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J Reconstr Microsurg
DOI: 10.1055/a-2506-1763
Original Article

Effect of Enhanced Recovery after Surgery in Morbidly Obese Patients Undergoing Free Flap Breast Reconstruction

Kristen L. Stephens 
1   Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
,
Robert G. DeVito
1   Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
,
Scott T. Hollenbeck
1   Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
,
Chris A. Campbell
1   Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
,
John T. Stranix
1   Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
› Institutsangaben Funding None.
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Abstract

Background Enhanced recovery after surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.

Methods A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), intensive care unit (ICU) utilization, opioid usage, cost, and flap outcomes were analyzed in patients with body mass index greater than 35 before and after ERAS implementation.

Results Thirty-five morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral versus bilateral or immediate versus delayed reconstruction. LOS decreased with ERAS (3.43 vs. 2.06 days, p < 0.0000001). ICU utilization decreased with ERAS (0.94 vs. 0.0 days, p < 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs. 17.9 morphine milligram equivalent [MME], p < 0.0001; 190.5 vs. 54.7 MME, p < 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs. $25,079, p = 0.0002) and increased cost margin ($4,458 vs. −$8,306, p = 0.004). There were no differences in donor or recipient site outcomes including flap loss, deep venous thrombosis/pulmonary embolism, hernia/bulge, delayed wound healing, revisions, and blood loss.

Conclusion ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased LOS, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.

Keywords

ERAS - breast reconstruction - obesity

Presentation

This work was presented at the Virginia Society of Plastic Surgeons Annual Meeting in September 2023 as an oral presentation and will be presented at Plastic Surgery The Meeting in September 2024 as an oral presentation.


Supplementary Material



Publikationsverlauf

Eingereicht: 30. Mai 2024

Angenommen: 11. Dezember 2024

Accepted Manuscript online:
19. Dezember 2024

Artikel online veröffentlicht:
21. Januar 2025

© 2025. Thieme. All rights reserved.

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  • References

  • 1 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin 2019; 69 (01) 7-34
    CrossrefPubMedSuche in Google Scholar
  • 2 Arnold M, Morgan E, Rumgay H. et al. Current and future burden of breast cancer: global statistics for 2020 and 2040. Breast 2022; 66: 15-23
    CrossrefPubMedSuche in Google Scholar
  • 3 Nano MT, Gill PG, Kollias J, Bochner MA, Malycha P, Winefield HR. Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg 2005; 75 (11) 940-947
    CrossrefPubMedSuche in Google Scholar
  • 4 Fang SY, Shu BC, Chang YJ. The effect of breast reconstruction surgery on body image among women after mastectomy: a meta-analysis. Breast Cancer Res Treat 2013; 137 (01) 13-21
    CrossrefPubMedSuche in Google Scholar
  • 5 Crompvoets S. Comfort, control, or conformity: women who choose breast reconstruction following mastectomy. Health Care Women Int 2006; 27 (01) 75-93
    CrossrefPubMedSuche in Google Scholar
  • 6 Neill KM, Armstrong N, Burnett CB. Choosing reconstruction after mastectomy: a qualitative analysis. Oncol Nurs Forum 1998; 25 (04) 743-750
    PubMedSuche in Google Scholar
  • 7 Nissen MJ, Swenson KK, Kind EA. Quality of life after postmastectomy breast reconstruction. Oncol Nurs Forum 2002; 29 (03) 547-553
    CrossrefPubMedSuche in Google Scholar
  • 8 Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32 (01) 32-38
    CrossrefPubMedSuche in Google Scholar
  • 9 Mehta SK, Olawoyin O, Chouairi F. et al. Worse overall health status negatively impacts satisfaction with breast reconstruction. J Plast Reconstr Aesthet Surg 2020; 73 (11) 2056-2062
    CrossrefPubMedSuche in Google Scholar
  • 10 Lee K, Kruper L, Dieli-Conwright CM, Mortimer JE. The impact of obesity on breast cancer diagnosis and treatment. Curr Oncol Rep 2019; 21 (05) 41
    CrossrefPubMedSuche in Google Scholar
  • 11 Panayi AC, Agha RA, Sieber BA, Orgill DP. Impact of obesity on outcomes in breast reconstruction: a systematic review and meta-analysis. J Reconstr Microsurg 2018; 34 (05) 363-375
    Thieme ConnectPubMedSuche in Google Scholar
  • 12 Gustafsson UO, Scott MJ, Hubner M. et al. Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS®) society recommendations: 2018. World J Surg 2019; 43 (03) 659-695
    CrossrefPubMedSuche in Google Scholar
  • 13 Stenberg E, Dos Reis Falcão LF, O'Kane M. et al. Guidelines for perioperative care in bariatric surgery: enhanced recovery after surgery (ERAS) society recommendations: a 2021 update. [published correction appears in World J Surg. 2022] World J Surg 2022; 46 (04) 729-751
    CrossrefPubMedSuche in Google Scholar
  • 14 Bogani G, Sarpietro G, Ferrandina G. et al. Enhanced recovery after surgery (ERAS) in gynecology oncology. Eur J Surg Oncol 2021; 47 (05) 952-959
    CrossrefPubMedSuche in Google Scholar
  • 15 Gort N, van Gaal BGI, Tielemans HJP, Ulrich DJO, Hummelink S. Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction. Breast 2021; 60: 53-57
    CrossrefPubMedSuche in Google Scholar
  • 16 Sharif-Askary B, Hompe E, Broadwater G, Anolik R, Hollenbeck ST. The effect of enhanced recovery after surgery pathway implementation on abdominal-based microvascular breast reconstruction. J Surg Res 2019; 242: 276-285
    CrossrefPubMedSuche in Google Scholar
  • 17 Anolik RA, Sharif-Askary B, Hompe E, Hopkins TJ, Broadwater G, Hollenbeck ST. Occurrence of symptomatic hypotension in patients undergoing breast free flaps: is enhanced recovery after surgery to blame?. Plast Reconstr Surg 2020; 145 (03) 606-616
    CrossrefPubMedSuche in Google Scholar
  • 18 Neeland IJ, Poirier P, Després JP. Cardiovascular and metabolic heterogeneity of obesity: clinical challenges and implications for management. Circulation 2018; 137 (13) 1391-1406
    CrossrefPubMedSuche in Google Scholar
  • 19 Piché ME, Poirier P, Lemieux I, Després JP. Overview of epidemiology and contribution of obesity and body fat distribution to cardiovascular disease: an update. Prog Cardiovasc Dis 2018; 61 (02) 103-113
    CrossrefPubMedSuche in Google Scholar
  • 20 CPT® (Current Procedural Terminology) American Medical Association. Accessed: May 3, 2024 at: https://www.ama-assn.org/amaone/cpt-current-procedural-terminology
    PubMed
  • 21 Adult obesity facts. 2022 Centers for Disease Control and Prevention. Accessed April 29, 2024 at: https://www.cdc.gov/obesity/data/adult.html
    PubMed
  • 22 Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg 2018; 153 (10) 891-899
    CrossrefPubMedSuche in Google Scholar
  • 23 Malekpour M, Malekpour F, Wang HT. Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome. World J Clin Cases 2023; 11 (10) 2201-2212
    CrossrefPubMedSuche in Google Scholar
  • 24 Offodile II AC, Gu C, Boukovalas S. et al. Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature. Breast Cancer Res Treat 2019; 173 (01) 65-77
    CrossrefPubMedSuche in Google Scholar
  • 25 Araya S, Webster TK, Egleston B. et al. Significant reduction in length of stay in deep inferior epigastric perforator flap breast reconstruction with implementation of multimodal ERAS protocol. Ann Plast Surg 2023; 91 (01) 90-95
    CrossrefPubMedSuche in Google Scholar
  • 26 Shin HD, Rodriguez AM, Abraham JT. et al. “Does ERAS benefit higher BMI patients? A single institutional review”. J Plast Reconstr Aesthet Surg 2021; 74 (03) 475-479
    CrossrefPubMedSuche in Google Scholar
  • 27 Persing S, Manahan M, Rosson G. Enhanced recovery after surgery pathways in breast reconstruction. Clin Plast Surg 2020; 47 (02) 221-243
    CrossrefPubMedSuche in Google Scholar
  • 28 Haddock NT, Garza R, Boyle CE, Liu Y, Teotia SS. Defining enhanced recovery pathway with or without liposomal bupivacaine in DIEP flap breast reconstruction. Plast Reconstr Surg 2021; 148 (05) 948-957
    CrossrefPubMedSuche in Google Scholar
  • 29 Park RH, Chou J, DeVito RG. et al. Effectiveness of liposomal bupivacaine transversus abdominis plane block in DIEP flap breast reconstruction: a randomized controlled trial. Plast Reconstr Surg 2024; 154 (4S): 52S-59S
    CrossrefPubMedSuche in Google Scholar
  • 30 Batdorf NJ, Lemaine V, Lovely JK. et al. Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2015; 68 (03) 395-402
    CrossrefPubMedSuche in Google Scholar
  • 31 Bonsignore MR. Obesity and obstructive sleep apnea. Handb Exp Pharmacol 2022; 274: 181-201
    CrossrefPubMedSuche in Google Scholar
  • 32 Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med 2022; 18 (02) 647-652
    CrossrefPubMedSuche in Google Scholar
  • 33 Perry C, Guillory TS, Dilks SS. Obesity and psychiatric disorders. Nurs Clin North Am 2021; 56 (04) 553-563
    CrossrefPubMedSuche in Google Scholar
  • 34 Rodnoi P, Dickey RM, Teotia SS, Haddock NT. Increased opioid consumption following DIEP flap breast reconstruction: effect of depression and anxiety. J Reconstr Microsurg 2022; 38 (09) 742-748
    Thieme ConnectPubMedSuche in Google Scholar
  • 35 Fischer JP, Nelson JA, Sieber B. et al. Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions. Plast Reconstr Surg 2013; 131 (05) 681e-692e
    CrossrefPubMedSuche in Google Scholar
  • 36 Jandali S, Nelson JA, Sonnad SS. et al. Breast reconstruction with free tissue transfer from the abdomen in the morbidly obese. Plast Reconstr Surg 2011; 127 (06) 2206-2213
    CrossrefPubMedSuche in Google Scholar
  • 37 Garvey PB, Buchel EW, Pockaj BA, Gray RJ, Samson TD. The deep inferior epigastric perforator flap for breast reconstruction in overweight and obese patients. Plast Reconstr Surg 2005; 115 (02) 447-457
    CrossrefPubMedSuche in Google Scholar
  • 38 Lymperopoulos NS, Sofos S, Constantinides J, Koshy O, Graham K. Blood loss and transfusion rates in DIEP flap breast reconstruction. Introducing a new predictor. J Plast Reconstr Aesthet Surg 2013; 66 (12) 1659-1664
    CrossrefPubMedSuche in Google Scholar
  • 39 Appleton SE, Ngan A, Kent B, Morris SF. Risk factors influencing transfusion rates in DIEP flap breast reconstruction. Plast Reconstr Surg 2011; 127 (05) 1773-1782
    CrossrefPubMedSuche in Google Scholar
  • 40 Ting J, Rozen WM, Le Roux CM, Ashton MW, Garcia-Tutor E. Predictors of blood transfusion in deep inferior epigastric artery perforator flap breast reconstruction. J Reconstr Microsurg 2011; 27 (04) 233-238
    Thieme ConnectPubMedSuche in Google Scholar
  • 41 Tuaño KR, Yang JH, Fisher MH. et al. Venous thromboembolism after deep inferior epigastric perforator flap breast reconstruction: review of outcomes after a postoperative prophylaxis protocol. Plast Reconstr Surg 2024; 154 (01) 13e-20e
    PubMedSuche in Google Scholar
  • 42 DeVito RG, Craft L, Campbell CA, Stranix JT. Optimizing perioperative outcomes in autologous breast reconstruction. Gland Surg 2023; 12 (04) 508-515
    CrossrefPubMedSuche in Google Scholar
  • 43 Oh C, Moriarty J, Borah BJ. et al. Cost analysis of enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2018; 71 (06) 819-826
    CrossrefPubMedSuche in Google Scholar