Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction

Abstract

Background and objective: After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway.

Methods: All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed.

Key content and findings: Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions.

Conclusions: Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.

Keywords: Enhanced recovery; breast reconstruction; enhanced recovery after surgery (ERAS); length of stay; outcomes.

Figure 1

PRISMA flowchart of study identification and selection.

Figure 2

Staircase diagram depicting milestones for discharge. GI, gastrointestinal.

Figure 3

Inpatient IV MME reported in autologous reconstruction protocol studies. Width indicates number of subjects included in the study. From left to right: Jablonka et al. 2017 (49), Sharif-Askary et al. 2019 (32), Kaoutzanis et al. 2018 (35), Sindali et al. 2019 (31), Ochoa et al. 2022 (22), Haddock et al. 2021 (23), Haddock et al. 2021 (24), Astanehe et al. 2018 (34), Afonso et al. 2017 (36), Batdorf et al. 2015 (39). IV, intravenous; MME, milligram morphine equivalents.

Figure 4

Postoperative length of stay reported in autologous reconstruction protocol studies. Y-axis depicts POD. Width indicates number of subjects included in study. Height indicates standard deviation in length of stay (days). Includes three studies reporting optimal results and the two largest included studies which reported results. From left to right: Haddock et al. 2021 (43), Jablonka et al. 2017 (49), Kaoutzanis et al. 2018 (35), Ochoa et al. 2018 (22), O’Neil et al. 2020 (27). POD, postoperative day.

Figure 5

A comprehensive enhanced recovery protocol for breast reconstruction. PO, per os; TD, transdermal; IV, intravenous; PR, per rectum; n/o, non-opioid.