Enhanced Recovery After Surgery (ERAS) as a Strategy to Address Breast Cancer Disparities

Introduction: Recently, enhanced recovery after surgery (ERAS) pathways have been gaining popularity within surgical sub-specialties. Key ERAS concepts include the standardization of perioperative care such as pre-operative counseling, protocolization of analgesia and anesthesia regimens as well as early mobilization, among others. This approach aims to achieve cost savings through decreased length of stay, reduced opioid complications, and overall improved outcomes. In concordance with this trend, many institutions are now implementing ERAS protocols for breast surgery, especially with cases of mastectomy followed by immediate reconstruction. Our institution implemented a Breast Surgery ERAS program in February of 2018, consisting of standardized peri-operative analgesia/anesthesia, most significantly including a pre-operative pectoral block performed by anesthesia. We hypothesize that the use of the pre-operative pectoral block in the ERAS cohort will result in improved post-operative pain scores from the Non-ERAS cohort; additionally, we expect that the percentage of patients requiring opioid prescriptions at discharge for pain control will be decreased in the ERAS cohort. Methods: The EMR was queried for patients who underwent breast surgery with immediate reconstruction. The experimental group consisted of ERAS patients from February 6, 2018 to February 1, 2019 with an n = 107. The control group consisted of non-ERAS patients from April 19, 2016 to January 30, 2018 with an n=117. Chart review was performed for discharge medications, as well as pain scores recorded from time immediately post-operative, to just prior to discharge. Statistical analysis of the data was performed with a comparison of difference in means and Fischer exact test. Results: The ERAS cohort was noted to have a statistically significant decrease in the mean immediate post-operative pain scores (ERAS 2.04, Non-ERAS 4.04; p-value < 0.0001). There was no difference with comparison of the means of last pain scores recorded prior to discharge between the ERAS and Non-ERAS groups (ERAS 3.36, Non-ERAS 3.63, p-value 0.34). There was a statistically significant decrease in the percentage of patients discharged with opioid prescriptions in the ERAS group compared to the Non-ERAS group (ERAS 58.9% v 87.2% Non-ERAS; p-value <0.0001). The ERAS cohort LOS was also statistically significantly less than the Non-ERAS (ERAS 1.28 days, Non-ERAS 1.61 days; p-value = 0.0002). Discussion: Our ERAS protocol utilizes multi-modal pain control methods beginning pre-operatively, including the addition of a pectoral block placed by anesthesia, which we expect contributed highly to the lower mean immediate post-operative pain scores expressed by the ERAS cohort. This is important in the context of our nation’s current opioid epidemic, where decreasing discharge opioid prescriptions is imperative for reducing the risk for development of addictive behaviors, as well as the risk for opioid side effects such as nausea, constipation, and altered mental status. With the implementation of our Breast Surgery ERAS program, we have demonstrated clear progress towards this goal with the hope for continued improvement. Citation Format: Ashley A Woodfin, Emily Ramirez, Alison Coogan, Nehl Mehta, Anuja K Antony, Deana Shenaq, Keith C Hood, Cristina O'Donoghue, Claudia Perez, Rosalinda Alvarado, Andrea Madrigrano. Breast surgery ERAS program: Trends since implementation on post-operative pain and discharge narcotic prescribing at our institution [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-08.

Introduction: Enhanced recovery after surgery (ERAS) pathways strive to minimize surgical stress and restore normal physiological function through the implementation of standardized and streamlined protocols. ERAS pathways have shown benefits in many surgical populations including cardiac, colorectal, urology and general surgery by aiming to accelerate recovery and reduce post-operative morbidity. As microsurgical breast reconstruction continues to become more popular, study objectives aim to determine possible benefits of ERAS pathway implementation during abdominal-based free flap breast reconstruction related to post-operative narcotic use and health-care resource utilization. Methods: A retrospective analysis of consecutive patients undergoing abdominal-based free flap breast reconstruction from Nov 2015 to April 2018 was performed. Study populations were defined relative to uniform implementation of an ERAS pathway, which included preoperative counseling, optimization of nutrition, perioperative fluid management, early mobilization, and multimodal analgesia. Patient age, medical comorbidities, and BMI were recorded preoperatively. Procedural characteristics and immediate postoperative morbidity were recorded along with length of hospitalization. Utilization of narcotics was standardized for the entire hospitalization by determining morphine milligram equivalents. Results: During the study period, 409 patients met inclusion criteria. The pre-ERAS group was comprised of 205 patients, while 204 patients were managed via ERAS pathway. Mean age, laterality (unilateral vs. bilateral), timing (immediate vs. delayed) of reconstruction, and number of previous abdominal surgeries were similar (p > 0.05) between both groups. Mean BMI (30.4 ± 4.8 vs. 29 ± 5.1) and incidence of autoimmune disease (3.9% vs. 0%) were significantly higher (p < 0.05) in the pre-ERAS group. Mean operative time (minutes) between both groups (450.1 ± 92.7 vs. 440.7 ± 93.5) was similar (p > 0.05). Incidence of vascular thrombosis (6 (2.9%) vs. 5 (2.5%)), hematoma (4 (2%) vs.4 (2%)), flap loss (1 (0.5%) vs. 4 (2.%), or return to OR for any reason (10 (4.9%) vs. 8 (3.9%)) was similar (p > 0.05) between pre-ERAS and ERAS groups, respectively. Mean intra-operative (58.9 ± 32.5 vs. 31.7 ± 23.4) and post-operative (129.5 ± 80.1 vs. 90 ± 93.9) morphine milligram equivalents used were significantly (p < 0.001) higher in the pre-ERAS group. Mean length of stay (days) was significantly (p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 vs. 3.2 ± 0.6). Bivariate linear regression analysis demonstrates operative time is positively associated with total narcotic requirements [slope (95% CI)=0.217 (0.114, 0.320)], p < 0.001 and length of stay [slope (95% CI) =0.00177 (0.0008, 0.0028)], p < 0.001. Conclusion: Without detrimental effects on operative morbidity, ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In the current study, patients managed via ERAS pathways required 46% less intraoperative and 31% less postoperative narcotics with a 29% reduction in length of stay. Citation Format: Oscar Ochoa, Meenakshi Rajan, Minas Chrysopoulo, Steven Pisano, Peter Ledoux, Gary Arishita, Ramon Garza III, Chet Nastala. Enhanced recovery after surgery (ERAS) pathway reduces hospital stay and narcotic use in microsurgical breast reconstruction [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD6-2.

This study aims to establish, execute, and assess the effectiveness of a perioperative enhanced recovery after surgery (ERAS) clinical care pathway in breast reconstruction patients with LD flap breast cancer treatment. The goal is to improve early recovery outcomes, reduce hospitalization time, and enhance patient satisfaction by implementing a standardized approach to postoperative care. This study was conducted at the University of Malaya Medical Center. The outcomes of 21 breast cancer patients who underwent autologous reconstructive breast surgery with the latissimus dorsi (LD) flap within six months before the implementation of the ERAS pathway (pre-ERAS) were compared with 26 patients who underwent the same surgery with the ultrasound-guided erector spinae plane (ESP) block for the (ERAS protocol implementation) cohort. The study was conducted from November 2019 to October 2020. The length of hospital stay, amount of analgesic usage, and incidence of postoperative nausea vomiting (PONV) were recorded. The implementation of the ERAS clinical care pathway resulted in shorter hospital stays compared with the preceding care. On average, ERAS patients were mostly discharged on Day 2 post-surgery, whereas pre-ERAS patients were mostly discharged on Day 7. ERAS patients had a lower incidence of PONV from Days 1 to 5, starting with 88.5% not experiencing the condition on Days 1 and 2 and increasing to 100% on Day 5. All pre-ERAS patients experienced PONV in the first 5days post-surgery. Fewer ERAS patients required antiemetics post-surgery (88.5%) compared with pre-ERAS patients (42.9%). The implementation of the ERAS protocol as part of clinical care in autologous reconstructive breast surgery with the LD flap can improve recovery by shortening hospital stay, decreasing the use of analgesia, and alleviating PONV.

Background: Breast cancer treatment outcomes have markedly improved over the years with advancements in knowledge and treatment options. Enhanced recovery after surgery (ERAS) has been introduced recently to enhance post-operative patient wellbeing, attain enhanced recovery for patients who undergo major surgery, and therefore facilitate a drop in hospital length of stay (LOS). These may also furnish an additional advantage of decreasing health care costs while refining the standard of care and patient contentedness. Methods: A quasi experimental study was conducted in the breast unit of Khyber Teaching Hospital, with a sample size of 30 in each group with a 95% confidence interval and a 5% margin of error. A consecutive non-probability sampling technique was used and the study was conducted in 6 months after taking ethical approval from the ethical review committee MTI, KTH. Comparison was done between both groups for effectiveness, noted with regard to hospital stay, post-op pain and complication rate. Results: The mean age of the patients in the ERAS group was 56.30±5.615 years while the mean age in the non-ERAS group was 56.07±6.11 years. The wound infection was observed in 11 patients with ERAS (36.7%) as compared to 12 (40.0%) without ERAS. Hospital stay was longer in non-ERAS as compared to ERAS with a mean difference of 1.833 and p-value of 0.000 while the post-op VAS mean difference was 1.267 with p value of 0.001. Conclusion: Evidence supports the effectiveness, affordability, and safety of ERAS protocols as it leads to a noticeable decrease in hospitalization duration, resulting in reduced resource consumption and financial burdens. Nonetheless, achieving the mentioned benefits may necessitate strict adherence to the protocol, which could be challenging due to professional, institutional, and personal resistance.

The evolving conceptualization of the management of surgical pain was a major contributor to the supply of narcotics that led to the opioid crisis. We designed and implemented a breast surgery-specific Enhanced Recovery After Surgery (ERAS) protocol using opioid-sparing techniques to eliminate narcotic prescription at discharge without sacrificing perioperative pain control. A pilot observational study included patients with and without cancer undergoing lumpectomy. The convenience sample consisted of an ERAS group and a control usual care (UC) group who underwent surgery during the same time period. Discharge narcotic prescriptions were compared after converting to oral morphine milligram equivalents (MME's). Postoperative day one and week one pain scores were also compared between the two groups. Ninety ERAS and 67 UC patients were enrolled. Most lumpectomies were wire-localized, and half of the patients in each group had breast cancer. There were more obese patients in the ERAS group. UC lumpectomy patients were discharged with a median of 54.5 MMEs (range 0-120), while the ERAS lumpectomy patients were discharged with none (p < 0.001). Postoperative pain scores were not significantly different between groups, and there were few complications. A breast surgery-specific ERAS protocol employing opioid-sparing techniques successfully eliminated postoperative narcotic prescription without sacrificing perioperative pain control or increasing postoperative complications. By promoting the adoption of similar protocols, surgeons can continue to improve patient outcomes while decreasing the quantity of narcotics available for diversion within our patients' communities.

Aim A closed loop audit to assess the enhanced recovery after surgery (ERAS) protocol before and after implementation of an ERAS proforma, in patients who have undergone breast free flap reconstruction. To analyse the impact on patients after implementation. Method Retrospective data collection from March to June 2022 and September to November 2023, in a tertiary oncoplastic breast unit. Inclusion criteria: all patients who had undergone breast free flap reconstruction for breast cancer. Thirty-one patients in total. An ERAS proforma was designed in line with Trust standards and based on input from the oncoplastic breast MDT. The proforma included the following categories: pre-operation, operation day, day one, two and three post operation. The data was collected, analysed, and compared to data collected before implementation. Results The first audit showed poor adherence to the ERAS protocol, this improved after implementation of an ERAS proforma in the following areas: location of the proforma in notes, 0% found in notes before, 92% after. Anti-emetics prescribed 32% before and 100% after. Anti-inflammatory medication plus proton pump inhibitor prescribed 32% before and 100% after. Analgesia, laxatives, and enoxaparin prescribed in 100% of patients before and after implementation. Day 1 TWOC occurred 0% before and 50% after implementation. Day 2 drain documentation/management 26% before and 100% after. The average length of hospital stay was 5.5 days before, 3.75 days after. Therefore, inpatient hospitalisation was reduced by 1.75 days. Conclusions Adherence to an ERAS protocol is beneficial in managing patients during the perioperative period and leads to reduced inpatient hospitalisation.

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

A lot of women choose the immediate breast reconstruction after mastectomy. The most common method is breast reconstruction using tissue expanders. Women's way of life and the economic crisis have created the need for adopting enhanced recovery after surgery (ERAS) protocols and early hospital discharge. The present study aims at informing perioperative nurses about the ERAS protocols and encouraging their implementation. ERAS protocols in breast cancer patients undergoing immediate post-mastectomy breast reconstruction include a combination of evidence-based interoperative interventions with the participation of surgeons, anesthetists, nurses, physiotherapists, and dietitians as members of the multidisciplinary team. This is a multifactorial approach to postoperative rehabilitation and care of the surgical patient. ERAS protocols are easy to apply, reduce morbidity, perioperative anxiety, postoperative pain, postoperative complications and hospitalization. In addition, they reduce the cost of treatment and hospitalization. The patient's approach to breast cancer following an ERAS protocol is divided into three phases: pre-surgical, intraoperative and post-operative. It starts before the patient’s hospitalization and continues until they are discharged, requiring active participation throughout the process. The total average hospitalization for post-mastectomy rehabilitation decreased from 3.6 days, prior to ERAS implementation, to 0 (discharging the same day) to 1.2 days post-surgery, releasing 30% of the beds. In conclusion, the ERAS protocols, following evidence-based perioperative care, promote the rapid recovery of patients aiming at reducing post-operative stress and its effects.

ERAS-Based Anesthetic Management of Patients Undergoing Abdominal-Based Free Flap Breast Reconstruction: A Narrative Review

Patients with locally advanced invasive breast cancer (LABC) are often considered inoperable, because of the anticipated chest wall defect and need for complex reconstruction. We present a series of patients who underwent mastectomy with extensive skin resection and immediate chest wall reconstruction using a local thoracoabdominal advancement flap (TAAF). All patients were managed after surgery with an ERAS (Enhanced Recovery After Surgery) protocol, to decrease length of stay in hospital. We also present 1 patient who subsequently had satisfactory bilateral delayed breast reconstruction with pedicled latissimus dorsi myocutaneous flaps with prepectoral silicone implants. This is a single-surgeon, single-institution retrospective chart review of patients with LABC who underwent mastectomy with skin resection and local TAAF from May 2017 to October 2019, with minimum 3-month follow-up. Thirteen patients met inclusion criteria. Twelve of 13 patients presented with stage III or IV invasive breast cancer, with skin involvement. The mean chest wall defect measured 248.7 cm2 (140-336 cm2; SD, 63.2 cm2), and all were successfully reconstructed with immediate local TAAF. There were no intraoperative complications, but 1 patient developed a postop hematoma. The mean hospital stay was 1.3 nights, with 9 patients (69.2%) staying less than 23 hours and 4 patients (30.8%) staying 2 nights. Nine patients (69.2%) underwent adjuvant therapy, beginning on average 32 days (13-55 days; SD, 13.1 days) after surgery. The mean follow-up time was 13.8 months (4.5-31.6 months; SD, 9.2 months). One patient underwent successful delayed bilateral breast reconstruction with pedicled latissimus dorsi myocutaneous flaps and silicone implant placement. Our study demonstrates that reconstruction with local TAAF is an outpatient procedure that reliably provides durable, immediate chest wall coverage, after mastectomy in patients with LABC. This technique has a short operative time, low blood loss, and low complication rate, allowing timely adjuvant therapy. Using an ERAS postop protocol we were able to reduce mean hospital stay to 1.3 days. Compared with other described techniques of reconstruction, the additional scars and donor site morbidity are minimal, allowing for delayed breast reconstruction. We also present survival outcomes data on these surgically managed patients.

The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia. A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII). Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar. This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.

Introduction: The epidemic of opioid addiction and overdose has become a public health emergency in the United States. Opioids prescribed for postoperative pain management have contributed significantly to this epidemic. At the Permanente Medical Group (TPMG), reducing postoperative opioid prescriptions has become a priority. A pilot study in 2016 led by TPMG breast surgeons showed that pain after lumpectomy can be managed effectively without opioids. The results of this study were disseminated to all TPMG breast surgeons via a February 2017 webinar. In November 2018, TPMG implemented an outpatient Enhanced Recovery After Surgery (ERAS) initiative that included reducing postoperative opioid prescriptions. The objective of our study was to evaluate self-reported changes in TPMG breast surgeon opioid-prescribing practices after these interventions. Methods: An online survey was created to assess perioperative and postoperative practices. This survey was distributed to TPMG breast surgeons before the 2017 educational webinar about non-opioid regimens, and again in June 2019, more than 6 months after the implementation of the outpatient ERAS initiative. Questions included how surgeons manage patient expectations during the initial consultation, surgeons’ preoperative pain medication regimens, intraoperative pain management including nerve blocks, local anesthetics, ketorolac use, and postoperative pain management. We used a chi-square test to compare differences between the two surveys. Results: We received 13 responses from a group of over 100 TPMG breast surgeons in 2017 and 29 responses from 59 surgeons in 2019. Overall, self-reported non-opioid regimens increased between 2017 and 2019, with only 23% of surgeons using these regimens for lumpectomy in 2017 and 79% in 2019 (p&amp;lt;0.001). TPMG Self-Reported Opioid Prescribing Patterns After Lumpectomy, 2017 vs 2019# Opioid Tablets Prescribed After Lumpectomy% of Surgeons Prescribingp-value2017201902379&amp;lt;0.0011 to 10870.9311 to 201570.3921 to 302330.045&amp;gt;30150NAUnspecified153NA Notably, non-opioid regimens were also reported by 66% of surgeons for lumpectomy with sentinel lymph node biopsy (SLNbx), 41% for mastectomy without reconstruction, and 14% for mastectomy with implant-based reconstruction. 2019 Self-Reported Opioid Prescribing Patterns After Different Types of Breast Operations% of Surgeons Prescribing# Opioid Tablets Prescribed, by Type of OperationLumpectomyLumpectomy With Sentinel Lymph Node BiopsyMastectomy Without ReconstructionMastectomy With Reconstruction0796641141 to 1071021311 to 20717282821-3033710&amp;gt;310007Unspecified3333Per plastics00034 Conclusion: Self-reported postoperative opioid prescribing practices for breast surgery have changed significantly after implementation of TPMG initiatives, with the majority of TPMG breast surgeons prescribing no opioids after lumpectomy with or without SLNbx, and many prescribing no opioids after mastectomy. In future work, we aim to validate the self-reported data using pharmacy prescription data from 2017-2019. We also plan to identify perioperative factors that are predictive of successful non-opioid postoperative pain management such as the use of nerve blocks, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, and acetaminophen. Citation Format: Avani R Patel, Gillian E Kuehner, Sharon B. Chang. Eliminating postoperative opioids for outpatient breast surgery in a large integrated healthcare system [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-23.

Background: ERAS protocols are perioperative interventions aimed at reducing postoperative complications, length of hospital stay (LOS) and early return to normal activities. This has improved outcome in many surgical specialties, including breast surgery. We present the surgical outcome of breast cancer (BC) patients treated over a 12-month period following the principle of ERAS protocols and highlight the underpinning evidence. Methods: A retrospective analysis of all BC patients diagnosed and had breast cancer surgery over 12 months. Data collected included patient’s demographics, type of surgery, LOS, other perioperative care and significant postoperative complications. Excluded were patients with bilateral cancer surgeries, diagnostic excision, margin clearance or breast reconstruction. Results: There were 621 BC diagnosed including 5 male and 12 bilateral female BC. The ages ranged from 25 to 93 years. Excluding bilateral BC, 351 patients (70.2 %) had breast conserving surgery (BCS) while 149 (29.8%) patients had mastectomy as index cancer surgery. Sixteen (4.5%) of the women who initially underwent BCS subsequently had a completion mastectomy. The overall rate of successful BCS was 335/500 (67%). 441 (85.5%) of patients were discharged same or next day. 12 (7.2%) cases of postoperative haematoma, 6 cases of wound infection and a case of seroma requiring surgical/radiological drainage recorded. Conclusion: ERAS protocol in BC surgery is associated with decreased LOS and low complication rate. Delayed discharges are mostly due to adverse social factors and medical comorbidity rather than post-operative surgical complications.

IntroductionInternationally, breast cancer is the second most diagnosed cancer with approximately 2.3 million people diagnosed each year. 40% will require a mastectomy which has an average length of hospital stay...