A Single-Institution Case Series of Outpatient Same-Day Mastectomy: Implementation of a Quality Improvement Project and Initiative for Enhanced Recovery After Surgery

Abstract

Background: National data demonstrate a trend toward outpatient same-day mastectomy. The possible drivers of this change include the costs related to hospital admission and effective management of postoperative pain. We retrospectively analyzed our single-institution experience with outpatient same-day mastectomy that incorporates a multimodal pain management regimen. Methods: We retrospectively reviewed the medical records of patients who underwent same-day mastectomy at a single academic hospital. All patients received a multimodal, perioperative pain management regimen consisting of the intraoperative administration of 1,000 mg of intravenous (IV) acetaminophen and 30 mg of IV ketorolac, combined with the operating surgeon performing a 4- to 5-level, midaxillary, intercostal nerve block using liposomal bupivacaine. All patients were discharged with a prescription for acetaminophen with codeine, along with options for nonnarcotic alternatives as needed for pain. Results: We reviewed the data on 72 patients who underwent mastectomies: 11 (15.3%) bilateral and 61 (84.7%) unilateral. The average age was 57 years, and average body mass index was 30 kg/m². The average length of stay of 4 to 6 hours was a marked reduction compared to a 23-hour observational period or an inpatient hospital stay. The average follow-up was 20.1 weeks. Five patients presented to the emergency department (ED) within the 30-day postoperative period, with 2 patients (2.8%) requiring readmission to the hospital for non-pain-related issues. The other 3 patients (4.2%) were evaluated for specific pain-related issues but did not require admission and were discharged home from the ED. Conclusion: Our data support outpatient same-day mastectomy incorporating a multimodal, perioperative pain management regimen as a safe and feasible treatment option. Potential additional benefits may include decreased oral opioid use and cost savings for the hospital.

Keywords: Ambulatory surgical procedures; bupivacaine; mastectomy; nerve block; opioid-related disorders; pain management.

Figure 1.

For the intercostal block technique, the rib is palpated, the needle is directed toward the lower aspect of the rib, and the liposomal bupivacaine is directly injected into the neurovascular bundle just within the intercostal space. The needle cannot be advanced too deeply because of the potential for causing a pneumothorax. Approximately 5 mL of liposomal bupivacaine is injected at each rib level.

Figure 2.

Completed bilateral mastectomy incisions are covered with a small-width layer of a nonadherent dressing and an occlusive, water-impermeable transparent film dressing, with single, 15-French, fully fluted, round drains in place.