ERAS protocols for breast cancer patients: safe and feasible outpatient mastectomy

The Enhanced Recovery After Surgery (ERAS) approach was initially pioneered for colorectal surgery by a group of surgeons in northern Europe, and the principles have since spread across the world and applied to various surgical specialties.¹

Recently, a study conducted at the Mayo Clinic Arizona evaluated the outcomes associated with the implementation of ERAS into their breast cancer surgery practice. The investigation, published in the Annals of Surgical Oncology, assessed the feasibility of outpatient mastectomies before and after ERAS.²

The retrospective review was performed for all women who underwent mastectomy with or without reconstruction between January 2013 and June 2018; patients who received autologous flap reconstruction were excluded. The cutoff point between the pre-ERAS and post-ERAS groups was February 1, 2017, when the ERAS pathway for mastectomy surgery was implemented at the Mayo Clinic Arizona.²

The study enrolled 487 patients. Of those, 374 (71.3%) underwent mastectomy with or without reconstruction pre-ERAS and 140 (28.7%) post-ERAS. Patient characteristics, oncologic profiles and perioperative medical treatments were not significantly different between the pre- and post-ERAS groups, except in rates of neoadjuvant treatment (p = 0.02).²

Operative interventions differed between the two groups, with higher rates of submuscular implant and tissue expander placement in the pre-ERAS group. Direct-to-implant reconstruction was performed in 45.7% of post-ERAS patients versus 34.3% in the pre-ERAS group. Additionally, long-acting liposomal bupivacaine was used more in the post-ERAS group, 62.1% versus 6.1% (p < 0.001).²

Furthermore, in the post-ERAS group, 58.6% of patients were discharged the same day of surgery compared with 7.2% in the pre-ERAS group (p < 0.001). The rate of reported complications was lower in the post-ERAS when compared to the pre-ERAS group (52.4% versus 32.9%) (p < 0.001). This study suggests that mastectomies can be performed safely as outpatient operations with no increased rates of postoperative morbidity.²

The data reported in this study highlight the benefits of applying ERAS principles to breast cancer patients undergoing mastectomy with or without reconstruction. Besides improved recovery for post-mastectomy patients, the application of ERAS protocols could lead to a decreased postoperative length of stay and increased cost-effectiveness.²

Written by Marta Palhas

Edited by Thomas Southgate

References:

1. Brindle M, Nelson G, Lobo D et al. Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines. BJS Open. 2019 Dec ;4(1):157-163.
2. Jogerst K, Thomas O, Kosiorek H et al. Same-Day Discharge After Mastectomy: Breast Cancer Surgery in the Era of ERAS®. Ann Surg Oncol. 2020 Mar. doi:10.1245/s10434-020-08386-w.