Journal of Plastic, Reconstructive & Aesthetic Surgery
Ambulatory latissimus dorsi flap breast reconstruction: A prospective cohort study of an enhanced recovery after surgery (ERAS) protocol
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.
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Cited by (20)
Perioperative protocols in ambulatory breast reconstruction: A systematic review
2023, Journal of Plastic, Reconstructive and Aesthetic SurgeryImpact of ERAS in breast reconstruction with a latissimus dorsi flap, compared to conventional management
2023, Journal of Plastic, Reconstructive and Aesthetic SurgeryAssessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review
2023, Journal of Plastic, Reconstructive and Aesthetic SurgeryDonor-site morbidity following breast reconstruction with a latissimus dorsi flap – A prospective study
2022, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :In most cases, TAP reconstruction requires the addition of a foreign body in form of a mesh or acellular dermal matrix (ADM) to support the implant and protect the perforator. ADM's typically lead to increased drain-output and may promote prolonged hospitalization, if the patients are not able to be discharged with drains23; whereas traditionally performed LD reconstruction may allow accelerated discharge within 1–3 days.24 Regarding functional donor-site morbidity, the TAP flap appears to have some advantages over the LD flap.
Does Anesthetic Choice Affect Surgical and Recovery Times?
2022, Evidence-Based Practice of AnesthesiologyEnhanced recovery after breast reconstruction with a pedicled Latissimus Dorsi flap—A prospective clinical study
2021, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :Throughout the past 20 years, ERAS has become a central part of post-operative care for a wide variety of specialties in many departments worldwide. Despite several reports of ERAS-programmes for microvascular breast reconstructions and breast reconstructions in general12-15, only few reports of ERAS programmes related to LD breast reconstructions have been published.16,17 Through implementation of a procedure-specific and relatively simple ERAS-programme, with a focus on the core elements of enhanced recovery we reduced the average LOS by almost four days without increasing the risk of surgical complications or readmissions for patients undergoing LD breast reconstruction.