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Taylor JM, Moman PD, Chevalier JM, Tseng CY, Festekjian JH, Delong MR. Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Tissue Expander-based Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5879. [PMID: 38855130 PMCID: PMC11161298 DOI: 10.1097/gox.0000000000005879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 06/11/2024]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have demonstrated success in reducing hospital stay and opioid consumption, but are less well studied in patients undergoing tissue expander-based breast reconstruction (TEBR). This study evaluates the effectiveness of an ERAS postoperative protocol for TEBR at a high-volume center. Methods All patients undergoing immediate tissue expander reconstruction after the introduction of ERAS were prospectively included from April 2019 to June 2023. An equivalent number of similar patients were retrospectively reviewed before this date as the non-ERAS control. Data included demographics, operative details, postoperative length of stay, inpatient and discharge narcotic quantities, inpatient pain assessments, postoperative radiation, and complications within 90 days. Results There were 201 patients in each cohort with statistically similar demographics. Patients in the ERAS cohort were more likely to undergo prepectoral reconstruction (83.1% versus 4.5%, P < 0.001), be discharged by day 1 (96.5% versus 70.2%, P < 0.001) and consume lower inpatient milligram morphine equivalent (MME) median (79.8 versus 151.8, P < 0.001). Seroma rates (17.4% versus 3.5%, P < 0.001) and hematoma incidence (4.5% versus 0%, P = 0.004) were higher in the ERAS cohort. Adjusting for implant location, ERAS was associated with a 60.7 MME reduction (β=-60.7, P < 0.001) and a shorter inpatient duration by 0.4 days (β =-0.4, P < 0.001). Additionally, prepectoral reconstruction significantly decreased MME (β=-30.9, P = 0.015) and was the sole predictor of seroma development (odds ratio = 5.2, P = 0.009). Conclusions ERAS protocols significantly reduce opioid use and hospital stay after TEBR.
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Affiliation(s)
- Jeremiah M. Taylor
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Precious D. Moman
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jose M. Chevalier
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Charles Y. Tseng
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jaco H. Festekjian
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Michael R. Delong
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
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2
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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.
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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
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3
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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 .
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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.
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Marxen T, Shauly O, Losken A. The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4448. [PMID: 35924002 PMCID: PMC9298472 DOI: 10.1097/gox.0000000000004448] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/02/2022] [Indexed: 11/25/2022]
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Samuel AR, Fuhr L, DeGeorge BR, Black J, Campbell C, Stranix JT. Prolonged Opioid Use Among Opioid-Naive Women Undergoing Breast Reconstructive Surgery. Arch Plast Surg 2022; 49:339-345. [PMID: 35832151 PMCID: PMC9142247 DOI: 10.1055/s-0042-1744419] [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] [Indexed: 10/26/2022] Open
Abstract
Abstract
Background Patients that undergo mastectomy for breast cancer with reconstruction may be prone to prolonged opioid use. As risk factors are not well-established, this article sought to better understand the risk factors that may be associated with this.
Methods Patients that underwent breast reconstruction between 2010 and 2018 were identified in PearlDiver, a national insurance claims database. Patient demographics and comorbidities were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis was used to evaluate the association of risk factors and complications.
Results Breast reconstruction patients of 24,765 were identified from this database. Obesity, tobacco use, benzodiazepine use, and anticonvulsant use were all associated with prolonged opioid prescriptions greater than 90 days after both alloplastic and autologous reconstruction.
Conclusion Prolonged opioid use continues to remain a topic of concern, and particularly in cancer patients that undergo breast reconstruction. Providers should be aware of potential risk factors for this to reduce this chance following breast reconstruction surgery.
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Affiliation(s)
- Ankhita R. Samuel
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Laura Fuhr
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Brent R. DeGeorge
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Jonathan Black
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Christopher Campbell
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - John T. Stranix
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
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Specht MC, Kelly BN, Tomczyk E, Ford OA, Webster AJ, Smith BL, Gadd MA, Colwell AS, Liao EC. One-Year Experience of Same-Day Mastectomy and Breast Reconstruction Protocol. Ann Surg Oncol 2022; 29:5711-5719. [PMID: 35543905 PMCID: PMC9092933 DOI: 10.1245/s10434-022-11859-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/04/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND The prevalence of same-day mastectomy with reconstruction has continued to increase across the United States in recent years. Prior studies have shown that same-day mastectomy with reconstruction leads to increased patient satisfaction and allows hospitals to use resources better. This study sought to evaluate the implementation of same-day mastectomy with a reconstruction recovery protocol for patients undergoing mastectomy at our institution. METHODS Under an institutional review board-approved protocol, a retrospective cohort analysis compared patients who underwent mastectomy April 2016 through April 2017 with those who had mastectomy March 2020 through March 2021. Length of stay, postoperative intravenous (IV) opioid administration, safety end points, and cost were the main variables examined. RESULTS The study compared 457 patients in 2016-2017 with 428 patients in 2020-2021. The median hospital length of stay decreased from 24.6 h in 2016-2017 to 5.5 h in 2020-2021 (p < 0.001). The percentage of patients requiring postoperative IV opioids decreased from 69.1 % in 2016-2017 to 50 % in 2020-2021 (p < 0.001). The rates of unplanned readmissions within 30 days after mastectomy did not differ between the two groups, with a rate of 3.7 % in 2016-2017 and a rate of 5.1 % in 2020-2021 (p = 0.30). Reducing the rate of overnight admissions after mastectomy by 65.8 % resulted in a cost reduction of 65.8 %. CONCLUSIONS Implementation of same-day mastectomy with a reconstruction protocol across a large academic center and two satellite sites was a safe alternative to conventional mastectomy recovery plans.
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Affiliation(s)
- Michelle C Specht
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Bridget N Kelly
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Eleanor Tomczyk
- Harvard Medical School, Boston, MA, USA.,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Olivia A Ford
- Harvard Medical School, Boston, MA, USA.,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Alexandra J Webster
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Michelle A Gadd
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Amy S Colwell
- Harvard Medical School, Boston, MA, USA.,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Eric C Liao
- Harvard Medical School, Boston, MA, USA.,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
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7
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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.
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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
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8
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High-Efficiency Same-Day Approach to Breast Reconstruction During the COVID-19 Crisis. Breast Cancer Res Treat 2020; 182:679-688. [PMID: 32562119 PMCID: PMC7304917 DOI: 10.1007/s10549-020-05739-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/09/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE As our hospitals conserve and re-allocate resources during the COVID-19 crisis, there is urgent need to determine how best to continue caring for breast cancer patients. During the time window before the COVID-19 critical peak and particularly thereafter, as hospitals are able to resume cancer operations, we anticipate that there will be great need to maximize efficiency to treat breast cancer. The goal of this study is to present a same-day protocol that minimizes resource utilization to enable hospitals to increase inpatient capacity, while providing care for breast cancer patients undergoing mastectomy and immediate breast reconstruction during the COVID-19 crisis. METHODS IRB exempt patient quality improvement initiative was conducted to detail the operationalization of a novel same-day breast reconstruction protocol. Consecutive patients having undergone immediate breast reconstruction were prospectively enrolled between February and March of 2020 at Massachusetts General Hospital during the COVID-19 crisis. Peri-operative results and postoperative complications were summarized. RESULTS Time interval from surgical closure to patient discharge was 5.02 ± 1.29 h. All patients were discharged home, with no re-admissions or emergency department visits. No postoperative complications were observed. CONCLUSION This report provides an instruction manual to operationalize a same-day breast reconstruction protocol, to meet demands of providing appropriate cancer treatment during times of unprecedented resource limitations. Pre-pectoral implant-based breast reconstruction can be the definitive procedure or be used as a bridge to autologous reconstruction. Importantly, we hope this work will be helpful to our patients and community as we emerge from the COVID-19 pandemic.
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9
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Egan KG, De Souza M, Muenks E, Nazir N, Korentager R. Opioid Consumption Following Breast Surgery Decreases with a Brief Educational Intervention: A Randomized, Controlled Trial. Ann Surg Oncol 2020; 27:3156-3162. [DOI: 10.1245/s10434-020-08432-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Indexed: 12/16/2022]
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10
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DeSnyder SM, Hanasono MM. Invited Editorial: "Enhanced Recovery Minimizes Opioid Use and Length of Stay in Patients Undergoing Mastectomy with Reconstruction". Ann Surg Oncol 2019; 26:3418-3419. [PMID: 31407183 DOI: 10.1245/s10434-019-07713-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Sarah M DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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