Enhanced recovery after surgery (ERAS) pathways in autologous breast reconstruction: a systematic review

Enhanced recovery after surgery (ERAS) pathways in autologous breast reconstruction: a systematic review

many patient demographic and operative characteristics, thereby improving the quality of the results. There were no statistical differences between th...

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many patient demographic and operative characteristics, thereby improving the quality of the results. There were no statistical differences between the 2 groups in terms of mastectomy flap thickness, weight of the specimen, initial fill volume, adjuvant chemoradiation, obesity, diabetes, or smoking. By including “high-risk” patients and resections in each group, the data were rendered less biased and will give surgeon-readers more security to alter their current prescriptive practice. It is interesting that of the postoperative infections that did occur, the 24-hour antibiotic group experienced earlier-onset infections but fewer requiring intravenous antibiotics and tissue expander removal. This result suggests that prolonged antibiotic use

could mask the presentation of an infection and delay the treatment. The prolonged-antibiotic group also experienced more atypical and resistant organisms, suggesting that the use of prolonged antibiotics induced more severe infections for the patients who experienced infections. While the results were not statistically significant with regard to infection severity, they certainly could influence patient outcomes and warrant additional study. Arguably, one of the most dreaded complications in breast reconstructive surgery is loss of the tissue expander, and while not ideal, oral antibiotic treatment of cellulitis is certainly favored over explantation. For surgeons involved in the daily care of patients undergoing breast

reconstruction, this study will definitely influence our prescriptive care postoperatively. Double-blinded, larger studies are needed to follow suit to investigate outliers. While clinical judgement will always remain paramount, decreased antibiotic use in appropriate patients is necessary to slow the ever-increasing array of drug-resistant organisms. While further studies are warranted in higherrisk patients, such as immunosuppressed and diabetic patients, the average patient seems better served with decreased antibiotic use.

Enhanced recovery after surgery (ERAS) pathways in autologous breast reconstruction: a systematic review

ture has identified decreased LOS, improved quality of care and reduced healthcare expenditures. We aimed to systematically review the current literature and assess the current state of ERAS in autologous breast reconstruction. A systematic review of MEDLINE, EMBASE, ScienceDirect, Cochrane Libraries and Web of Science databases in October 2015 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Articles pertaining to the use of ERAS in plastic and reconstructive surgery were included for analysis. Review articles, conference proceedings and correspondence were excluded from the assessment. Five hundred fifty-seven articles were identified, of which three suitable articles were included for assessment. Of these, one series outlined the learning curve associated with ERAS pathways and two series were comparative in nature. Meta-analytical analysis was

not possible do to insufficient data and heterogeneity in outcome measures. In two of these comparative series, there was no statistical difference in rates of systemic infective (OR 0.91, 95% CI 0.29 to 2.80, p ¼ 0.86), total flap loss (OR 1.09, 95% CI 0.37 to 3.19, p ¼ 0.87), partial flap loss (OR 1.64, 95% CI 0.66 to 4.10, p ¼ 0.29) or wound infection (OR 1.38, 95% CI 0.78 to 2.34, p ¼ 0.29). LOS was significantly reduced in the ERAS group in both comparative studies from 7.4 to 6.2 days (p < 0.001) and 6.6 to 3.9 days (p < 0.001), respectively. ERAS pathways in breast reconstruction appear to consistently reduce LOS. From the available literature there were no significant detrimental effects on patient care following the implementation of ERAS pathways. Further research is required to definitively determine safety in the assessed cohort and to determine reductions in healthcare-related expenditures. Level of evidence.dNot ratable.

Gnaneswaran N, Perera M, Perera N, et al (Royal Brisbane Hosp, Australia; The Univ of Queensland, Brisbane, Australia; Univ of Melbourne, Parkville, Victoria, Australia) Eur J Plast Surg 39:165-172, 2016

Enhanced recovery after surgery (ERAS) pathways aim to achieve earlier recovery and reduced hospital length-of-stay (LOS) by providing multi-modal perioperative care. The tenets of ERAS pathways include preoperative optimisation, prevention of surgical complications, reduction of physiological stress response to surgery and rehabilitation to normal function. To date, ERAS protocols have gained broad acceptance by many surgical specialities. Contemporary litera-

M. S. Roubaud, MD C. E. Butler, MD

Breast Diseases: A Year BookÒ Quarterly Vol 27 No 4 2017

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In this systematic review, Gnaneswaran and colleagues detailed the results of their investigation into the current status of enhanced recovery in oncoplastic breast surgery. Although over 2 decades old, the concept of enhanced recovery or fast-track surgery has exploded into the landscape of surgical care throughout the world over the past 5 years. However, penetration into the cancer surgery space, outside of minimally invasive colon cancer surgery, has been slow. The authors of this review were able to identify only a handful of viable publications examining enhanced recov-

ery within the oncoplastic breast surgery space. As with other areas, even these early analyses showed reduced LOS after surgery. It can be assumed that this reduction in inpatient stay is coupled to reduced complications, standardized care pathways, and ultimately a truly better recovery experience for the patient. Importantly, future studies will need to flesh out these areas and others, including cost and comparative effectiveness of the 5 pillars of enhanced recovery success: patient education, goaldirected fluid therapy, non-narcotic

analgesia, early feeding, and early ambulation. Lastly, I would challenge readers, whose interest in this topic has directed them to this publication, to develop and use patient-reported outcomes tools to measure the benefits of enhanced recovery in their environments. The future of this area of surgery depends on our ability to score, grade, and report on the patient experience with recovery, which can be accomplished only via patientreported outcomes. T. A. Aloia, MD

BREAST CONSERVING THERAPY Distance to Radiation Facility and Treatment Choice in EarlyStage Breast Cancer Acharya S, Hsieh S, Michalski JM, et al (Washington Univ School of Medicine-St. Louis, MO; et al) Int J Radiat Oncol Biol Phys 94:691-699, 2016

Purpose.dBreast-conserving therapy (BCT) is a recommended alternative to mastectomy (MT) for earlystage breast cancer. Limited access to radiation therapy (RT) may result in higher rates of MT. We assessed the association between distance to the nearest RT facility and the use of MT, in a modern cohort of women. Methods and Materials.dWomen with stage 0-II breast cancer eligible for BCT diagnosed from 2004 to 2010 were identified from the Florida Cancer Data System (FCDS). Distan-

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ces from patient census tracts to the nearest RT facility census tract were calculated. Multivariate logistic regression was used to identify explanatory variables that influenced MT use. Results.dOf the 27,489 eligible women, 32.1% (n ¼ 8841) underwent MT, and 67.8% (n ¼ 18,648) underwent BCS. Thirty-two percent of patients lived in a census tract that was >5 miles from an RT facility. MT use increased with increasing distance to RT facility (31.1% at #5 miles, 33.8% at >5 to <15 miles, 34.9% at 15 to <40 miles, and 51% at $40 miles, P < .001). The likelihood was that MT was independently associated with increasing distance to RT facility on multivariate analysis (P < .001). Compared to patients living <5 miles away from an RT facility, patients living 15 to <40 miles away were 1.2 times more likely to be treated with MT (odds ratio [OR]: 1.19, 95% confi-

Breast Diseases: A Year BookÒ Quarterly Vol 27 No 4 2017

dence interval [CI]: 1.05-1.35, P < .01), and those living $40 miles away were more than twice as likely to be treated with MT (OR: 2.17, 95% CI: 1.483.17, P < .001). However, in patients younger than 50 years (n ¼ 5179), MT use was not associated with distance to RT facility (P ¼ .235). Conclusions.dMT use in a modern cohort of women is independently associated with distance to RT facility. However, for young patients, distance to RT is not a significant explanatory variable for MT use. No man is going to make another impotent while he’s asleep without his permission, but there’s no hesitation if it’s a woman’s breast.dRose Kushner In the modern era, rarely do we see the removal of an entire organ as necessary treatment of an early-stage cancer. Until recent decades, the