Abstract: Elective, Outpatients Immediate Breast Reconstruction: A Single-Centre Retrospective and Systematic Literature Review

Abstract

INTRODUCTION: The United Kingdom’s landmark audit (January 2008 – March 2009) of its breast reconstructive practice reported on 15,479 mastectomy patients, with a 21% (3,216) immediate reconstruction rate (IBR) and network variance of 9 – 43% (p<0.001) 1. This 4-fold difference is replicated in other national studies and appears not to be determined by patients’ underlying oncology, but by multi-disciplinary network access variables. Ambulatory care (same-day discharge) has become normative for the majority of index breast procedures, driven by convenience, cost benefit,2 improved efficiencies and the aggregation of evolved techniques such as anatomical flap dissection, dual probe sentinel node staging, multimodal pain management, surgical site infection control bundles, integrated discharge planning3 and validated outcome datasets.4 This report aims to demonstrate proof of principle, by utilising ambulatory care protocols to leverage IBR access. We systematically review the evidence for ambulatory immediate breast reconstruction to date; and report on a single unit’s clinical experience over six months (April – September 2016). METHODS: A systematic (PRISMA) review was undertaken in January 2017. Search keywords included ‘breast reconstruction’, ‘mammaplasty’, ‘ambulatory surgery’ and ‘enhanced recovery after surgery’. We queried Medline (Ovid), Embase, NHS IC audits for clinical studies (2005- 2016) with no language or sample- size restrictions. Our IBR practice includes: 24- hour discharge monitoring by nurse- led practitioners; Novel, ambulatory IBR was grafted onto the existing pathway in discussion with suitable patients. We describe the cohorts’ demographics oncology dataset, perioperative times and outcomes. RESULTS: There are no reported studies evaluating ambulatory, immediate breast reconstruction. Between April and September 2016, three patients underwent ambulatory implant-based IBR. They were selected ‘organically’ with normative peri-operative screening and outcomes. They all underwent skin sparing mastectomies with implant/ADM (Surgimend PRS) IBR: mean operative time of 2 hours, 35mins; mean time to discharge 4 hours and 27mins; and 6 months follow-up with no unplanned readmissions and a normative postoperative recovery pathway. CONCLUSION: There is no reported evidence for ambulatory IBR we are aware of. Utilising our existing ambulatory care pathway, outpatient elective IBR is feasible. A prospective outcomes study5 with validated patient reported instruments would be a way to offer enhanced access to IBR in suitable patients. Reference Citations: 1. NMBR 2010 - www.hrbchdr.com/sites/default/files/MBRAuditThirdAnnualReport2010.pdf 2. Goldfarb CA et al. J Am Acad Orthop Surg 2017; 25: 12–22. Ambulatory surgical centres: A review of complications and adverse events 3. Mathis MR et al Anaesthesiology 2013; 119(6):1310- 1321. Patient selection for day case - eligible surgery: Identifying those at high risk for major complications 4. Marla S et al Int J of Surg 2009; 7: 318- 323. Systematic review of day surgery for breast cancer. 5. Bundred N et al BMJ 1998; 317: 1275- 9. Randomised controlled trial of effects of early discharge after surgery for breast cancer.