Ambulatory latissimus dorsi flap breast reconstruction: A prospective cohort study of an enhanced recovery after surgery (ERAS) protocol

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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.

Introduction

Enhanced recovery after surgery (ERAS) protocols are evidence-based perioperative programs successfully adopted in multiple surgical disciplines to improve postoperative morbidity, patient satisfaction, and length of stay in hospital. This multimodal approach typically involves varying degrees of preadmission counseling, goal-directed fluid resuscitation, multimodal analgesia, and expedited hospital discharge.1 Recently, these protocols have been implemented safely and effectively in the context of both alloplastic2, 3 and autologous4 breast reconstruction. Existing studies on ERAS pathways in breast reconstruction, however, predominantly focus on free flaps owing to their extended hospital stay and the disproportionate resources involved.5

Latissimus dorsi (LD) flap breast reconstruction combines autologous tissue transposition with expander or implant placement. To date, the role of ERAS protocols for LD flap breast reconstruction is not well established and is particularly useful considering the unique pain profile and the fact that inpatient flap monitoring is not necessary. Despite the transition to ambulatory surgery at some centers,6, 7 the vast majority of patients undergoing LD flap breast reconstruction will be admitted to hospital with lengths of stay ranging from 1 to 12 days.8, 9, 10

The objective of this study was to prospectively enroll patients who underwent LD flap breast reconstruction using an ERAS protocol and compare postoperative outcomes, length of stay, and hospital-perspective costs with those of previous patients who underwent LD flap reconstruction using the traditional recovery after surgery (TRAS) protocol.

Section snippets

Methods

Research ethics board approval (#20160216-01H) was obtained in June 2016 for a prospective cohort of women who underwent LD flap breast reconstruction enrolled in the ERAS group. Data were collected for a retrospective cohort of women undergoing the same surgery but who received treatment by the TRAS protocol. A summary of preoperative, intraoperative, and postoperative elements of the ERAS protocol is outlined in Appendix 1.

A preoperative consult determined the patient eligibility for an

Patient demographics

Seventy-eight patients were included in the study; 20 patients were prospectively enrolled into the ERAS group and 58 patients enrolled as retrospective controls in the TRAS group (Table 1). Patients in the ERAS and TRAS groups were adequately matched for age, BMI, comorbidities, smoking status, and radiation (p > 0.05). The ERAS group had significantly higher preoperative ASA scores (ASA3 65% vs. 5%, ASA1 0% vs. 62%, p < 0.0001) and the TRAS group had higher preoperative chemotherapy rates

Discussion

In the context of Canada's public health care system, there are increasing regulatory pressures to maximize clinical outcomes and patient satisfaction while minimizing healthcare expenditures. As such, ERAS protocols have emerged in multiple surgical domains as an innovative way to enhance the perioperative experience while safely decreasing length of stay and hospital expenditures.

The objective of the present study was to evaluate the feasibility of shifting LD flap breast reconstruction to a

Conclusion

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 sending all patients home within 24 h, and the expedited discharge was associated with an acceptable complication rate, reduced hospital length of stay, and excellent quality of recovery. Conversion from TRAS to ERAS protocols was associated with $3223.45 cost savings per patient.

Financial disclosures

This study was performed without external funding. None of the authors have commercial associations or financial disclosures that might pose a conflict of interest with information presented in this manuscript.

Declaration of Competing Interest

None of the listed authors have conflicts of interest or any disclosures.

References (18)

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