Enhanced Recovery Pathway in Microvascular Autologous Tissue-Based Breast Reconstruction: Should it Become the Standard of Care?

Background: Enhanced Recovery Pathway (ERP) programs have demonstrated improved perioperative care and shorter length of hospital stay (LOS) in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue-based breast reconstruction (ABR) before and after the implementation of an ERP program. Methods: We retrospectively reviewed consecutive patients who underwent ABR by two surgeons before and after the implementation of the ERP at a university center over a three-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-ERP) and ERP patients. Multivariate logistic regression was performed to identify risk factors for LOS. Cost analysis was performed. Results: Between April 2014 and January 2017, 100 consecutive women were identified; 50 in each group. Both groups had similar demographics, co-morbidities, and reconstruction types. Postoperatively, the ERP cohort used significantly less opiate and more acetaminophen when compared to the pre-ERP cohort. Median LOS was shorter with the ERP cohort, which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342. Participation in an ERP program and lower total morphine equivalent use were independent predictors for decreased LOS. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were similar between the groups. Conclusions: ERP program implementation should be considered as the standard approach for perioperative care in ABR since it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased LOS leading to downstream healthcare cost savings. Financial Disclosures: None of the authors has a financial interest in any of the products, devices or drugs mentioned in this manuscript. Financial Support: Financial support by Vanderbilt Institute for Clinical and Translational Research (VICTR) for assistance with the statistical analysis through the Department of Biostatistics at the Vanderbilt School of Medicine. The project was supported by the National Center of Research Resources, Grant UL1 RR024975-01, and is now at the National Center for Advancing Translational Sciences, Grant 2 UL1 TR000445-06. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Author roles: Christodoulos Kaoutzanis: study design, data collection, manuscript preparation; Nishant Ganesh Kumar: study design, data collection, manuscript edits; Dillon O'Neill: data collection, manuscript edits; Blair Wormer: statistical analysis, manuscript edits; Julian Winocour: study design, manuscript edits; John Layliev: study design, manuscript edits; Matthew McEvoy and Adam King: enhanced recovery pathway monitoring during hospitalization, manuscript edits; Stephane A. Braun: patient accrual, manuscript edits; K. Kye Higdon: designed the enhanced recovery pathway, patient accrual, manuscript edits. Corresponding Author: Name:Christodoulos Kaoutzanis, Address: Department of Plastic Surgery, Vanderbilt University Medical Center, D-4207 Medical Center North, Nashville, TN 37232-2345, USA. Email: ckaoutzanis@gmail.com, Phone:734-834-0597 ©2018American Society of Plastic Surgeons

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