Breast Enhanced Recovery after Surgery: Improvement of Patient Experience

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1 Breast Enhanced Recovery after Surgery: Improvement of Patient Experience Vaishali Patel DO, Selyne Samuel MD, Sophia Horattas MD, Abigail Tremelling MD, Joseph Gabra DEng, Andrew Fenton MD, Mary Murray MD, Amanda Mendiola MD Cleveland Clinic Akron General, Akron, Ohio

2 Disclosures I have no disclosures

3 Introduction The aim of the Breast Enhanced Recovery after Surgery (ERAS) pathway was to evaluate factors that could optimize the recovery of breast surgery patients The outcomes of interest were decreased postoperative nausea, vomiting and pain

4 Background Enhanced recovery protocols are well established and used in a variety of surgical subspecialties These consist of patient optimization in the preoperative, operative and postoperative setting ERAS protocols have been shown to shorten length of hospital stay by 30-50% and have demonstrated similar reductions in complications and readmission rates 1

5 Methods We performed a postoperative survey for 3 months prior and for 3 months after the initiation of the ERAS pathway The survey participants were patients who had undergone breast surgery including: excisional biopsy, partial mastectomy, mastectomy, and any axillary procedure Patients were preoperatively administered scopolamine patches, PO celecoxib 200 mg and gabapentin 600 mg Intra-operatively, they received intravenous anti-emetics and pectoral blocks

6 Methods These patients were asked to complete surveys at their first postoperative visit Nausea and pain: Immediately after surgery 24 hour 48 hour 1 week They were asked to rate these on a scale of 1 through 5 (1= none, 5= very bad) Mann-Whitney U tests were used to compare postoperative pain, nausea levels between the Pre-ERAS and Post-ERAS patient groups

7 Results Table 1: Postoperative Nausea and Pain Levels Among Patients, Median (Average ± Standard Deviation) Pre-ERAS ERAS (n=154) (n=147) Immediately 3.0 (2.87 ± 1.20) 2.0 (2.43 ± 1.21) Pain At 24 hrs 3.0 (2.87 ± 1.10) 3.0 (2.67 ± 1.17) At 48 hrs 3.0 (2.47 ± 1.10) 3.0 (2.57 ± 1.14) At 1 wk 2.0 (2.14 ± 1.07) 2.0 (2.18 ± 1.09) Immediately 1.0 (1.65 ± 1.21) 1.0 (1.52 ± 0.91) Nausea At 24 hrs 1.0 (1.40 ± 0.90) 1.0 (1.34 ± 0.77) At 48 hrs 1.0 (1.23 ± 0.63) 1.0 (1.27 ± 0.82) Note: Abstentions were excluded from analyses

8 Results Postoperative pain improved with the implementation of an ERAS protocol Pain immediately after surgery was significantly lower in Post-ERAS group compared to the Pre-ERAS group (p = 0.001) no significant difference at other time points With respect to nausea, there was no significant difference between the Pre- ERAS and Post-ERAS patient groups for any postoperative time point (p > 0.638) **However, there was an overall reduction in the percentage of patients who rated their immediate postoperative nausea as a 4 or 5 in the ERAS group despite this not having statistical significance

9 Discussion Substantial data and consensus statements exist Colorectal, bariatric, head and neck, gynecology, urology 3 Minimal data on ERAS with respect to breast surgery No consensus statement in this field While most breast surgeries are performed as same day procedures, the common reasons for overnight stays are postoperative nausea, vomiting or pain

10 Discussion The findings show significant impact on pain in the immediate postoperative setting as well as shift towards improved nausea as well as decreased pain beyond the immediate post-operative setting Trends towards improvement in postoperative nausea and narcotic usage in this study are considered meaningful, despite not being statistically significant

11 Conclusion After implementing ERAS, we saw a statistically significant reduction in immediate post-operative pain Overall trends toward improvement in nausea and pain in this series are a promising outcome It is our goal to help create a consensus statement regarding the most beneficial ERAS protocol for breast surgery patients

12 References 1. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3): Arsalani-zadeh R, Elfadl D, Yassin N, Macfie J. Evidence-based review of enhancing postoperative recovery after breast surgery. Br J Surg. 2011;98(2):