Enhanced Recovery After Surgery and Postoperative Nausea and Length of Stay in Mastectomy Patients With Reconstruction

INTRODUCTION

Surgery is a mainstay of curative breast cancer treatment and is associated with postoperative nausea and vomiting (PONV) negatively impacting the patient experience. Enhanced recovery after surgery (ERAS) protocols are a combination of evidence-based strategies applied to traditional perioperative practices with the goal to reduce postoperative complications. ERAS protocols have been traditionally underutilized in breast surgery. We investigated if the implementation of an ERAS protocol was associated with decreased rates of PONV as well as length of stay (LOS) in patients undergoing mastectomy with breast reconstruction.

METHODS

We conducted a retrospective chart review case-control study in which we compared PONV and LOS between ERAS cases and non-ERAS controls. Our data set consisted of 138 ERAS cases and 96 non-ERAS controls. All patients were >18 y old and underwent mastectomy with immediate implant or tissue expander-based reconstruction between 2018 and 2020. The non-ERAS group consisted of procedure-matched controls that were treated prior to implementation of the ERAS protocol.

RESULTS

In univariate comparisons, patients who underwent the ERAS protocol had significantly decreased postoperative nausea (mean 37.5% of controls versus 18.1% of ERAS, P < 0.001) and shorter LOS (1.21 versus 1.49 d, P < 0.001). Using a multivariable regression to control for potential confounders, ERAS protocol was associated with less postoperative nausea (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.13-0.5), LOS 1 d versus > 1 d (OR = 0.19, 95% CI = 0.1-0.35), and less postoperative ondansetron use (OR = 0.03, 95% CI = 0.01-0.07).

CONCLUSIONS

Our results indicate that implementation of the ERAS protocol in women undergoing mastectomy with immediate reconstruction is associated with improved patient outcomes in postoperative nausea and LOS.

Keeping tabs: Reducing postoperative opioid prescriptions for patients after breast surgical procedures

BACKGROUND

As the opioid crisis continues, it is critical that health care providers ensure they are not overprescribing opioid medications. At our institution (Walter Reed National Military Medical Center, Bethesda, MD), postoperative patients after breast surgeries are discharged with variable amounts of opioid medications. However, many patients report minimal opioid use. The objectives of this study were to characterize postoperative opioid usage and prescribing practices for patients undergoing various breast surgeries and to recommend the number of opioid pills for discharge for each procedure.

METHODS

This was a prospective, single-institution study of all patients undergoing breast surgery from October 2018 to 2019. All patients were enrolled in our institution's enhanced recovery after surgery protocol. Patients were given questionnaires at their 2-week postoperative clinic appointment that evaluated perioperative pain and use of pain medications. The electronic medical record was reviewed to obtain additional information. Appropriate parametric and nonparametric tests were used for analysis.

RESULTS

A total of 190 breast surgery patients completed the survey. We observed no significant differences in pain scores except between re-excision and mastectomy. Of these patients, 99% were prescribed opioids; however, only 53% of patients used them. Of those patients who were prescribed opioids, on average, all were prescribed more pills than were used.

CONCLUSION

Our study demonstrates that it is possible to discharge all breast surgery patients with fewer than 10 opioid pills, except for special circumstances. This is the first study to provide a set of specific recommended discharge medications. Utilization of an enhanced recovery after surgery protocol with standardized discharge opioids can be used successfully to reduce the number of opioids prescribed to patients.