1
|
Lombana NF, Beard C, Mehta IM, Falola RA, Park P, Altman AM, Saint-Cyr MH. The effect of a local anesthetic cocktail in a serratus anterior plane and PECS 1 block for implant-based breast reconstruction. JPRAS Open 2024; 41:116-127. [PMID: 38984322 PMCID: PMC11231500 DOI: 10.1016/j.jpra.2024.04.008] [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: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 07/11/2024] Open
Abstract
Introduction Enhanced recovery after surgery (ERAS) protocols have been implemented to decrease opioid use and decrease patient hospital length of stay (LOS, days). Serratus anterior plane (SAP) blocks anesthetize the T2 through T9 dermatomes of the breast and can be applied intraoperatively. The purpose of this study was to compare postoperative opioid (OME) consumption and LOS between a control group, an ERAS group, and an ERAS/local anesthetic cocktail group in patients who underwent implant-based breast reconstruction. Methods In this study, 142 women who underwent implant-based breast reconstruction between 2004 and 2020 were divided into Group A (46 patients), a historical cohort; Group B (73 patients), an ERAS/no-block control group; and Group C (23 patients), an ERAS/anesthetic cocktail study group. Primary outcomes of interest were postanesthesia care unit (PACU), inpatient and total hospital OME consumption, and PACU LOS. Results A significant decrease was observed from Group A to C in PACU LOS (103.3 vs. 80.2 vs. 70.5; p = 0.011), OME use (25.1 vs. 11.4 vs. 5.7; p < 0.0001), and total hospital OME (120.3 vs. 95.2 vs. 35.9; p < 0.05). No difference was observed in inpatient OMEs between the three groups (95.2 vs. 83.8 vs. 30.8; p = 0.212). Despite not reaching statistical significance, Group C consumed an average of 50-60 % less opioids per patient than did Group B in PACU, inpatient, and total hospital OMEs. Conclusion Local anesthetic blocks are important components of ERAS protocols. Our results demonstrate that a combination regional block with a local anesthetic cocktail in an ERAS protocol can decrease opioid consumption in implant-based breast reconstruction.
Collapse
Affiliation(s)
- Nicholas F Lombana
- Division of Plastic Surgery, Department of General Surgery Texas A&M Medical School - Baylor Scott & White Memorial Hospital Temple, TX, United States of America
| | - Courtney Beard
- Division of Plastic Surgery, Department of General Surgery Texas A&M Medical School - Baylor Scott & White Memorial Hospital Temple, TX, United States of America
| | - Ishan M Mehta
- Division of Plastic Surgery, Department of General Surgery Texas A&M Medical School - Baylor Scott & White Memorial Hospital Temple, TX, United States of America
| | - Reuben A Falola
- Division of Plastic Surgery, Department of General Surgery Texas A&M Medical School - Baylor Scott & White Memorial Hospital Temple, TX, United States of America
| | - Peter Park
- Texas A&M College of Medicine, Temple, TX, United States of America
| | - Andrew M Altman
- Division of Plastic Surgery, Department of General Surgery Texas A&M Medical School - Baylor Scott & White Memorial Hospital Temple, TX, United States of America
| | - Michel H Saint-Cyr
- Division of Plastic Surgery, Department of General Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, United States of America
| |
Collapse
|
2
|
Tarr JT, Coomer CL, Kim SY, Ng M. Overnight to Outpatient: A Single Institution's Experience With Mastectomy and Reconstruction Before and After the Start of the COVID-19 Pandemic. Ann Plast Surg 2024; 93:43-47. [PMID: 38885164 DOI: 10.1097/sap.0000000000003922] [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: 06/20/2024]
Abstract
PURPOSE Minimizing resource use while optimizing patient outcomes has become an ever-growing component in modern healthcare, especially in the era of COVID-19. One essential component of this is deciding whether patients need hospital admission following elective procedures. The aim of this study is to investigate operative factors and patient outcomes when mastectomies with or without reconstruction are performed as ambulatory procedures versus planned inpatient admissions. METHODS Patient charts for those undergoing mastectomy with or without reconstruction were retrospectively analyzed ranging from March 2019 until February 2021. Factors such as demographic information, operative type, operating room time, cancer stage, total stay time in the medical environment, and postoperative complications were assessed and compared between the 2 groups. RESULTS A total of 89 patient charts were reviewed, 46 from before the COVID-19 pandemic and 43 from after the start of the pandemic. No differences were observed in demographic factors between the 2 groups. After surgical cases resumed a significant proportion, 79%, of mastectomies with or without reconstruction were performed in the ambulatory center, versus just 2% pre-COVID-19. Similarly, of all of these cases performed, only 19% resulted in hospital admission versus the previous rate of 100% (P < 0.00001). Together, these changes resulted in a significant reduction in length of stay of 39.77 ± 19.2 hours pre-COVID-19 versus 14.81 ± 18.4 hours afterward (P < 0.00001). Unfortunately, a higher number of patients who received surgery after the start of the pandemic elected to forego immediate reconstruction 49% versus 72% (P = 0.032). Most importantly, there were no observable differences found in 7-day readmission, reoperation, or emergency department visit between groups. There was also no difference in 30-day complication rate between groups. CONCLUSIONS Mastectomy with or without reconstruction can be safely performed in the ambulatory setting without additional risk of complications or negative patient factors. This divergence from traditional the protocol of inpatient overnight admission may contribute positively toward patient comfort, minimize the use of healthcare costs and resources, and allow for increased scheduling flexibility for patient and provider alike.
Collapse
Affiliation(s)
- Joseph T Tarr
- From the Northwell Health, Division of Plastic and Reconstructive Surgery, Great Neck, NY
| | - Cynara L Coomer
- Texas Health Harris Methodist Fort Worth City, Fort Worth, TX
| | - Sara Y Kim
- Scripps Clinical Medical Group, La Jolla, CA
| | - Marilyn Ng
- Northwell Health, Division of Plastic and Reconstructive Surgery, Staten Island, NY
| |
Collapse
|
3
|
Abstract
SUMMARY As value-based care gains traction in response to towering health care expenditures and issues of health care inequity, hospital capacity, and labor shortages, it is important to consider how a value-based approach can be achieved in plastic surgery. Value is defined as outcomes divided by costs across entire cycles of care. Drawing on previous studies and policies, this article identifies key opportunities in plastic surgery to move the levers of costs and outcomes to deliver higher value care. Specifically, outcomes in plastic surgery should include conventional measures of complication rates and patient-reported outcome measures to drive quality improvement and benchmark payments. Meanwhile, cost reduction in plastic surgery can be achieved through value-based payment reform, efficient workflows, evidence-based and cost-conscious selection of medical devices, and greater use of outpatient surgical facilities. Lastly, the authors discuss how the diminished presence of third-party payers in aesthetic surgery exemplifies the cost-conscious and patient-centered nature of value-based plastic surgery. To lead in future health policy and care delivery reform, plastic surgeons should strive for high-value care, remain open to new ways of care delivery, and understand how plastic surgery fits into overall health care delivery.
Collapse
Affiliation(s)
| | | | - Thomas C Tsai
- Boston, MA
- From the Harvard Medical School
- Divisions of General and Gastrointestinal Surgery
- Plastic Surgery, Brigham and Women's Hospital
- Harvard T.H. Chan School of Public Health
| | - Justin M Broyles
- From the Harvard Medical School
- Plastic Surgery, Brigham and Women's Hospital
| |
Collapse
|
4
|
Clark RC, Segal R, Kordahi A, Sendek G, Alving-Trinh A, Abramson W, Sztain J, Swisher M, Gabriel RA, Gosman A, Said ET, Reid CM. An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery. Ann Plast Surg 2024; 92:549-556. [PMID: 38563567 DOI: 10.1097/sap.0000000000003833] [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: 04/04/2024]
Abstract
INTRODUCTION Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions. METHODS All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared. RESULTS Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01). CONCLUSIONS This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.
Collapse
Affiliation(s)
| | | | | | | | | | - Wendy Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Jacklynn Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Matthew Swisher
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | | | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | | |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Ghosh K, Shakir A, Kuchta K, Seth A, Sisco M. Safety and factors affecting same-day discharge following mastectomy and immediate alloplastic reconstruction. J Surg Oncol 2024; 129:201-207. [PMID: 37869984 DOI: 10.1002/jso.27491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients undergoing breast reconstruction following mastectomy are often admitted overnight. In 2020, our institution implemented a protocol change to discharge clinically stable patients immediately. In this study, we examine the safety of same-day discharge following mastectomy and reconstruction. METHODS Our retrospective study included female adults undergoing mastectomy and immediate alloplastic reconstruction from August 2019 to January 2020, before implementation of the same-day discharge protocol, and from March 2020 to September 2021, after the protocol implementation. Independent t-test and chi-square analysis was conducted to examine statistical differences. RESULTS Two hundred and eighty-five patients were included. Forty-two patients underwent reconstruction before the protocol change (Group 1) and 243 patients underwent reconstruction after the protocol change (Group 2). Group 2 had a greater percentage of prepectoral implant placement. There was no difference in demographics, complications, readmission, or reoperation. Within Group 2, 157 patients were discharged the same day (Group 2a) and 88 patients required overnight admission (Group 2b). Group 2b had higher body mass index, higher percentage of bilateral mastectomy, and larger mastectomy weights. Despite no differences in complications, Group 2b exhibited higher rates of requiring intravenous antibiotics and reoperation. CONCLUSIONS Patients may be safely discharged the same day following mastectomy and alloplastic reconstruction without an increase in complications.
Collapse
Affiliation(s)
- Kanad Ghosh
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Afaaf Shakir
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Kristine Kuchta
- Department of Surgery, Division of Plastic and Reconstructive Surgery, NorthShore University HealthSystem, Northbrook, Illinois, USA
| | - Akhil Seth
- Department of Surgery, Division of Plastic and Reconstructive Surgery, NorthShore University HealthSystem, Northbrook, Illinois, USA
| | - Mark Sisco
- Department of Surgery, Division of Plastic and Reconstructive Surgery, NorthShore University HealthSystem, Northbrook, Illinois, USA
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Xia Z, Chen Y, Xie J, Zhang W, Tan L, Shi Y, Liu J, Wang X, Tan G, Zeng A. Faster Return to Daily Activities and Better Pain Control: A Prospective Study of Enhanced Recovery After Surgery Protocol in Breast Augmentation. Aesthetic Plast Surg 2023; 47:2261-2267. [PMID: 37488312 DOI: 10.1007/s00266-023-03504-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/30/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has been proven to decrease the amount of opioid use and reduce postoperative pain for a variety of surgeries, including breast reconstruction. However, data on ERAS in breast augmentation is lacking. OBJECTIVES This study aims to investigate the effectiveness and safety of ERAS for breast augmentation. METHODS A standardized ERAS protocol was established with full consideration of all aspects of perioperative care. Patients undergoing implant-based breast augmentation were prospectively recruited between December 2020 and January 2023, and assigned to either the ERAS or non-ERAS group randomly. The primary outcome was the activity of daily living after surgery. The secondary was postoperative pain and other outcomes included time to freely elevation, vomiting frequency, the use of analgesics, and complications. RESULTS A total of 122 patients were included, with 70 in the ERAS group and 52 in the non-ERAS group. Compared to non-ERAS patients, ERAS patients had a shorter time to freely elevation of upper limbs (2.3 d vs. 5.5 d, P < 0.001). For ERAS patients, the pain scores were significantly lower on postoperative days 1 to 3, the activity of daily living index was significantly higher on postoperative days 1 to 3 and the opioids consumption was decreased (7.1 mg vs. 46.2 mg, P = 0.018). No difference was observed in complication and hospital costs between the two groups. CONCLUSION The ERAS protocol significantly reduced postoperative pain and the use of opioids and promoted a return to daily activities without increasing complications in breast augmentation. LEVEL OF EVIDENCE IV 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 .
Collapse
Affiliation(s)
- Zenan Xia
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Yuliang Chen
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Jiangmiao Xie
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Wenchao Zhang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Linjuan Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Yanping Shi
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Jie Liu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Xiaojun Wang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Ang Zeng
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China.
| |
Collapse
|
9
|
Park JJ, Colon RR, Chaya BF, Rochlin DH, Chibarro PD, Shetye PR, Staffenberg DA, Flores RL. Implementation of an Ambulatory Cleft Lip Repair Protocol: Surgical Outcomes. Cleft Palate Craniofac J 2023; 60:1220-1229. [PMID: 35469454 DOI: 10.1177/10556656221096567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Cleft lip repair has traditionally been performed as an inpatient procedure. There has been an interest toward outpatient cleft lip repair to reduce healthcare costs and avoid unnecessary hospital stay. We report surgical outcomes following implementation of an ambulatory cleft lip repair protocol and hypothesize that an ambulatory repair results in comparable safety outcomes to inpatient repair. DESIGN/SETTING This is a single-institution, retrospective study. PATIENTS/PARTICIPANTS Patients undergoing primary unilateral (UCL) and bilateral (BCL) cleft lip repair from 2012 to 2021 with a minimum 30-day follow-up. A total of 226 patients with UCL and 58 patients with BCL were included. INTERVENTION Ambulatory surgery protocol in 2016. OUTCOME MEASURES Variables include demographics and surgical data including 30-day readmission, 30-day reoperation, and postoperative complications. RESULTS There were no differences in rates of 30-day readmission, reoperation, wound complications, or postoperative complications between the pre- and post-protocol groups. Following ambulatory protocol implementation, 80% of the UCL group and 56% of the BCL group received ambulatory surgery. Average length of stay dropped from 24 h pre-protocol to 8 h post-protocol. The 20% of the UCL group and 44% of the BCL group chosen for overnight stay had a significantly higher proportion of congenital abnormalities and higher American Society of Anesthesiology (ASA) class. Reasons for overnight stay included cardiac/airway monitoring, prematurity, and monitoring of comorbidities. There were no differences in surgical outcomes between the ambulatory and overnight stay groups. CONCLUSIONS An ambulatory cleft lip repair protocol can significantly reduce average length of stay without adversely affecting surgical outcomes.
Collapse
|
10
|
Rourke K, Halyk LJ, MacNeil J, Malic C. Perioperative protocols in ambulatory breast reconstruction: A systematic review. J Plast Reconstr Aesthet Surg 2023; 85:252-263. [PMID: 37536192 DOI: 10.1016/j.bjps.2023.06.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/25/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Recent studies have successfully employed perioperative protocols and Enhanced Recovery After Surgery (ERAS) protocols to promote and increase the range of breast reconstruction procedures performed in ambulatory settings. This systematic review aims to identify the common perioperative protocol items associated with successful ambulatory breast reconstruction. METHODS A systematic review of electronic databases (Ovid Medline, EMBASE, and Cochrane) was conducted. Studies that described the perioperative care protocol for postmastectomy breast reconstruction in ambulatory settings (discharge within 24 h) were included. Two reviewers independently screened the literature and extracted the data. Risk of bias was assessed with the National Heart, Lung, and Blood Institute quality tool. The perioperative protocol details, type of reconstruction, information regarding patient selection criteria, successful discharge rates, and complication rates were extracted. RESULTS Twelve studies were included in the systematic review, with 1484 patients undergoing ambulatory breast reconstruction with a well-defined perioperative protocol. Sixteen perioperative items were identified. The most discussed items were preoperative counseling (11/12), preoperative and intraoperative multimodal analgesia (11/12), and postoperative analgesia (10/12). Our recommendation includes two new items and seven modified items compared to previous ERAS guidelines. Overall, the mean number of items was 9.22 in same-day discharge and 6.75 in 24-h discharge (P = 0.169). 78.4% of the patients (1123 of 1433) were successfully discharged within 24 h. No studies identified an increase in readmission or complications with ambulatory discharge. CONCLUSION Sixteen core items were defined for a successful perioperative ERAS protocol for 24-h discharge breast reconstruction. Implementing perioperative protocols can facilitate under-24-h discharge for alloplastic and autologous surgery.
Collapse
Affiliation(s)
| | - Laura Jane Halyk
- University of Ottawa, Canada; The Ottawa Hospital, Division of Plastic Surgery, Canada
| | - Jenna MacNeil
- University of Ottawa, Canada; The Ottawa Hospital Department of Anesthesiology, Canada
| | - Claudia Malic
- University of Ottawa, Canada; The Ottawa Hospital, Division of Plastic Surgery, Canada
| |
Collapse
|
11
|
Taba G, Ceccato V, Fernandes O, Michel S, Darrigues L, Girard N, Gauroy E, Pauly L, Gaillard T, Reyal F, Hotton J. Impact of ERAS in breast reconstruction with a latissimus dorsi flap, compared to conventional management. J Plast Reconstr Aesthet Surg 2023; 85:202-209. [PMID: 37524032 DOI: 10.1016/j.bjps.2023.06.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/12/2023] [Accepted: 06/29/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs are associated with improved management, reduced hospital stays, and lower complication rates. OBJECTIVE To evaluate the impact of ERAS on mean length of stay (LOS) and postoperative morbidity in breast reconstruction with latissimus dorsi flap (LDF) compared with conventional recovery program. PATIENTS AND METHOD All patients operated by LDF between December 2014 and October 2020: those managed before April 2018, when the ERAS protocol was introduced, were included in the "no ERAS" group, and beyond in the "ERAS" group. RESULTS Out of 193 patients, 129 were included in the "ERAS" group and 64 in the "no ERAS" group. There was a significant difference between the two groups in LOS (4.2 ± 1.5 days in the "ERAS" group vs. 5.4 ± 1.9 days in the "no ERAS" group; p < 0.001), high-grade complications at 30 days (9.3% in the "ERAS" group vs. 25% in the "no ERAS" group; p = 0.01), reintervention rate (13.9% vs. 26.6%, respectively; p = 0.02), and 30-day rehospitalization rate (6.2% in the "ERAS" group vs. 15.6% in the "no ERAS" group; p = 0.03). CONCLUSION The ERAS protocol has a positive impact on breast reconstruction with LDF without generating additional adverse effects. These results support the democratization of these programs for breast reconstruction surgery.
Collapse
Affiliation(s)
- G Taba
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - V Ceccato
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - O Fernandes
- Department of Anesthesia, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - S Michel
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - L Darrigues
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - N Girard
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - E Gauroy
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - L Pauly
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - T Gaillard
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - F Reyal
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - J Hotton
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France.
| |
Collapse
|
12
|
Little AK, Patmon DL, Sandhu H, Armstrong S, Anderson D, Sommers M. Inpatient versus Outpatient Immediate Alloplastic Breast Reconstruction: Recent Trends, Outcomes, and Safety. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5135. [PMID: 37744774 PMCID: PMC10513287 DOI: 10.1097/gox.0000000000005135] [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: 04/16/2022] [Accepted: 06/06/2023] [Indexed: 09/26/2023]
Abstract
Background Immediate alloplastic breast reconstruction was traditionally performed as an inpatient procedure. Despite several reports in the literature demonstrating comparable safety outcomes, there remains hesitancy to accept breast reconstruction performed as an outpatient procedure. Methods A retrospective review of National Surgical Quality Improvement Program data from 2014 to 2018 was utilized to evaluate recent trends and 30-day postoperative complication rates for inpatient versus outpatient immediate prosthetic-based breast reconstruction. Propensity score matching was used to obtain comparable groups. Results During the study period, 33,587 patients underwent immediate alloplastic breast reconstruction. Of those, 67.5% of patients were discharged within 24 hours, and 32.4% of patients had a hospital stay of more than 24 hours. Immediate alloplastic reconstruction had an overall growth rate of 16.9% from 2014 to 2018. After propensity score matching, intraoperative variables that correlated with significantly increased inpatient status included increased work relative value units (16.3 ± 2.3 versus 16.2 ± 2.6; P < 0.001), longer operative times (228 ± 86 versus 206 ± 77; P < 0.001), and bilateral procedure (44.0% versus 43.5%; P < 0.001). There were higher rates of pulmonary embolism, wound dehiscence, urinary tract infection, transfusions, sepsis, readmissions, and reoperations in the group with the longer hospital stay. Conclusion Based on increased complication rates and costs in the inpatient setting, we propose outpatient reconstructive surgery as a safe and cost-effective alternative for immediate alloplastic breast reconstruction.
Collapse
Affiliation(s)
- Andrea K. Little
- From the Division of Plastic and Reconstructive Surgery, Spectrum Health Michigan State University Plastic Surgery Residency, Grand Rapids, Mich
| | - Darin L. Patmon
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Harminder Sandhu
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | | | - Daniella Anderson
- From the Division of Plastic and Reconstructive Surgery, Spectrum Health Michigan State University Plastic Surgery Residency, Grand Rapids, Mich
| | - Megan Sommers
- From the Division of Plastic and Reconstructive Surgery, Spectrum Health Michigan State University Plastic Surgery Residency, Grand Rapids, Mich
| |
Collapse
|
13
|
Temple-Oberle C, Yakaback S, Webb C, Assadzadeh GE, Nelson G. Effect of Smartphone App Postoperative Home Monitoring After Oncologic Surgery on Quality of Recovery: A Randomized Clinical Trial. JAMA Surg 2023; 158:693-699. [PMID: 37043216 PMCID: PMC10099099 DOI: 10.1001/jamasurg.2023.0616] [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: 08/25/2022] [Accepted: 12/26/2022] [Indexed: 04/13/2023]
Abstract
Importance There has been an increase in health care-focused smartphone apps, including those for encouraging healthy behaviors and managing chronic conditions, but app-assisted postsurgical care has yet to be fully explored. Objective To compare quality of recovery and patient satisfaction between conventional in-person follow-up and smartphone app-assisted follow-up for patients following Enhanced Recovery After Surgery Society (ERAS) protocols. Design, Setting, and Participants This randomized clinical trial, conducted from June 2019 to April 2021, included women older than 18 years undergoing oncologic breast reconstruction or major gynecologic oncology surgery following ERAS protocols with the care of 2 surgeons at an academic tertiary care center. Interventions Patients were randomized 1:1 to receive smartphone app-assisted follow-up or conventional in-person follow-up. The smartphone group used a surgeon-monitored app to record Quality of Recovery 15 (QoR15) scores, European Organisation for Research and Treatment of Cancer-selected adverse events, drain outputs, and surgical site photographs over 6 weeks. Patient satisfaction scores were assessed using validated Patient Satisfaction Questionnaire III (PSQ-III) subscales at 2 and 6 weeks postoperatively. The conventional follow-up group also completed the QoR15 and PSQ-III questionnaires at these intervals. Main Outcomes and Measures The primary outcomes were quality of recovery and patient satisfaction, as measured by the QoR15 and PSQ-III, respectively. Secondary outcomes were costs of follow-up; the number of contacts with the medical system, complications, and surgeons' contacts with patients; and surgeons' perceptions of app-assisted care. Results Of 72 patients included in the trial, 36 underwent breast reconstruction (mean [SD] age, 45.30 [9.13] years) and 36 underwent gynecologic oncology surgery (mean [SD] age, 54.90 [11.18] years). Three patients dropped out (2 who underwent breast reconstruction [1 in the app group, 1 in the control group], 1 who underwent gynecologic oncology surgery [control group]). The app group had significantly higher mean (SD) QoR15 scores than the control group (2 weeks: 127.58 [22.03] vs 117.68 [17.52], P = .02; 6 weeks: 136.64 [17.53] vs 129.76 [16.42], P = .03). Patients were equally satisfied between groups in all subsets of the PSQ-III at these intervals. The mean (SD) number of complications was similar in both groups, and a similar number of surgeon contacts per patient occurred (1.6 [1.2] vs 2.1 [2.0], P = .16). Surgeons appreciated early identification of complications with the app. Conclusions and Relevance In this randomized clinical trial, postoperative follow-up for patients undergoing breast reconstruction and gynecologic oncology surgery using smartphone app-assisted monitoring led to improved quality of recovery and equal satisfaction with care compared with conventional in-person follow-up. Trial Registration ClinicalTrials.gov Identifier: NCT03456167.
Collapse
Affiliation(s)
- Claire Temple-Oberle
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Spencer Yakaback
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Carmen Webb
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Gregg Nelson
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
14
|
Brantley RA, Thuman J, Hudson T, Gregoski MJ, Scomacao I, Herrera FA. Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database. Ann Plast Surg 2023; 90:S395-S402. [PMID: 37332211 PMCID: PMC11177554 DOI: 10.1097/sap.0000000000003459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay. METHODS The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05. RESULTS A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001). CONCLUSION National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.
Collapse
Affiliation(s)
| | - Jenna Thuman
- Division of Plastic Surgery, Medical University of South Carolina
| | - Todd Hudson
- College of Medicine, Medical University of South Carolina
| | - Mathew J. Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Isis Scomacao
- College of Medicine, Medical University of South Carolina
- Division of Plastic Surgery, Medical University of South Carolina
| | - Fernando A. Herrera
- College of Medicine, Medical University of South Carolina
- Division of Plastic Surgery, Medical University of South Carolina
| |
Collapse
|
15
|
Olimpiadi Y, Goldenberg AR, Postlewait L, Gillespie T, Arciero C, Styblo T, Cao Y, Switchenko JM, Rizzo M. Outcomes of the same-day discharge following mastectomy before, during and after COVID-19 pandemic. J Surg Oncol 2023; 127:761-767. [PMID: 36621857 PMCID: PMC10874497 DOI: 10.1002/jso.27195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/23/2022] [Accepted: 12/23/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES The majority of patients undergoing mastectomy before the COVID-19 pandemic were admitted for 23-h observation to the hospital. Indications for observation included drain care education, pain control and observation for possible early surgical complications. This study compared the rates of outpatient mastectomy before, during, and after the COVID-19 pandemic and indirectly evaluated the safety of same-day discharge. METHODS We retrospectively analyzed patients undergoing mastectomy using Current Procedural Terminology code 19303. RESULTS A total of 357 patients were included: 113 were treated pre-COVID-19, 82 patients during COVID-19 and 162 post-COVID-19. The rate of outpatient mastectomies tripled during the pandemic from 17% to 51% (p < 0.001); after the pandemic remain high at 48%. The rate of bilateral mastectomies decreased during the pandemic to 30% from 48% prepandemic (p = 0.015). Pectoralis muscle block utilization increased during the COVID-19 period from 36% to 59% (p = 0.002). No difference in complication rates, including surgical site infections, hematomas, and readmissions, pre and during COVID. CONCLUSIONS The rate of outpatient mastectomy increased during the COVID-19 pandemic. During this timeframe, perioperative complications did not increase, suggesting the safety of this practice. After the pandemic, the rate of outpatient mastectomy continued to be significantly higher than pre-COVID.
Collapse
Affiliation(s)
- Yuliya Olimpiadi
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Alison R. Goldenberg
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Lauren Postlewait
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Theresa Gillespie
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Cletus Arciero
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Toncred Styblo
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Yicun Cao
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jeffrey M. Switchenko
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Monica Rizzo
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Martin LD, Chiem JL, Hansen EE, Low DK, Reece K, Casey C, Wingate CS, Bezzo LK, Merguerian PA, Parikh SR, Susarla SM, O'Reilly-Shah VN. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg 2022; 135:1271-1281. [PMID: 36384014 DOI: 10.1213/ane.0000000000006256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. METHODS A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. RESULTS The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. CONCLUSIONS This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.
Collapse
Affiliation(s)
- Lynn D Martin
- From the Departments of Anesthesiology & Pain Medicine and Pediatrics
| | - Jennifer L Chiem
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Elizabeth E Hansen
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Daniel K Low
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Kayla Reece
- Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of
| | - Corrie Casey
- Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of
| | - Christina S Wingate
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Leah K Bezzo
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | | | - Sanjay R Parikh
- Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Srinivas M Susarla
- Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Vikas N O'Reilly-Shah
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
19
|
Knotts T, Mease K, Sangameswaran L, Felx M, Kramer S, Donovan J. Pharmacokinetics and local tissue response to local instillation of vocacapsaicin, a novel capsaicin prodrug, in rat and rabbit osteotomy models. J Orthop Res 2022; 40:2281-2293. [PMID: 35128722 PMCID: PMC9790453 DOI: 10.1002/jor.25271] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 10/01/2021] [Accepted: 01/16/2022] [Indexed: 02/04/2023]
Abstract
Vocacapsaicin is a novel prodrug of trans-capsaicin (trans-8-methyl-N-vanillyl-6-nonenamide) being developed as a nonopioid, long-lasting, site-specific treatment for postsurgical pain management. The objective of these studies was to examine the safety and tolerability of vocacapsaicin in an osteotomy model in two animal species and to evaluate bone healing parameters. Rats undergoing unilateral femoral osteotomy received a single perioperative administration (by instillation) of vocacapsaicin (vehicle, 0.15, 0.3, and 0.6 mg/kg). Rabbits undergoing unilateral ulnar osteotomy received a single perioperative administration (by infiltration and instillation) of vocacapsaicin (vehicle, 0.256 and 0.52 mg) alone or in combination with 0.5% ropivacaine. Clinical signs, body weights, food consumption, radiography, histopathologic examinations, ex vivo bone mineral density measurements (rats only), and biomechanical testing were evaluated at 4 and 8 weeks in rats and at 2 and 10 weeks in rabbits. Plasma samples were also collected in rabbits. There were no vocacapsaicin-related effects on mortality, clinical observations, body weight, or food consumption in either species. Systemic exposure to vocacapsaicin and its metabolites, including capsaicin, was transient. In rats, vocacapsaicin was devoid of deleterious effects on bone healing parameters, and there was a trend for enhanced bone healing in rats treated with the mid-dose. In rabbits, vocacapsaicin administered alone or in combination with ropivacaine did not adversely affect bone healing parameters. In conclusion, a single perioperative administration of vocacapsaicin in unilateral osteotomy models was well tolerated, locally and systemically, supporting its continued development as a novel, nonopioid treatment for postsurgical pain management.
Collapse
|
20
|
Broderick RC, Li JZ, Blitzer RR, Ahuja P, Race A, Yang G, Sandler BJ, Horgan S, Jacobsen GR. A steady stream of knowledge: decreased urinary retention after implementation of ERAS protocols in ambulatory minimally invasive inguinal hernia repair. Surg Endosc 2022; 36:6742-6750. [PMID: 34982228 DOI: 10.1007/s00464-021-08950-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair. METHODS A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention. RESULTS Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective. CONCLUSION Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.
Collapse
Affiliation(s)
- Ryan C Broderick
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA
| | - Jonathan Z Li
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA.
- Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA.
| | - Rachel R Blitzer
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA
| | - Pranav Ahuja
- University of California San Diego, San Diego, CA, USA
| | - Alice Race
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA
| | - Gene Yang
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA
| |
Collapse
|
21
|
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]
|
22
|
The Quest for Outpatient Mastectomy in COVID-19 Era: Barriers and Facilitators. Breast J 2022; 2022:1863519. [PMID: 35711886 PMCID: PMC9186523 DOI: 10.1155/2022/1863519] [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: 01/21/2022] [Accepted: 05/16/2022] [Indexed: 12/04/2022]
Abstract
Background The rate of inpatient mastectomies remains high despite multiple studies reporting favourably on outpatient mastectomies. Outpatient mastectomies do not compromise quality of patient care and are more efficient than inpatient care. The objective of this study was to evaluate the feasibility of outpatient mastectomy. Materials and Methods Implementation of an outpatient mastectomy program was evaluated in a retrospective study. All patients who underwent mastectomy between January 2019 and September 2021 were included. Results 213 patients were enrolled in the study: 62.4% (n = 133) outpatient mastectomies versus 37.6% (n = 80) inpatient mastectomies. A steady rise in outpatient mastectomies was observed over time. The second quarter of 2020, coinciding with the first COVID-19 wave, showed a peak in outpatient mastectomies. The only significant barrier to outpatient mastectomy proved to be bilateral mastectomy. Unplanned return to care was observed in 27.8% of the outpatient versus 36.3% of the inpatient mastectomies (P=0.198); the reason for unplanned return of care was similar in both groups. Conclusions Outpatient mastectomy is shown to be feasible and safe with a steady increase during the study period. A barrier to outpatient mastectomy was bilateral mastectomy. Incidence of unplanned return to care or complications did not differ significantly between the outpatient and inpatient cohorts.
Collapse
|
23
|
Erz L, Larson B, Mirhaidari S, Cook C, Wagner D. Precise Analgesic Instructions Improve Narcotic Usage: A Randomized Trial. Aesthet Surg J 2022; 42:NP385-NP390. [PMID: 34982826 DOI: 10.1093/asj/sjab435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Given the ongoing battle with opioid abuse and overuse in the United States, new strategies are consistently being implemented to reduce opioid utilization and overprescribing. OBJECTIVES The purpose of this study was to determine if a more regulated explicit pain management instruction plan could reduce the number of opioids taken. METHODS Blinded randomized prospective study comparing a total of 110 (Group A = 55, Group B = 55) women who underwent elective outpatient bilateral breast reduction surgery by 2 different plastic surgeons. Patients were randomly divided into either Group A (control) that received general pain management instructions or Group B (experimental) that received explicit pain management instructions from the surgeons and nurses. Participants were asked to record the number of times they treated their pain with each separate modality. They were also asked to record their average daily pain scale for the days that they were treating their pain. RESULTS Patients in Group B took on average 1.5 oxycodone (5 mg) and patients in Group A took on average 5.7 oxycodone (5 mg) (P < 0.01). Thirty-four patients in Group B took no oxycodone. Patients in Group B also had statistically significant lower subjective pain scores. CONCLUSIONS Based on these results, it appears that standardizing how patients are instructed to treat their pain postoperatively may reduce the number of narcotics needed, thus reducing the number of narcotics prescribed without compromising pain control. LEVEL OF EVIDENCE: 2
Collapse
Affiliation(s)
- Logan Erz
- Department of General Surgery, Akron City Hospital, Akron, OH, USA
| | - Brandon Larson
- Department of General Surgery, Akron City Hospital, Akron, OH, USA
| | - Shayda Mirhaidari
- Department of Plastic and Reconstructive Surgery, Crystal Clinic, Akron, OH, USA
| | - Chad Cook
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Doug Wagner
- Department of Plastic and Reconstructive Surgery, Crystal Clinic, Akron, OH, USA
| |
Collapse
|
24
|
Ludwig K, Wexelman B, Chen S, Cheng G, DeSnyder S, Golesorkhi N, Greenup R, James T, Lee B, Pockaj B, Vuong B, Fluharty S, Fuentes E, Rao R. Home Recovery After Mastectomy: Review of Literature and Strategies for Implementation American Society of Breast Surgeons Working Group. Ann Surg Oncol 2022; 29:5799-5808. [PMID: 35503389 DOI: 10.1245/s10434-022-11799-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/07/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Practices regarding recovery after mastectomy vary significantly, including overnight stay versus discharge same day. Expanded use of Enhanced Recovery After Surgery (ERAS) algorithms and the recent COVID pandemic have led to increased number of patients who undergo home recovery after mastectomy (HRAM). METHODS The Patient Safety Quality Committee of the American Society of Breast Surgeons created a multispecialty working group to review the literature evaluating HRAM after mastectomy with and without implant-based reconstruction. A literature review was performed regarding this topic; the group then developed guidance for patient selection and tools for implementation. RESULTS Multiple, retrospective series have reported that patients discharged day of mastectomy have similar risk of complications compared with those kept overnight, including risk of hematoma (0-5.1%). Multimodal strategies that improve nausea and analgesia improve likelihood of HRAM. Patients who undergo surgery in ambulatory surgery centers and by high-volume breast surgeons are more likely to be discharged day of surgery. When evaluating unplanned return to care, the only significant factors are African American race and increased comorbidities. CONCLUSIONS Review of current literature demonstrates that HRAM is a safe option in appropriate patients. Choice of method of recovery should consider patient factors, such as comorbidities and social situation, and requires input from the multidisciplinary team. Preoperative education regarding pain management, drain care, and after-hour access to medical care are crucial components to a successful program. Additional investigation is needed as these programs become more prevalent to assess quality measures such as unplanned return to care, complications, and patient satisfaction.
Collapse
Affiliation(s)
- Kandice Ludwig
- Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | - Gloria Cheng
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Ted James
- Harvard Medical School, Boston, MA, USA
| | | | | | - Brooke Vuong
- Kaiser Permanente Medical Center, Sacramento, CA, USA
| | | | | | | | | |
Collapse
|
25
|
A national analysis of outpatient mastectomy and breast reconstruction trends from 2013 through 2019. J Plast Reconstr Aesthet Surg 2022; 75:2920-2929. [PMID: 35753925 DOI: 10.1016/j.bjps.2022.04.071] [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: 01/18/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Traditionally, patients with breast reconstruction (BR) were hospitalized at least one day postoperatively. However, new trends suggest that outpatient surgery is a viable and safe alternative. This study aims to assess trends among patients with breast cancer who underwent outpatient mastectomy alone, with immediate BR (IBR) or delayed BR (DBR). METHODS A retrospective analysis of the 2013-2019 ACS NSQIP® database was conducted. All women who underwent outpatient mastectomy were included in this study. The cohort was divided as follows: (1) mastectomy without BR, (2) IBR, and (3) DBR. A Cochran-Armitage test and adjusted multivariable logistic regression models were performed to evaluate linear trends over time within groups, and overall and pairwise comparisons between groups across the years, respectively. RESULTS A total of 84,954 women were included in this study. Overall, 54.9%, 16.2%, and 28.9% underwent mastectomy without BR, IBR, and DBR, respectively. From the BR groups, the majority had implant placement. A significant difference in incidence trends between the three groups was evidenced over time (p<0.001). The greatest increase was evidenced in the IBR group and the lowest in the mastectomy without BR group. CONCLUSION In this cohort of patients, a significant difference in linear trends was evidenced over time within and between the three groups. Our results suggest that outpatient IBR procedures are increasing in a greater proportion compared to other surgical approaches. Further studies are required to better characterize this population and comprehend the decision-making process toward a surgical procedure within each of the three groups.
Collapse
|
26
|
Dong Y, Shen C, Wang Y, Zhou K, Li J, Chang S, Ma H, Che G. Safety and Feasibility of Video-Assisted Thoracoscopic Day Surgery and Inpatient Surgery in Patients With Non-small Cell Lung Cancer: A Single-Center Retrospective Cohort Study. Front Surg 2021; 8:779889. [PMID: 34869571 PMCID: PMC8635799 DOI: 10.3389/fsurg.2021.779889] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/15/2021] [Indexed: 02/05/2023] Open
Abstract
Background and Objective: This study was undertaken to evaluate how safe and viable the use of video-assisted thoracoscopic day surgery (VATDS) is for individuals diagnosed with early-stage non-small cell lung cancer (NSCLC). Methods: Data obtained from the selected patients with NSCLC who underwent video-assisted thoracoscopic surgery (VATS) in the same medical group were analyzed and a single-center, propensity-matched cohort study was performed. In total, 353 individuals were included after propensity score matching (PSM) with 136 individuals in the day surgery group (DSG) and 217 individuals in the inpatient surgery group (ISG). Results: The 24-h discharge rate in the DSG was 93.38% (127/136). With respect to the postoperative complications (PPCs), no difference between the two groups was found (DSG vs. ISG: 11.76 vs. 11.52%, p = 0.933). In the DSG, a shorter length of stay (LOS) after surgery (1.47 ± 1.09 vs. 2.72 ± 1.28 days, p < 0.001) and reduced drainage time (8.45 ± 3.35 vs. 24.11 ± 5.23 h, p < 0.001) were found, while the drainage volume per hour (mL/h) was not notably divergent between the relevant groups (p = 0.312). No difference was observed in the cost of equipment and materials between the two groups (p = 0.333). However, the average hospital cost and drug cost of the DSG were significantly lower than those of the ISG (p < 0.001). Conclusion: The study indicated that the implementation of VATDS showed no difference in PPCs, but resulted in shorter in-hospital stays, shorter drainage times, and lower hospital costs than inpatient surgery. These results indicate the safety and feasibility of VATDS for a group of highly selected patients with early-stage NSCLC.
Collapse
Affiliation(s)
- Yingxian Dong
- Department of Thoracic Surgery, West-China Hospital, Sichuan University, Chengdu, China
| | - Cheng Shen
- Department of Thoracic Surgery, West-China Hospital, Sichuan University, Chengdu, China
| | - Yan Wang
- Department of Thoracic Surgery, West-China Hospital, Sichuan University, Chengdu, China
| | - Kun Zhou
- Department of Thoracic Surgery, West-China Hospital, Sichuan University, Chengdu, China
| | - Jue Li
- Department of Thoracic Surgery, West-China Hospital, Sichuan University, Chengdu, China
| | - Shuai Chang
- Department of Thoracic Surgery, West-China Hospital, Sichuan University, Chengdu, China
| | - Hongsheng Ma
- Day Surgery Center, West China Hospital, Sichuan University, Chengdu, China
| | - Guowei Che
- Department of Thoracic Surgery, West-China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
27
|
Hammond JB, Thomas O, Jogerst K, Kosiorek HE, Rebecca AM, Cronin PA, Casey WJ, Kruger EA, Pockaj BA, Teven CM. Same-day Discharge Is Safe and Effective After Implant-Based Breast Reconstruction. Ann Plast Surg 2021; 87:144-149. [PMID: 33470624 DOI: 10.1097/sap.0000000000002667] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Same-day discharge after mastectomy is a recently described treatment approach. Limited data exist investigating whether same-day discharge can be successfully implemented in patients undergoing mastectomy with immediate implant-based breast reconstruction (IBR). METHODS Patients having mastectomy with IBR from 2013 to 2019 were reviewed. Enhanced recovery with same-day discharge was implemented in 2017. Patient characteristics, oncologic treatments, surgical techniques, and 90-day postoperative complications and reoperations were analyzed comparing enhanced recovery patients with historical controls. RESULTS A total of 363 patients underwent nipple-sparing (214, 59%) or skin-sparing (149, 41%) mastectomy with 1-stage (270, 74%) or tissue expander (93, 26%) IBR. Enhanced recovery was used for 151 patients, with 79 of these patients (52%) discharged same-day. Overall, enhanced recovery patients experienced a significantly lower rate of 90-day complications (21% vs 41%, P < 0.001), including hematoma (3% vs 11%, P = 0.002), mastectomy flap necrosis (7% vs 15%, P = 0.02), seroma (1% vs 9%, P < 0.001), and wound breakdown (3% vs 9%, P = 0.05). Postoperative complication rates did not significantly differ among enhanced recovery patients discharged same day. Postoperative admissions significantly decreased after enhanced recovery implementation (100% to 48%, P < 0.001), and admitted enhanced recovery patients experienced a lower length of stay (1.2 vs 1.8, P < 0.001). Enhanced recovery patients experienced a lower incidence of ≥1 unplanned reoperation (22% vs 33%, P = 0.01); overall average unplanned and total reoperations did not significantly differ between groups. CONCLUSIONS In conjunction with enhanced recovery practices, same-day discharge after mastectomy with IBR is a safe and feasible treatment approach.
Collapse
Affiliation(s)
| | | | | | - Heidi E Kosiorek
- Department of Health Sciences Research, Section of Biostatistics, Mayo Clinic, Scottsdale
| | | | - Patricia A Cronin
- Division of Surgical Oncology and Endocrine Surgery, Mayo Clinic, Phoenix, AZ
| | | | - Erwin A Kruger
- Division of Surgical Oncology and Endocrine Surgery, Mayo Clinic, Phoenix, AZ
| | - Barbara A Pockaj
- Division of Surgical Oncology and Endocrine Surgery, Mayo Clinic, Phoenix, AZ
| | | |
Collapse
|
28
|
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
Collapse
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
| |
Collapse
|
29
|
Khoury A, Bailey S, Mackey SP. Optimal postoperative management of perineal flaps in oncologic patients undergoing extralevator abdominoperineal excision: An introduction of a postoperative monitoring and flap management protocol. J Perioper Pract 2021; 32:10-14. [PMID: 33957819 DOI: 10.1177/1750458920959565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is extensive discussion regarding method of perineal defect closure extralevator abdominoperineal excision, but little consideration of optimal postoperative management of the flaps, or use of Enhanced Recovery After Surgery in flap reconstruction. Literature review revealed little discussion of optimum postoperative care of perineal flaps following extralevator abdominoperineal excision. We have developed a protocol for postoperative care of perineal flaps for use in conjunction with colorectal Enhanced Recovery After Surgery pathways, easily followed in units not specialising in plastic surgery. The protocol was developed using translatable evidence from guidelines for flap care from other subspecialties, as well as the experience of management of post-extralevator abdominoperineal excision perineal flaps in our trust, with the aim of enabling early detection of deterioration in this complex cohort, with a multidisciplinary enhanced recovery approach.
Collapse
Affiliation(s)
| | - Simon Bailey
- Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | | |
Collapse
|
30
|
No Opioids after Septorhinoplasty: A Multimodal Analgesic Protocol. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3305. [PMID: 33425613 PMCID: PMC7787342 DOI: 10.1097/gox.0000000000003305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/09/2020] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is available in the text. Background: From a public health perspective, nasal surgery accounts for many unused opioids. Patients undergoing septorhinoplasty require few opioids, and efforts to eliminate this need may benefit both patients and the public. Methods: A multimodal analgesic protocol consisting of 15 components encompassing all phases of care was implemented for 42 patients. Results: Median age and BMI were 34 years and 23, respectively. Most were women (79%), White (79%), primary surgeries (62%), and self-pay (52%). Comorbid conditions were present in 74% of the patients, with anxiety (33%) and depression (21%) being the most common. Septoplasties (67%) and osteotomies (45%) were common. The median operative time was 70 minutes. No patients required opioids in recovery, and median time in recovery was 63 minutes. Ten (24%) patients required an opioid prescription after discharge. In those patients, median time to requirement was 27 hours (range 3–81), and median total requirement was 20 mg morphine equivalents (range 7.5–85). Protocol compliance inversely correlated to opioid use (P = 0.007). Compliance with local and regional anesthetic (20% versus 63%, P = 0.030) as well as ketorolac (70% versus 100%, P = 0.011) was lower in patients who required opioids. Patients who required opioids were less likely to be administered a beta blocker (0% versus 34%, P = 0.041). Pain scores were higher in opioid users on postoperative days 1–5 (P < 0.05). No complications occurred in those requiring opioids, and satisfaction rates were equivalent between groups. Conclusion: This protocol allowed us to safely omit opioid prescriptions in 76% of patients following septorhinoplasty, without adverse effects on outcomes or patient satisfaction.
Collapse
|
31
|
A Single-Institution Case Series of Outpatient Same-Day Mastectomy: Implementation of a Quality Improvement Project and Initiative for Enhanced Recovery After Surgery. Ochsner J 2020; 20:388-393. [PMID: 33408576 PMCID: PMC7755563 DOI: 10.31486/toj.20.0040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: National data demonstrate a trend toward outpatient same-day mastectomy. The possible drivers of this change include the costs related to hospital admission and effective management of postoperative pain. We retrospectively analyzed our single-institution experience with outpatient same-day mastectomy that incorporates a multimodal pain management regimen. Methods: We retrospectively reviewed the medical records of patients who underwent same-day mastectomy at a single academic hospital. All patients received a multimodal, perioperative pain management regimen consisting of the intraoperative administration of 1,000 mg of intravenous (IV) acetaminophen and 30 mg of IV ketorolac, combined with the operating surgeon performing a 4- to 5-level, midaxillary, intercostal nerve block using liposomal bupivacaine. All patients were discharged with a prescription for acetaminophen with codeine, along with options for nonnarcotic alternatives as needed for pain. Results: We reviewed the data on 72 patients who underwent mastectomies: 11 (15.3%) bilateral and 61 (84.7%) unilateral. The average age was 57 years, and average body mass index was 30 kg/m2. The average length of stay of 4 to 6 hours was a marked reduction compared to a 23-hour observational period or an inpatient hospital stay. The average follow-up was 20.1 weeks. Five patients presented to the emergency department (ED) within the 30-day postoperative period, with 2 patients (2.8%) requiring readmission to the hospital for non–pain-related issues. The other 3 patients (4.2%) were evaluated for specific pain-related issues but did not require admission and were discharged home from the ED. Conclusion: Our data support outpatient same-day mastectomy incorporating a multimodal, perioperative pain management regimen as a safe and feasible treatment option. Potential additional benefits may include decreased oral opioid use and cost savings for the hospital.
Collapse
|
32
|
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.
Collapse
|
33
|
Prospective Evaluation of a Standardized Opioid Reduction Protocol after Anorectal Surgery. J Surg Res 2020; 256:564-569. [DOI: 10.1016/j.jss.2020.07.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/26/2020] [Accepted: 07/11/2020] [Indexed: 01/12/2023]
|
34
|
Vuong B, Dusendang JR, Chang SB, Mentakis MA, Shim VC, Schmittdiel J, Kuehner G. Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care. J Am Coll Surg 2020; 232:35-44. [PMID: 33022403 PMCID: PMC7532421 DOI: 10.1016/j.jamcollsurg.2020.09.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 01/16/2023]
Abstract
Background After implementation of the Surgical Home Recovery (SHR) initiative for mastectomy within a large, integrated health delivery system, most patients are discharged on the day of the procedure. We sought to identify predictors of SHR and unplanned return to care (RTC). Study Design Mastectomy cases with and without reconstruction from October 2017 to August 2019 were analyzed. Patient characteristics, operative variables, and multimodal pain management were compared between admitted patients and SHR patients using logistic regression. We identified predictors of RTC in SHR patients, defined as 7-day readmission, reoperation, or emergency department visit. Results Of 2,648 mastectomies, 1,689 (64%) were outpatient procedures and the mean age of patients was 58.5 years. Predictors of SHR included perioperative IV acetaminophen (odds ratio [OR] 1.59; 95% CI, 1.28 to 1.97), perioperative opiates (OR 1.47; 95% CI, 1.06 to 2.02), and operation performed by a high-volume breast surgeon (OR 2.12; 95% CI, 1.42 to 3.18). Bilateral mastectomies (OR 0.70; 95% CI, 0.54 to 0.91), immediate reconstruction (OR 0.52; 95% CI, 0.39 to 0.70), and American Society of Anesthesiologists class 3 to 4 (OR 0.69; 95% CI, 0.54 to 0.87) decreased the odds of SHR. Of SHR patients, 111 of 1,689 patients (7%) experienced RTC. Patients with American Society of Anesthesiologists class 3 to 4 (OR 2.01; 95% CI, 1.29 to 3.14) and African American race (OR 2.30; 95% CI, 1.38 to 4.91) were more likely to RTC; receiving IV acetaminophen (OR 0.56; 95% CI, 0.35 to 0.88) and filling an opiate prescription (OR 0.51; 95% CI, 0.34 to 0.77) decreased the odds of RTC. Conclusions Surgeon volume and multimodal pain medication increased the odds of SHR. Within the SHR group, American Society of Anesthesiologists Class 3 to 4 and African American patients increased the likelihood of RTC. This study helps optimize patient selection and perioperative practice for successful SHR.
Collapse
Affiliation(s)
- Brooke Vuong
- Kaiser Permanente South Sacramento Medical Center, Sacramento, CA.
| | | | | | | | | | | | | |
Collapse
|
35
|
Unplanned 30-day readmission rates after plastic and reconstructive surgery procedures: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
36
|
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.
Collapse
|
37
|
Oxley PJ, McNeely C, Janzen R, Mian RA, Lee AT, Murabit A, Wang P, McNeely D. Successful same day discharge after immediate post-mastectomy alloplastic breast reconstruction: A single tertiary centre retrospective audit. J Plast Reconstr Aesthet Surg 2020; 73:1068-1074. [DOI: 10.1016/j.bjps.2020.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 11/29/2019] [Accepted: 01/05/2020] [Indexed: 11/26/2022]
|
38
|
Siotos C, Cheah MA, Karahalios A, Seal SM, Manahan MA, Rosson GD. Interventions for reducing the use of opioids in breast reconstruction. Hippokratia 2020. [DOI: 10.1002/14651858.cd013568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Charalampos Siotos
- Rush University Medical Center; Department of Surgery, Division of Plastic and Reconstructive Surgery; Chicago IL USA
| | - Michael A Cheah
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore MD USA 21287
| | - Amalia Karahalios
- Monash University; School of Public Health and Preventive Medicine; Melbourne Australia
| | - Stella M Seal
- Johns Hopkins University School of Medicine; Welch Medical Library; 2024 E. Monument St. Baltimore MD USA 21287
| | - Michele A Manahan
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore MD USA 21287
| | - Gedge D Rosson
- Johns Hopkins University School of Medicine; Department of Plastic and Reconstructive Surgery; 601 N. Caroline Street Baltimore MD USA 21287
| |
Collapse
|
39
|
Motuziuk I, Sydorchuk O, Kostiuchenko Y, Kovtun N, Poniatovskyi P. Fast-Track Approach for Breast Reconstructive Surgery in Patients With Breast Cancer. BREAST CANCER-BASIC AND CLINICAL RESEARCH 2019; 13:1178223419876931. [PMID: 31555048 PMCID: PMC6749777 DOI: 10.1177/1178223419876931] [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: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 11/15/2022]
Abstract
Aim: The aim of this study was to develop and implement the concept of fast-track surgery (FTS) for reconstructive breast surgery in patients with breast cancer (BC) to improve early and long-term results of treatment. Materials and methods: The study includes 749 patients with stage 1 to 3 BC. A total of 253 patients with BC got treatment according to FTS program and were included to the core group. Other 496 patients with BC (control group) were not included to the FTS program. Patients were treated from December 2010 to December 2014. All age groups were covered (18-70 years old). Results: There was a significant difference in the average length of hospital stay (LOS) which was 14.27 ± 7.00 days in the core group and 20.11 ± 7.70 days in the control group (P < .001). In advanced BC cases in the core group, LOS was >8 days lower comparing with the control group on average. The LOS in patients who underwent adjuvant chemotherapy was 2.7 times lower in the FTS group comparing with the control group. Conclusions: The study results allow us to recommend the concept of FTS for implementation in broad medical practice for breast reconstructive surgery in patients with BC. The FTS program was shown to be effective in all types of breast surgery, including immediate oncoplastic and reconstructive surgeries. The gradual reduction of LOS increased the number of surgeries in our department by 75% from 2008 till 2018.
Collapse
Affiliation(s)
- Igor Motuziuk
- Oncology Department, Bogomolets National Medical University, Kyiv, Ukraine
| | - Oleg Sydorchuk
- Oncology Department, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Natalia Kovtun
- Statistics and Demography Department, Faculty of Economics, Taras Shevchenko National University of Kyiv, Kyiv, Ukraine
| | - Petro Poniatovskyi
- Oncology Department, Bogomolets National Medical University, Kyiv, Ukraine
| |
Collapse
|
40
|
Vuong B, Graff-Baker AN, Yanagisawa M, Chang SB, Mentakis M, Shim V, Knox M, Romero L, Kuehner G. Implementation of a Post-mastectomy Home Recovery Program in a Large, Integrated Health Care Delivery System. Ann Surg Oncol 2019; 26:3178-3184. [PMID: 31396779 DOI: 10.1245/s10434-019-07551-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The number of outpatient mastectomies, with and without reconstruction, has increased nationwide. In well-selected patient populations, same-day surgery for mastectomy is a safe option. A pilot project was initiated within the Kaiser Permanente Northern California healthcare system to facilitate surgical home recovery (SHR) for mastectomy patients, including patients undergoing implant-based reconstruction and bilateral mastectomies. METHODS Surgical home recovery for mastectomy patients was implemented in October 2017. Specific measures in this initiative included management of patient expectations at initial consultation, education about postoperative home care, multimodality pain management, and timely post-discharge follow-up. All patients undergoing mastectomy were included, except those undergoing autologous tissue reconstructions. After a 6-month implementation period, rate of same day discharge over 6 months was compared before and after the SHR initiative. We also compared emergency department (ED) visits, reoperations, and readmissions within 7 days. RESULTS Twenty-one medical centers participated in this initiative. Before implementing SHR, 164 of the 717 (23%) mastectomies were outpatient procedures, compared with 403 of the 663 (61%) after the implementation period. Although the rate of outpatient mastectomy increased significantly, there were no statistically significant differences in ED visits (5.2% vs. 5.1%, p = 0.98), reoperation (3.5% vs. 3.5%, p = 0.99), or readmission rates (1.4% vs. 2.7%, p = 0.08). CONCLUSIONS By implementing standard expectations and sharing best practices, there was a significant increase in the rate of home recovery for mastectomy without compromising quality of patient care. The success of this pilot program supports SHR for mastectomy.
Collapse
Affiliation(s)
- Brooke Vuong
- Surgical Oncology, Department of Surgery, Kaiser Permanente South Sacramento Medical Center, 6600 Bruceville Road, Sacramento, CA, 95823, USA.
| | | | - Mio Yanagisawa
- Department of Surgery, University of California Davis Health System, Sacramento, CA, USA
| | - Sharon B Chang
- Department of Surgery, The Permanente Medical Group, Fremont, CA, USA
| | - Margaret Mentakis
- Surgical Oncology, Department of Surgery, Kaiser Permanente South Sacramento Medical Center, 6600 Bruceville Road, Sacramento, CA, 95823, USA
| | - Veronica Shim
- Department of Surgery, The Permanente Medical Group, Oakland, CA, USA
| | - Michele Knox
- Department of Ophthalmology, The Permanente Medical Group, Fremont, CA, USA
| | - Lucinda Romero
- Department of Surgery, The Permanente Medical Group, Santa Rosa, CA, USA
| | - Gillian Kuehner
- Department of Surgery, The Permanente Medical Group, Vallejo, CA, USA
| |
Collapse
|
41
|
Tan YZ, Lu X, Luo J, Huang ZD, Deng QF, Shen XF, Zhang C, Guo GL. Enhanced Recovery After Surgery for Breast Reconstruction: Pooled Meta-Analysis of 10 Observational Studies Involving 1,838 Patients. Front Oncol 2019; 9:675. [PMID: 31417864 PMCID: PMC6682620 DOI: 10.3389/fonc.2019.00675] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose: This study aims to explore the effectiveness and safety of the enhanced recovery after surgery (ERAS) protocol vs. traditional perioperative care programs for breast reconstruction. Methods: Three electronic databases (PubMed, EMBASE, and Cochrane Library) were searched for observational studies comparing an ERAS program with a traditional perioperative care program from database inception to 5 May 2018. Two reviewers independently screened the literature according to the inclusion and exclusion criteria, extracted the data, and evaluated study quality using the Newcastle-Ottawa Scale. Subgroup and sensitivity analyses were performed. The outcomes included the length of hospital stay (LOS), complication rates, pain control, costs, emergency department visits, hospital readmission, and unplanned reoperation. Results: Ten studies were included in the meta-analysis. Compared with a conventional program, ERAS was associated with significantly decreased LOS, morphine administration (including postoperative patient-controlled analgesia usage rate and duration; intravenous morphine administration on postoperative day [POD] 0, 1, 2, and 4; total intravenous morphine administration on POD 0–3; oral morphine consumption on POD 0–4; and total postoperative oral morphine consumption), and pain scores (postoperative pain score on POD 0 and total pain score on POD 0–3). The other variables did not differ significantly. Conclusion: Our results suggest that ERAS protocols can decrease LOS and morphine equivalent dosing; therefore, further larger, and better-quality studies that report on bleeding amount and patient satisfaction are needed to validate our findings.
Collapse
Affiliation(s)
- Ya-Zhen Tan
- Center of Women's Health Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xuan Lu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jie Luo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Zhen-Dong Huang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Qi-Feng Deng
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xian-Feng Shen
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Guang-Ling Guo
- Center of Women's Health Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| |
Collapse
|
42
|
Ambulatory latissimus dorsi flap breast reconstruction: A prospective cohort study of an enhanced recovery after surgery (ERAS) protocol. J Plast Reconstr Aesthet Surg 2019; 72:1950-1955. [PMID: 31488381 DOI: 10.1016/j.bjps.2019.06.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/24/2019] [Accepted: 06/29/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols improve quality of recovery and decrease length of stay for patients undergoing both alloplastic and autologous breast reconstruction. Their use in latissimus dorsi (LD) flap reconstruction has not been well established. The purpose of this study was to compare postoperative outcomes, length of stay, and total costs in a prospectively enrolled group of patients who underwent LD flap breast reconstruction using an ERAS protocol to those of a retrospective cohort of patients who were treated with a traditional recovery after surgery (TRAS) protocol. METHODS In a prospective cohort study conducted from 2016 to 2019, an ERAS protocol was implemented for patients undergoing LD flap breast reconstruction. The primary outcome was 24-h discharge, and secondary outcomes were readmission rate, complications, and quality of recovery. Outcomes of patients who underwent LD flap reconstruction with the ERAS protocol were compared with those of a retrospective cohort of patients who underwent LD flap reconstruction with TRAS protocols. RESULTS Twenty patients enrolled in the ERAS group were compared with 58 patients in the TRAS group. Postoperatively, 100% of ERAS patients were discharged within 24 h (60% on the same day) as compared to 21% (9% on the same day) in the TRAS group (p<0.0001). Minor and major complication rates were similar (30% ERAS vs. 33% TRAS and 20% ERAS vs. 10% TRAS, respectively, p > 0.05). There was significant reduction in length of stay and total cost between the two groups (6.4 h vs. 58.5 h (p = 0.003) and $5,666.80 vs. $8890.25 (p = 0.0003), respectively). CONCLUSIONS Breast reconstruction with the LD flap can be performed safely and effectively in the ambulatory setting. The implementation of an ERAS protocol was successful in discharging all patients home within 24 h, and the expedited discharge was associated with an acceptable complication rate, reduced length of stay, and excellent quality of recovery. Conversion from TRAS to ERAS protocols was associated with $3,223.45 cost savings per patient.
Collapse
|
43
|
Adoption of Enhanced Recovery after Surgery Protocols in Breast Reconstruction in Alberta Is High before a Formal Program Implementation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2249. [PMID: 31333971 PMCID: PMC6571347 DOI: 10.1097/gox.0000000000002249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/15/2019] [Indexed: 11/29/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Enhanced recovery after surgery (ERAS) techniques have consistently demonstrated improved patient outcomes across multiple surgical specialties. We have lead international consensus guidelines on ERAS protocols for breast reconstruction and recently implemented these guidelines in Alberta. This study looks at adoption rates of ERAS pathways for breast reconstruction within Alberta, whereas also addressing barriers to ERAS implementation. Methods: A retrospective analysis of online operative reports in the Synoptec database consisting of patients undergoing alloplastic or autogenous breast reconstruction in Alberta was conducted. Primary outcomes of interest included whether ERAS protocols were utilized and what the reported barriers to ERAS utilization were. Results: Of the 372 patients undergoing breast reconstruction surgery, 215 (57%) patients were placed on an ERAS protocol. Autogenous reconstruction patients were more likely than alloplastic reconstruction patients to be placed on ERAS protocols (72% versus 53%, P = 0.002). A lack of resources was the most commonly cited reason for not adopting ERAS protocols for both autogenous and alloplastic reconstruction groups (53% and 53%). Surgeons in Southern Alberta were more likely than surgeons in Northern Alberta to utilize ERAS protocols for their alloplastic (73% versus 8%, P < 0.001) and autogenous (99% versus 4%, P < 0.001) reconstructions. Conclusions: Adoption of ERAS protocols in Alberta was strong (57% adherence) before a formal program implementation. We are encouraged that the recent official launch of ERAS protocols in breast reconstruction within the province will further enhance the uptake and care of this unique surgical population.
Collapse
|