Enhanced recovery after surgery (ERAS) pathways in autologous breast reconstruction: a systematic review

Enhanced recovery after surgery (ERAS) pathways aim to achieve earlier recovery and reduced hospital length-of-stay (LOS) by providing multi-modal perioperative care. The tenets of ERAS pathways include pre-operative optimisation, prevention of surgical complications, reduction of physiological stress response to surgery and rehabilitation to normal function. To date, ERAS protocols have gained broad acceptance by many surgical specialities. Contemporary literature has identified decreased LOS, improved quality of care and reduced healthcare expenditures. We aimed to systematically review the current literature and assess the current state of ERAS in autologous breast reconstruction. A systematic review of MEDLINE, EMBASE, ScienceDirect, Cochrane Libraries and Web of Science databases in October 2015 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Articles pertaining to the use of ERAS in plastic and reconstructive surgery were included for analysis. Review articles, conference proceedings and correspondence were excluded from the assessment. Five hundred fifty-seven articles were identified, of which three suitable articles were included for assessment. Of these, one series outlined the learning curve associated with ERAS pathways and two series were comparative in nature. Meta-analytical analysis was not possible do to insufficient data and heterogeneity in outcome measures. In two of these comparative series, there was no statistical difference in rates of systemic infective (OR 0.91, 95\ua0% CI 0.29 to 2.80, p = 0.86), total flap loss (OR 1.09, 95\ua0% CI 0.37 to 3.19, p = 0.87), partial flap loss (OR 1.64, 95\ua0% CI 0.66 to 4.10, p = 0.29) or wound infection (OR 1.38, 95\ua0% CI 0.78 to 2.34, p = 0.29). LOS was significantly reduced in the ERAS group in both comparative studies from 7.4 to 6.2\ua0days (p < 0.001) and 6.6 to 3.9\ua0days (p < 0.001), respectively. ERAS pathways in breast reconstruction appear to consistently reduce LOS. From the available literature there were no significant detrimental effects on patient care following the implementation of ERAS pathways. Further research is required to definitively determine safety in the assessed cohort and to determine reductions in healthcare-related expenditures. Level of evidence: Not ratabl