and hospital length of stay in mastectomy patients undergoing tissue expander-based reconstruction.

LEVEL OF EVIDENCE: 4

Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways.

SUMMARY

In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.

Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study

Background

Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus bupivacaine after deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods

This retrospective cohort study used the IQVIA claims databases to identify patients undergoing primary DIEP flap breast reconstruction in 2016-2019. Patients receiving LB and those receiving bupivacaine were compared to assess opioid utilization in morphine milligram equivalents (MMEs) and healthcare resource utilization during perioperative (2 weeks before surgery to 2 weeks after discharge) and 6-month postdischarge periods. A generalized linear mixed-effects model and inverse probability of treatment weighting method were performed.

Results

Weighted baseline characteristics were similar between cohorts (LB, n = 669; bupivacaine, n = 348). The LB cohort received significantly fewer mean MMEs versus the bupivacaine cohort during the perioperative (395 versus 512 MMEs; rate ratio [RR], 0.771 [95% confidence interval (CI), 0.677-0.879]; P = 0.0001), 72 hours after surgery (63 versus 140 MMEs; RR, 0.449 [95% CI, 0.347-0.581]; P < 0.0001), and inpatient (154 versus 303 MMEs; RR, 0.508 [95% CI, 0.411-0.629]; P < 0.0001) periods; postdischarge filled opioid prescriptions were comparable. The LB cohort was less likely to have all-cause inpatient readmission (odds ratio, 0.670 [95% CI, 0.452-0.993]; P = 0.046) and outpatient clinic/office visits (odds ratio, 0.885 [95% CI, 0.785-0.999]; P = 0.048) 3 months after discharge than the bupivacaine cohort; other all-cause healthcare resource utilization outcomes were not different.

Conclusions

LB was associated with fewer perioperative MMEs and all-cause 3-month inpatient readmissions and outpatient clinic/office visits than bupivacaine in patients undergoing DIEP flap breast reconstruction.

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.

Outpatient Prescription Opioid Use following Discharge after Deep Inferior Epigastric Perforator Breast Reconstruction with and without an Educational Intervention

BACKGROUND

 There is limited evidence for appropriate postoperative opioid prescribing in autologous breast reconstruction. We sought to describe postoperative outpatient prescription opioid use following discharge after deep inferior epigastric perforator (DIEP) breast reconstruction with and without an educational video.

METHODS

 Patients undergoing DIEP reconstruction were given a 28-day postoperative pain and medication logbook from August 2022 to June 2023. Our practice implemented an educational video upon discharge on proper opioid consumption. Descriptive statistics on patient characteristics, intraoperative and postoperative opioid consumption, and outpatient prescription opioid use after discharge were compared between the two cohorts.

RESULTS

 A total of 53 logbooks were completed with 20 patients in the no video cohort and 33 in the video cohort. On average, the days to cessation of opiates was longer in the no video cohort (8.2 vs. 5.1 days, p = 0.003). The average number of oxycodone 5 mg equivalents consumed following discharge was 13.8 in the no video cohort and 7.8 in the video cohort, which was statistically significant (p = 0.01). Overall, the percentage of opioids prescribed that were consumed in the video cohort was 28.3% versus 67.1% in the no video cohort.

CONCLUSION

 For patients discharging home after DIEP reconstruction, we recommend a prescription for 12 oxycodone 5 mg tablets. With the use of an educational video regarding proper opioid consumption, we were able to reduce the total outpatient opioid use to 5 oxycodone 5 mg tablets following hospital discharge.

Efficacy of the enhanced recovery after surgery protocol on reducing surgical disparities related to overweight/obesity in deep inferior epigastric perforator flap breast reconstruction

BACKGROUND

When choosing a method of deep inferior epigastric perforator (DIEP) flap for breast reconstruction, concerns regarding the potentially detrimental effects of obesity on postoperative recovery remain. Enhanced recovery after surgery (ERAS) is known to facilitate rapid postoperative recovery. This study aimed to examine the effect of the ERAS protocol on the disparity between normal/underweight and overweight/obese patients after DIEP flap breast reconstruction.

METHODS

A retrospective review of consecutive patients who underwent DIEP flap breast reconstruction between January 2015 and November 2022 was conducted. The patients were categorized into two groups: pre-ERAS and post-ERAS. In each group, associations between overweight/obese patients (BMI ≥25 kg/m2 ) and postoperative course were evaluated.

RESULTS

In total, 217 patients in the pre-ERAS group (including 71 overweight/obese) and 165 in the post-ERAS group (including 58 overweight/obese) were analyzed. The post-ERAS group had shorter length of stay (LOS) (8.0 versus 7.0 days, p-value <.001) and lower postoperative pain scores (5.0 versus 3.0 at postoperative day (POD) 1, p-value <.001) than the pre-ERAS group. The complication profiles did not differ according to ERAS adoption. In the pre-ERAS group, overweight/obese patients showed a significantly longer LOS (8.0 versus 9.0 days, p-value = .017) and a higher postoperative pain score (3.0 versus 4.0 at POD 2, p-value = .018) than normal/underweight patients; however, these differences disappeared in the post-ERAS group, showing similar LOS, pain scores, and analgesic consumption.

CONCLUSIONS

Implementation of the ERAS protocol in DIEP free-flap breast reconstruction may reduce overweight/obesity-related disparities in postoperative recovery.

Paravertebral and erector spinae plane blocks decrease length of stay compared with local infiltration analgesia in autologous breast reconstruction

BACKGROUND

Autologous breast reconstruction is associated with significant pain impeding early recovery. Our objective was to evaluate the impact of replacing surgeon-administered local infiltration with preoperative paravertebral (PVB) and erector spinae plane (ESP) blocks for latissimus dorsi myocutaneous flap reconstruction.

METHODS

Patients who underwent mastectomy with latissimus flap reconstruction from 2018 to 2022 were included in three groups: local infiltration, PVB, and ESP blocks. Block effect on postoperative length of stay (LOS) and the association between block status and pain, opioid consumption, time to first analgesic, and postoperative antiemetic administration were assessed.

RESULTS

122 patients met the inclusion criteria for this retrospective cohort study: no block (n=72), PVB (n=26), and ESP (n=24). On adjusted analysis, those who received a PVB block had a 20-hour shorter postoperative stay (95% CI 11 to 30; p<0.001); those who received ESP had a 24-hour (95% CI 15 to 34; p<0.001) shorter postoperative stay compared with the no block group, respectively. Using either block was associated with a reduction in intraoperative opioids (23 morphine milligram equivalents (MME)), 95% CI 14 to 31, p<0.001; ESP versus no block: 23 MME, 95% CI 14 to 32, p<0.001).

CONCLUSIONS

Replacing surgical infiltration with PVB and ESP blocks for autologous breast reconstruction reduces LOS. The comparable reduction in LOS suggests that ESP may be a viable alternative to PVB in patients undergoing latissimus flap breast reconstruction following mastectomy. Further research should investigate whether ESP or PVB have better patient outcomes in complex breast reconstruction.

To Ablate or Not to Ablate: Does Umbilectomy Decrease Donor-Site Complications in DIEP Flap Breast Reconstruction?

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.

Enhanced recovery after surgery pathways for deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis

BACKGROUND

Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach.

METHODS

Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4).

RESULTS

A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant.

CONCLUSIONS

The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol.

"Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review

The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy.

Methods

MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al.

Results

There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin.

Conclusions

The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.

Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review

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.

Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety

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.

Enhanced Recovery after Surgery (ERAS) in DIEP-Flap Breast Reconstructions-A Comparison of Two Reconstructive Centers with and without ERAS-Protocol

Enhanced recovery after surgery (ERAS) is established for autologous breast reconstruction. ERAS leads to a shortened hospital stay and improved outcome after elective surgery. In this retrospective, two-center case−control study, we compared two different treatment regimens for patients undergoing a DIEP-flap breast reconstruction from two centers, one with an established ERAS protocol and one without. All patients with DIEP breast reconstructions over the period of 12 months were included. The primary outcome measure was the length of hospital stay (LOS) in days. A total of 79 patients with 95 DIEP-flaps were analyzed. In group A (ERAS) 42 patients were operated with DIEP flaps, in group B (non-ERAS) 37 patients. LOS was significantly reduced in the ERAS group (4.51 days) compared to the non-ERAS group (6.32; p < 0.001). Multivariate analysis showed that, in group A, LOS is significantly affected by surgery duration. BMI in the ERAS group had no effect on LOS. In group B a higher BMI resulted in a significantly higher LOS. In multivariate analysis, neither age nor type for surgery (primary/secondary/after neoadjuvant therapy, etc.) affected LOS. In both groups, no systemic or flap-related complications were observed. Comparing two reconstructive centers with and without implemented ERAS, ERAS led to a significantly decreased LOS for all patients. ERAS implementation does not result in an increased complication rate or flap loss. Postoperative pain can be well managed with basic analgesia using NSAID when intraoperative blocks are applied. The reduced use of opioids was well tolerated. With implementation of ERAS the recovery experience can be enhanced making autologous breast reconstructions more available and attractive for various patients.