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Breast: Original Articles

Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations

Temple-Oberle, Claire M.D., M.Sc.; Shea-Budgell, Melissa A. M.Sc.; Tan, Mark M.D.; Semple, John L. M.D., M.Sc.; Schrag, Christiaan M.D.; Barreto, Marcio M.D.; Blondeel, Phillip M.D., Ph.D.; Hamming, Jeremy M.D.; Dayan, Joseph M.D.; Ljungqvist, Olle M.D., Ph.D.; for the ERAS Society

Author Information
Plastic and Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1056e-1071e
doi: 10.1097/PRS.0000000000003242
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  • Discussion

Abstract

Recovery can be improved in breast surgery.1 Enhanced recovery after surgery represents evidenced-based care elements that have revolutionized perioperative care in colorectal surgery,2 thereby reducing morbidity and length of stay, and improving survival.3–5 This guideline (Table 1) was developed by an international expert panel of physicians under the guidance of the Enhanced Recovery after Surgery (ERAS) Society (www.erassociety.org) to formalize enhanced recovery after surgery protocols for breast reconstruction.1,6

Table 1.
Table 1.:
ERAS Society Enhanced Recovery after Surgery Recommendations for Perioperative Care in Breast Reconstruction

METHODS

An international team of breast reconstruction experts teleconferenced monthly from January through June of 2015. Guideline items were developed and the MEDLINE and Cochrane databases were searched from 1965 through January of 2015. Key words included “breast cancer,” “mastectomy,” “breast neoplasm,” and “breast carcinoma”; combined with “reconstruction,” “reconstructive surgery,” “implant,” “flap,” “expander,” “acellular dermal matrix,” “mesh,” and “graft.” The resulting citations were combined with additional topic-specific key words. Reference lists of all eligible articles were hand-searched for additional studies.

All titles and abstracts were screened to identify potentially relevant articles. Any discrepancies in the interpretation of articles were resolved during working group meetings. Where available, randomized controlled trials and systematic reviews in patients undergoing breast reconstruction were used. Lower level data were considered where no high-level data were available. Only the most recent, highest level evidence is cited. Study quality was assessed using the criteria developed by the Centre for Evidence Based Medicine (Oxford, England).7

Recommendations were developed using an evidence-based consensus approach. Using the results of the systematic review, the panel provided expert interpretation of the evidence and discussed and modified each recommendation until no further modifications were required and consensus was reached. Recommendations were graded as “weak” or “strong” according to the Grading of Recommendations, Assessment, Development and Evaluation system.8

EVIDENCE BASE AND RECOMMENDATIONS

ERAS Items

Preadmission Information, Education, and Counseling

Providing surgical and anesthetic information preoperatively improves recovery by reducing fear and anxiety.9 Information about the procedure assists patients in reaching postoperative milestones and has been shown to reduce complications by improving perioperative feeding, pain control, and respiratory physiotherapy.10

Women value presurgical education about breast reconstruction,11 yet many feel that they do not receive adequate information,12 leading to dissatisfaction with their reconstruction decisions.13,14 Patient involvement in co–decision-making about breast reconstruction leads to higher satisfaction, independent of the reconstruction type.15 Sufficient information improves knowledge and lessens decision regret.16,17 Preconsultation educational group interventions are one method of reducing decisional conflict.17

  1. Summary and recommendation: Patients should receive detailed preoperative counseling.
  2. Evidence level: Moderate.
  3. Recommendation grade: Strong (low harm).

Preadmission Optimization

Smoking predisposes women to postmastectomy reconstruction complications,18–20 including mastectomy skin flap necrosis, abdominal flap necrosis, and hernias.21 Former smokers (i.e., those who quit 3 to 4 weeks preoperatively) and nonsmokers have similar complication rates.22,23

Obesity (i.e., body mass index >30 kg/m2) increases flap loss and donor-site morbidity.24–27 National Surgical Quality Improvement Program data of 2899 women with free flap reconstructions have revealed a strong correlation between obesity and surgical-site infections, venous thromboembolism, and other complications.28,29 Patients should therefore be encouraged to lose weight before surgery. Muscle-preserving abdominal flaps [i.e., deep inferior epigastric perforator (DIEP) flap] reduce abdominal wall complications compared with non–muscle-sparing flaps [i.e., free or pedicle transverse rectus abdominis musculocutaneous (TRAM) flap] in obese patients.27,30

Regarding diabetes, National Surgical Quality Improvement Program data on 29,736 women with breast reconstruction have linked type 2 diabetes mellitus to surgical complications (OR, 1.51) and type 1 diabetes mellitus to medical (OR, 1.82) and overall complications (OR, 1.85).31 Poor glycemic control is associated with worse outcomes in primary closure of surgical wounds in high-risk patients.32

Heavy alcohol consumption (five or more drinks on each of 5 or more days in the past 30 days) is also associated with poor outcomes, particularly attributable to surgical-site infections. National Surgical Quality Improvement Program data on 9315 patients undergoing immediate reconstruction have revealed heavy alcohol consumption as an independent risk factor for surgical-site infections.33

  1. Summary and recommendation: For daily smokers, 1 month of abstinence before surgery is beneficial. For patients who are obese, weight reduction to achieve a body mass index less than or equal to 30 kg/m2 before surgery is beneficial. For alcohol abusers, 1 month of abstinence before surgery is beneficial. For appropriate groups, referral should be made to resources for these behavior changes.
  2. Evidence level: Moderate for smoking; high for obesity; low for alcohol.
  3. Recommendation grade: Strong for all (high benefit, low harm).

Perforator Flap Planning

Meta-analysis has shown the benefit of computed tomographic angiography over Doppler ultrasonography in mapping the dominant DIEP perforators; benefits include reduced flap complications, donor-site morbidity, and operative times.34 Risks include potential contrast allergy, nephrotoxicity, and exposure to radiation.35 Modern computed tomographic angiography scanning protocols have reduced radiation exposure.36 Magnetic resonance angiography avoids radiation, but image quality remains a challenge that is improving with a variety of technical refinements.37–39

  1. Summary and recommendation: If preoperative perforator mapping is required, computed tomographic angiography is recommended.
  2. Evidence level: Moderate.
  3. Recommendation grade: Strong.

Preoperative Fasting

A Cochrane review of 22 randomized controlled trials has shown that drinking clear fluids 2 hours preoperatively is safe and does not increase the risk of regurgitation or aspiration.40 Existing ERAS guidelines recommend a 6-hour fast for solid foods and a 2-hour fast for clear liquids before general anesthesia.41 Recommendations have not been applied to patients at increased risk of delayed gastric emptying.

  1. Summary and recommendation: Preoperative fasting should be minimized and patients should be allowed to drink clear fluids up to 2 hours before surgery.
  2. Evidence level: Moderate (based on extrapolated data).
  3. Recommendation grade: Strong.

Preoperative Carbohydrate Loading

Taken 2 hours before surgery, maltodextrin-based drinks (400 ml) specifically designed and tested for preoperative use have positive metabolic effects, such as increasing insulin sensitivity and reducing preoperative thirst and anxiety.42–44 Carbohydrate loading reduces the catabolic effects of surgery, including losses of nitrogen and protein, lean body mass, and muscle strength,45–48 which has translated into shorter hospital stays.49 In patients with well-controlled type 2 diabetes, a carbohydrate drink given up to 3 hours before surgery alongside their normal medication does not appear to delay gastric emptying and will allow glucose concentrations the additional time required (i.e., 180 minutes versus 120 minutes in healthy subjects) to return to baseline.50

  1. Summary and recommendation: Preoperative maltodextrin-based drinks should be given to patients 2 hours before surgery.
  2. Evidence level: Low (based on extrapolated data).
  3. Recommendation grade: Strong (low risk of harm) in the general patient population.

Prophylaxis against Venous Thromboembolism

National Surgical Quality Improvement Program data on 68,285 patients have shown that venous thromboembolism in reconstruction patients approaches twice that of lumpectomy or mastectomy alone (0.41 percent versus 0.13 percent and 0.29 percent; p < 0.0001).28 Retrospective reviews have reported rates as high as 3.4 percent.51,52 Nationwide Inpatient Sample data on 35,883 patients undergoing autologous reconstruction have revealed a lower rate of venous thromboembolism (0.13 percent); however, the rate of venous thromboembolism was highest for TRAM flap reconstruction at 0.26 percent.52 Immediate breast reconstruction is an independent risk factor for venous thromboembolism.53

Patients undergoing mastectomy and immediate reconstruction meet the criteria for “higher” risk of venous thromboembolism and may be considered “highest” risk if they are obese or elderly, according to the American Society of Plastic Surgeons Executive Committee–approved Caprini Risk Assessment Module.54,55 For this patient population, pharmacologic anticoagulation with or without mechanical methods (i.e., intermittent pneumatic compression) is recommended.55,56 Prophylaxis should begin before surgery and continue for at least 7 to 10 days.57 Extended prophylaxis up to 4 weeks reduces the risk of radiologically confirmed venous thromboembolism following major abdominopelvic surgery.58 A prospective cohort and two large retrospective cohorts on low-molecular-weight heparin did not report increased bleeding risk58–60; however, in breast surgery specifically, some studies have shown that low-molecular-weight heparin has a higher bleeding risk than unfractionated heparin.61,62

  1. Summary and recommendation: Patients should be assessed for venous thromboembolism risk. Unless contraindicated, and balanced by the risk of bleeding, patients at a higher risk should receive low-molecular-weight heparin or unfractionated heparin until they are ambulatory or discharged. Mechanical methods should be added.
  2. Evidence level: Moderate.
  3. Recommendation grade: Strong.

Antimicrobial Prophylaxis

Infection rates following mastectomy are higher than those expected for clean surgery (i.e., 3 to 15 percent versus 2 percent).63,64 The risk of infection is further increased with the addition of a prosthesis or a flap.65–67 National Surgical Quality Improvement Program data on 2899 patients with flaps and 12,163 patients with tissue expanders have revealed that patient factors such as hypertension, body mass index, and smoking increase infection risk after breast reconstruction.29,68

Prophylactic antibiotics reduce surgical-site infections.69 Antibiotics against common skin organisms (i.e., cephalosporins) should be administered 1 hour before incision.70,71 The majority of data support the perioperative use of prophylactic antibiotics.64,65,70–72 Despite the common practice to use postoperative antibiotics until drains are removed, data from a well-conducted systematic review have shown that more than 24 hours of antibiotics appears to be associated with higher rates of surgical-site infections in acellular dermal matrix reconstructions.65 It should be noted that this was a meta-analysis of observational studies and not randomized controlled trials. Aside from this meta-analysis, there are no other published data to inform duration of antibiotic use, and further research is needed. Prolonged use of antibiotics beyond 24 hours has not been proved beneficial.73–75

Chlorhexidine-based antiseptics immediately before surgery decrease surgical-site infections.76,77 In implant reconstruction, bacterial burden can be reduced through antibiotic irrigation of the breast pocket, which may decrease capsular contracture but has not been proven to decrease surgical-site infections.78 Methicillin-resistant Staphylococcus aureus infections are increasing; however, a Cochrane review did not support a switch to glycopeptide antibiotics (i.e., vancomycin).69

  1. Summary and recommendation: Chlorhexidine skin preparation and intravenous antibiotics covering common skin organisms should be given within 1 hour of incision.
  2. Evidence level: Moderate (based on extrapolated data).
  3. Recommendation grade: Strong.

Preoperative and Intraoperative Prophylaxis against Postoperative Nausea and Vomiting

A meta-analysis demonstrated the superiority of 5-hydroxytryptamine-3 receptor antagonists over placebo in reducing postoperative nausea and vomiting in breast surgery.79 Steroids reduce postoperative nausea and vomiting and pain, and a combination of 5-hydroxytryptamine-3 antagonists and steroids is superior to either alone.80–82 Neurokinin-1 receptor antagonists provide even further reduction in postoperative nausea and vomiting compared with 5-hydroxytryptamine-3, but must be given preoperatively.83–88

  1. Summary and recommendation: Women should receive preoperative and intraoperative multimodal medications to mitigate postoperative nausea and vomiting.
  2. Evidence level: Moderate.
  3. Recommendation grade: Strong (high benefit, low harm).

Preoperative and Intraoperative Analgesia

Gabapentin89–91 reduces postoperative analgesic requirements and pain in women undergoing mastectomy. Nonsteroidal antiinflammatory drugs offer effective analgesia given preoperatively or intraoperatively, and decrease chronic breast pain without increasing bleeding complications.92,93 Perioperative cyclooxygenase-2 inhibitors have a similar beneficial effect.94 Bupivacaine infiltration in the area of planned surgical incision for mastectomy decreases pain intensity and opiate demand after surgery.95

Adenosine,96 systemic magnesium,97 venlafaxine,98 and clonidine99 are effective analgesics given preoperatively. Preoperative ketamine does not moderate postoperative pain.100 The majority of data were extrapolated from breast surgery, but for longer duration operations such as free tissue transfer reconstructions, the preoperative advantage may be diminished; thus, these medications may be best given intraoperatively.

  1. Summary and recommendation: Women should receive multimodal analgesia to mitigate pain.
  2. Evidence level: Moderate (based on extrapolated data).
  3. Recommendation grade: Strong (high benefit, low harm).

Standard Anesthetic Protocol

Retrospective data have suggested that the use of regional anesthesia, compared with general anesthesia, lowers the recurrence of subsequent breast cancer,101 potentially through natural killer T cells.102 Similar early findings in prostate and colorectal cancer have led to a large prospective, multicenter, randomized, controlled trial that is currently investigating this hypothesis for breast cancer patients.103–105 The findings from this study, when completed, may have a major impact on the choice of anesthetic technique.

There are three common modalities for maintenance of anesthesia during breast surgery, including general anesthesia with total intravenous anesthesia, general anesthesia with a volatile anesthetic, and regional anesthesia. Regional anesthesia decreases postoperative narcotic use106–108 but does not decrease pain, nausea, sedation, time to ambulation, or hospital stay duration.107 General anesthesia is the most frequently used modality of anesthesia for breast surgery; general anesthesia under total intravenous anesthesia decreases postoperative nausea and vomiting compared with a volatile anesthetic.109,110

  1. Summary and recommendation: General anesthesia with total intravenous anesthesia is recommended.
  2. Evidence level: Moderate.
  3. Recommendation grade: Strong.

Preventing Intraoperative Hypothermia

Maintaining a core body temperature over 36°C reduces multiple complications.111 The Surgical Care Improvement Project linked hypothermia with impaired wound healing, prolonged hospitalization, and three-fold higher wound infection rates.112 A systematic review in multiple surgery types showed that warming decreases wound infection.1 Attention to active thermal therapy is required when using intermittent pneumatic compression devices, which move cooled extremity blood to the core.113 Preoperative patient-warming strategies augment intraoperative warming strategies.114,115 Simply prewarming the operating room itself is not enough.116

Forced-air warming has an excellent safety profile and efficacy in a systematic review of multiple randomized controlled trials.117 Forced air is superior to resistive underbody warming.118,119 Circulating water garments,120 thermal mattresses,121–123 and circulating-water leg wraps124 offer some increase in temperature; however, the safety, low cost, and ease of use of forced-air warming supplant other systems.

Warmed intravenous fluid reduces hypothermia in short surgical procedures,125 but in orthopedic surgery, warming irrigation fluid is insufficient to prevent hypothermia.126 In liver transplantation, humidification of inspired gas warms the patient effectively.127 Amino acid and magnesium infusions reduce shivering.128,129

  1. Summary and recommendation: Preoperative and intraoperative measures, such as forced air, to prevent hypothermia should be instituted. Temperature monitoring is required to ensure the patient’s body temperature is maintained above 36°C.
  2. Evidence level: Moderate (based on extrapolated data).
  3. Recommendation grade: Strong.

Perioperative Intravenous Fluid Management

A randomized controlled trial demonstrated that a restricted IV fluid regimen decreases complications in abdominal surgery by 59 percent.130 Optimizing fluid balance begins by taking clear fluids orally up to 2 hours preoperatively. Goal-directed therapy (i.e., intensive monitoring and aggressive management of perioperative hemodynamics) improves length of stay and complication rates131–134; however, a recent meta-analysis showed that the benefit of goal-directed therapy was muted in patients managed in an enhanced recovery after surgery setting.135 Measurement of venous oxygen saturation has utility in major surgery, but its use in breast surgery has not been established.136 Balanced crystalloid solutions are superior to 0.9% saline for electrolyte balance.137,138

Overresuscitation contributes to cardiopulmonary events, wound infection, poor wound healing, and increased length of hospital stay.139–141 It is especially harmful in microvascular reconstruction.142–145 Underresuscitation increases postoperative microvascular thrombosis.137 Vasopressors to maintain blood pressure have been historically avoided in flap patients, but have been found to be safe in normovolemic patients.146–149 Dextran-40, traditionally used to reduce the risk of microvascular thrombosis, lacks efficacy and has a high complication rate.150

  1. Summary and recommendation: Overresuscitation or underresuscitation of fluids should be avoided, and water and electrolyte balance should be maintained. Goal-directed therapy is a useful method to achieve these goals. Balanced crystalloid solutions rather than saline is recommended. Vasopressors are recommended to support fluid management and do not negatively affect free flaps.
  2. Evidence level: Moderate for all (based on extrapolated data).
  3. Recommendation grade: Strong.

Postoperative Analgesia

Postoperative pain control needs to be adequate to facilitate early mobilization. Reducing the contribution of opioids to the analgesic regimen reduces postoperative nausea and vomiting and constipation, effectively facilitating early mobilization. A meta-analysis of intravenous acetaminophen (paracetamol) has shown that it reduces pain in only 37 percent of patients.151 Although acetaminophen alone is less effective than nonsteroidal antiinflammatory drugs,152 Cochrane data from three randomized controlled trials have demonstrated that the combination is more effective than either alone.153

Nonsteroidal antiinflammatory drugs reduce the need for narcotics with minimal surgical-site bleeding risk in multiple randomized controlled trials.154–156 Cyclooxygenase-2 inhibitors reduce the potential for gastrointestinal tract bleeding and surgical-site bleeding157–159 but can increase the risk of stroke or myocardial infarction in patients with ischemic heart disease.160 Preoperative or postoperative gabapentin reduces narcotic requirements.161–163

Regional or local blocks minimize pain and sedation. Continuous bupivacaine infusion catheters reduce opioid requirements in several studies.164–166 Randomized controlled trial evidence shows that transversus abdominis plane blocks decrease abdominal donor-site pain in flap patients.106,167 A single injection of liposomal bupivacaine lasts for several days, potentially avoiding the need for catheter-based infusions.168 Randomized controlled trial data on pulse electromagnetic field therapy in TRAM flap patients have shown decreases in pain and narcotic use.169

  1. Summary and recommendation: Multimodal postoperative pain management regimens are opioid-sparing and should be used.
  2. Evidence level: High.
  3. Recommendation grade: Strong.

Early Feeding

An early oral or enteral diet within 24 hours of surgery is safe and associated with improved wound healing, reduced infection, and reduced hospital stay.170 The benefits of early refeeding171 need to be weighed against the rare risk of a potential urgent return to the operating room, whereby a fed patient is at risk for aspiration. The urgent return arises in 2 to 5 percent of patients who develop a microvascular thrombosis in their free flap breast reconstruction.172–174 Modern anesthetic techniques should mitigate the risk of aspiration in this uncommon scenario.175

  1. Summary and recommendation: Patients should be encouraged to take fluids and food orally as soon as possible, preferably within 24 hours after surgery.
  2. Evidence level: Moderate (based on extrapolated data).
  3. Recommendation grade: Strong.

Postoperative Flap Monitoring

Microvascular thrombosis occurs in the anastomosis of the free flap in 2 to 5 percent of cases and usually occurs within the first 72 hours.172–174 Most commonly (60 to 74 percent), a microvascular thrombosis will occur venously.173,176 Salvage of a compromised free flap is improved with earlier exploration and return of flow176,177; therefore, routine frequent monitoring, including clinical observation (i.e., color, temperature, and capillary refill) and use of devices, is highly warranted.

Hand-held Doppler is an extension of clinical observation, as it is noninvasive and inexpensive and has widespread use.178 Frequent monitoring is required in the first 72 hours and a reasonable monitoring protocol may include hourly monitoring for the first 24 hours, every 2 hours for the next 24 hours, then every 3 to 4 hours for the next 24 hours.

Implantable Doppler monitors have excellent sensitivity in detecting flap compromise, but can detach and thus carry a higher false-positive rate than clinical observation.179 Studies comparing clinical observation with or without implantable Doppler monitors, are equivocal in terms of improved flap salvage.181,182 For buried flaps, implantable Doppler monitoring offers the only objective measure.178 Other methods of monitoring flaps include a venous coupler with an embedded implantable Doppler device, laser Doppler monitoring, infrared spectroscopy, tissue oximetry, and microdialysis.183–185

  1. Summary and recommendation: Flap monitoring within the first 72 hours should occur frequently. Clinical evaluation is sufficient for monitoring, with implantable Doppler monitoring recommended in cases of buried flaps.
  2. Evidence level: Moderate.
  3. Recommendation grade: Strong (low harm).

Postoperative Wound Management

Breast and abdominal incisions following breast reconstruction are generally closed with layered intradermal absorbable sutures.186 Antimicrobial-coated versus plain sutures do not show a significant reduction in surgical-site infections in randomized controlled trials.187,188 Other randomized controlled trials evaluating the skin adhesive octyl-2-cyanoacrylate in breast surgery show patient preference for the adhesive but no objective difference in cosmesis or complications.189–192 A surgical skin closure film has been found to be faster than sutures, but with no difference in complication rates.193 An ongoing randomized controlled trial is evaluating the effect of dressing wear time (1 day versus 6 days) on surgical-site infections.194

Complex wounds associated with mastectomy flap, DIEP flap, or abdominal skin necrosis are recognized complications of breast reconstruction.195,196 Negative-pressure wound therapy is an effective aid in wound management after surgical débridement, with a systematic review of breast wounds showing that 97 percent receiving negative-pressure wound therapy in conjunction with débridement healed completely.197

  1. Summary and recommendation: For incisional closure, conventional sutures are recommended. Complex wounds following skin necrosis are treatable with débridement and negative-pressure wound therapy.
  2. Evidence level: High for sutures; moderate for negative-pressure wound therapy.
  3. Recommendation grade: Strong.

Early Mobilization

Early in-hospital mobilization improves muscle strength198 and reduces pulmonary embolism, pneumonia, and decubitus ulcers. Early mobilization decreases length of hospitalization and improves psychological well-being.199–205 Conversely, prolonged bed rest has been shown to reduce work capacity.206 Prolonged inactivity combined with a catabolic state (i.e., postoperative stress) exacerbates strength and lean muscle loss.207

  1. Summary and recommendation: Patients should be mobilized within the first 24 hours after surgery.
  2. Evidence level: Moderate (based on extrapolated data).
  3. Recommendation grade: Strong (low risk).

Postdischarge Home Support and Physiotherapy

Early physical rehabilitation improves physical and emotional recovery after mastectomy and axillary dissection.208,209 Postoperative physical rehabilitation programs in breast cancer patients improve mobility, reduce pain, and improve quality of life.210 Randomized controlled trial data on the effect of early supervised exercise have demonstrated that exercise leads to quicker recovery, earlier mobility, and enhanced patient comfort, but fails to improve lymphedema.208,211

Qualitative studies show that visiting nurses play an important role in providing physical care and delivering education and psychosocial support following TRAM flap reconstruction.212,213 Postdischarge telephone and mobile application support are “virtual” adjuncts to in-home nursing visits and outpatient visits.210,214

  1. Summary and recommendation: Early physiotherapy, supervised exercise programs, and other supportive care initiatives should be instituted after discharge.
  2. Evidence level: Moderate (based on extrapolated data).
  3. Recommendation grade: Strong (low harm).

CONCLUSIONS

The literature surrounding breast reconstruction has evolved from establishing oncologic safety and optimal timing, refining surgical techniques, and improving cosmesis, to the point where we now use patient-reported outcome measures215,216 to evaluate what matters to patients. Patient-reported outcome measures show that despite our optimization of procedures, recovery is suboptimal across reconstruction types.15

An enhanced recovery experience has been realized in major abdominal surgery through the introduction of ERAS guidelines.217,218 Most of the recommendations in the colorectal guideline are directly relevant and can be extrapolated to breast reconstruction. Practitioners now avoid long fasting periods, attend to patient temperature, and use multimodal pain and postoperative nausea and vomiting prevention strategies.219,220

These 18 recommendations represent a synthesis of the current body of literature by an international group of experts and can be applied to most patients, with the goal of providing a rapid recovery with low complication rates and decreased care time. As with any practice guideline, clinicians should use independent judgment of an individual patient’s clinical circumstances to direct care. This consensus guideline is not intended to be leveraged as a rationale for funding bodies to restrict payment for care based on hospital length of stay. Rather, patient safety must be considered first and these practices should be implemented in a measured, thoughtful, and studied manner.

To effectively change practice, guidelines must be supported by strong data. Many of these recommendations can be strengthened with data from patients undergoing breast reconstruction in the setting of an ERAS protocol. For women undergoing implant-based breast reconstruction, the recently demonstrated benefits of an ERAS protocol include reduced length of stay and better quality of recovery, with no differences in complication rates or emergency room visits.221 Minimizing care time and complications is the goal for this group of women and can be measured through audit of infection rates, deep venous thrombosis, and other outcomes; however, the recovery experience is also important and should be assessed through validated outcome measures, such as the Quality of Recovery-15 scale.222

These recommendations will require revision as new evidence emerges. Each recommendation alone is unlikely to change the recovery process, but bundled together and applied with good sense and care, these recommendations may transform the recovery experience for patients and for the health care system.218

REFERENCES

1. Arsalani-Zadeh R, ElFadl D, Yassin N, MacFie J. Evidence-based review of enhancing postoperative recovery after breast surgery. Br J Surg. 2011;98:181196.
2. Lassen K, Soop M, Nygren J, et al.; Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009;144:961969.
3. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: A meta-analysis of randomized controlled trials. World J Surg. 2014;38:15311541.
4. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J; Enhanced Recovery After Surgery Study Group. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011;146:571577.
5. Gustafsson UO, Oppelstrup H, Thorell A, Nygren J, Ljungqvist A. Adherence to the ERAS-protocol is associated with 5-year survival after colorectal cancer surgery: A retrospective cohort study. World J Surg. 2016;40:17411747.
6. Batdorf NJ, Lemaine V, Lovely JK, et al. Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68:395402.
7. Centre for Evidence-Based Medicine. Oxford Centre for Evidence-based Medicine: Levels of Evidence (March 2009). Available at: http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/. Accessed January 2, 2015.
8. Guyatt GH, Oxman AD, Kunz R, et al.; GRADE Working Group. Going from evidence to recommendations. BMJ 2008;336:10491051.
9. Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R. Psychological influences on surgical recovery: Perspectives from psychoneuroimmunology. Am Psychol. 1998;53:12091218.
10. Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med. 2004;32(Suppl):S76S86.
11. Wolf L. The information needs of women who have undergone breast reconstruction: Part II. Information giving and content of information. Eur J Oncol Nurs. 2004;8:315324.
12. Lam A, Secord S, Butler K, et al. A breast reconstruction needs assessment: How does self-efficacy affect information access and preferences? Can J Plast Surg. 2012;20:3742.
13. Zhong T, Hu J, Bagher S, et al. Decision regret following breast reconstruction: The role of self-efficacy and satisfaction with information in the preoperative period. Plast Reconstr Surg. 2013;132:724e734e.
14. Ho AL, Klassen AF, Cano S, Scott AM, Pusic AL. Optimizing patient-centered care in breast reconstruction: The importance of preoperative information and patient-physician communication. Plast Reconstr Surg. 2013;132:212e220e.
15. Temple-Oberle C, Ayeni O, Webb C, Bettger-Hahn M, Ayeni O, Mychailyshyn N. Shared decision-making: Applying a person-centered approach to tailored breast reconstruction information provides high satisfaction across a variety of breast reconstruction options. J Surg Oncol. 2014;110:796800.
16. Heller L, Parker PA, Youssef A, Miller MJ. Interactive digital education aid in breast reconstruction. Plast Reconstr Surg. 2008;122:717724.
17. Causarano N, Platt J, Baxter NN, et al. Pre-consultation educational group intervention to improve shared decision-making for postmastectomy breast reconstruction: A pilot randomized controlled trial. Support Care Cancer 2015;23:13651375.
18. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000;105:23742380.
19. Padubidri AN, Yetman R, Browne E, et al. Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers. Plast Reconstr Surg. 2001;107:342349; discussion 350.
20. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: A randomized controlled trial. Ann Surg. 2003;238:15.
21. Fischer JP, Wes AM, Tuggle CT, Serletti JM, Wu LC. Risk analysis and stratification of surgical morbidity after immediate breast reconstruction. J Am Coll Surg. 2013;217:780787.
22. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: A randomised clinical trial. Lancet 2002;359:114117.
23. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2010;7:CD002294.
24. Fischer JP, Nelson JA, Kovach SJ, Serletti JM, Wu LC, Kanchwala S. Impact of obesity on outcomes in breast reconstruction: Analysis of 15,937 patients from the ACS-NSQIP datasets. J Am Coll Surg. 2013;217:656664.
25. Schaverien MV, Mcculley SJ. Effect of obesity on outcomes of free autologous breast reconstruction: A meta-analysis. Microsurgery 2014;34:484497.
26. Fischer JP, Nelson JA, Sieber B, et al. Free tissue transfer in the obese patient: An outcome and cost analysis in 1258 consecutive abdominally based reconstructions. Plast Reconstr Surg. 2013;131:681e692e.
27. Lee KT, Mun GH. Effects of obesity on postoperative complications after breast reconstruction using free muscle-sparing transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, and superficial inferior epigastric artery flap: A systematic review and meta-analysis. Ann Plast Surg. 2016;76:576584.
28. Nwaogu I, Yan Y, Margenthaler JA, Myckatyn TM. Venous thromboembolism after breast reconstruction in patients undergoing breast surgery: An American College of Surgeons NSQIP analysis. J Am Coll Surg. 2015;220:886893.
29. Chung CU, Wink JD, Nelson JA, Fischer JP, Serletti JM, Kanchwala SK. Surgical site infections after free flap breast reconstruction: An analysis of 2,899 patients from the ACS-NSQIP datasets. J Reconstr Microsurg. 2015;31:434441.
30. Mennie JC, Mohanna PN, O’Donoghue JM, Rainsbury R, Cromwell DA. Donor-site hernia repair in abdominal flap breast reconstruction: A population-based cohort study of 7,929 patients. Plast Reconstr Surg. 2015;136:19.
31. Qin C, Vaca E, Lovecchio F, Ver Halen JP, Hansen NM, Kim JY. Differential impact of non-insulin-dependent diabetes mellitus and insulin-dependent diabetes mellitus on breast reconstruction outcomes. Breast Cancer Res Treat. 2014;146:429438.
32. Endara M, Masden D, Goldstein J, Gondek S, Steinberg J, Attinger C. The role of chronic and perioperative glucose management in high-risk surgical closures: A case for tighter glycemic control. Plast Reconstr Surg. 2013;132:9961004.
33. Nguyen TJ, Costa MA, Vidar EN, et al. Effect of immediate reconstruction on postmastectomy surgical site infection. Ann Surg. 2012;256:326333.
34. Ohkuma R, Mohan R, Baltodano PA, et al. Abdominally based free flap planning in breast reconstruction with computed tomographic angiography: Systematic review and meta-analysis. Plast Reconstr Surg. 2014;133:483494.
35. Symonette CJ, Gan BS. Computed tomography-based preoperative vascular imaging in autologous breast reconstruction: A Canadian perspective. Can J Plast Surg. 2013;21:1114.
36. Phillips TJ, Stella DL, Rozen WM, Ashton M, Taylor GI. Abdominal wall CT angiography: A detailed account of a newly established preoperative imaging technique. Radiology 2008;249:3244.
37. Kagen AC, Hossain R, Dayan E, et al. Modern perforator flap imaging with high-resolution blood pool MR angiography. Radiographics 2015;35:901915.
38. Scott JR, Liu D, Said H, Neligan PC, Mathes DW. Computed tomographic angiography in planning abdomen-based microsurgical breast reconstruction: A comparison with color duplex ultrasound. Plast Reconstr Surg. 2010;125:446453.
39. Newman TM, Vasile J, Levine JL, et al. Perforator flap magnetic resonance angiography for reconstructive breast surgery: A review of 25 deep inferior epigastric and gluteal perforator artery flap patients. J Magn Reson Imaging 2010;31:11761184.
40. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;4:CD004423.
41. Feldheiser A, Aziz O, Baldini G, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: Consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. 2016;60:289334.
42. Bilku DK, Dennison AR, Hall TC, Metcalfe MS, Garcea G. Role of preoperative carbohydrate loading: A systematic review. Ann R Coll Surg Engl. 2014;96:1522.
43. Hausel J, Nygren J, Lagerkranser M, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg. 2001;93:13441350.
44. Nygren J, Soop M, Thorell A, Efendic S, Nair KS, Ljungqvist O. Preoperative oral carbohydrate administration reduces postoperative insulin resistance. Clin Nutr. 1998;17:6571.
45. Crowe PJ, Dennison A, Royle GT. The effect of pre-operative glucose loading on postoperative nitrogen metabolism. Br J Surg. 1984;71:635637.
46. Yuill KA, Richardson RA, Davidson HI, Garden OJ, Parks RW. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively: A randomised clinical trial. Clin Nutr. 2005;24:3237.
47. Henriksen MG, Hessov I, Dela F, Hansen HV, Haraldsted V, Rodt SA. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand. 2003;47:191199.
48. Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF. Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial. Colorectal Dis. 2006;8:563569.
49. Nygren J, Thorell A, Ljungqvist O. Preoperative oral carbohydrate nutrition: An update. Curr Opin Clin Nutr Metab Care 2001;4:255259.
50. Gustafsson UO, Nygren J, Thorell A, et al. Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol Scand. 2008;52:946951.
51. Lemaine V, McCarthy C, Kaplan K, et al. Venous thromboembolism following microsurgical breast reconstruction: An objective analysis in 225 consecutive patients using low-molecular-weight heparin prophylaxis. Plast Reconstr Surg. 2011;127:13991406.
52. Masoomi H, Paydar KZ, Wirth GA, Aly A, Kobayashi MR, Evans GR. Predictive risk factors of venous thromboembolism in autologous breast reconstruction surgery. Ann Plast Surg. 2014;72:3033.
53. Tran BH, Nguyen TJ, Hwang BH, et al. Risk factors associated with venous thromboembolism in 49,028 mastectomy patients. Breast 2013;22:444448.
54. Murphy RX Jr, Alderman A, Gutowski K, et al. Evidence-based practices for thromboembolism prevention: Summary of the ASPS Venous Thromboembolism Task Force Report. Plast Reconstr Surg. 2012;130:168e175e.
55. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51:7078.
56. Patiar S, Kirwan CC, McDowell G, Bundred NJ, McCollum CN, Byrne GJ. Prevention of venous thromboembolism in surgical patients with breast cancer. Br J Surg. 2007;94:412420.
57. Rasmussen MS, Jørgensen LN, Wille-Jørgensen P, et al. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev. 2009;1:CD004318.
58. Kim EK, Eom JS, Ahn SH, Son BH, Lee TJ. The efficacy of prophylactic low-molecular-weight heparin to prevent pulmonary thromboembolism in immediate breast reconstruction using the TRAM flap. Plast Reconstr Surg. 2009;123:912.
59. Pannucci CJ, Wachtman CF, Dreszer G, et al. The effect of postoperative enoxaparin on risk for reoperative hematoma. Plast Reconstr Surg. 2012;129:160168.
60. Liao EC, Taghinia AH, Nguyen LP, Yueh JH, May JW Jr, Orgill DP. Incidence of hematoma complication with heparin venous thrombosis prophylaxis after TRAM flap breast reconstruction. Plast Reconstr Surg. 2008;121:11011107.
61. Lapid O, Pietersen L, van der Horst CM. Reoperation for haematoma after breast reduction with preoperative administration of low-molecular-weight heparin: Experience in 720 patients. J Plast Reconstr Aesthet Surg. 2012;65:15131517.
62. Hardy RG, Williams L, Dixon JM. Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin. Br J Surg. 2008;95:834836.
63. Cruse PJ, Foord R. The epidemiology of wound infection: A 10-year prospective study of 62,939 wounds. Surg Clin North Am. 1980;60:2740.
64. Sanguinetti A, Rosato L, Cirocchi R, et al. Antibiotic prophylaxis in breast surgery: Preliminary results of a multicenter randomized study on 1400 cases (in Italian). Ann Ital Chir. 2009;80:275279.
65. Phillips BT, Bishawi M, Dagum AB, Bui DT, Khan SU. A systematic review of infection rates and associated antibiotic duration in acellular dermal matrix breast reconstruction. Eplasty 2014;14:e42.
66. Sajid MS, Hutson K, Akhter N, Kalra L, Rapisarda IF, Bonomi R. An updated meta-analysis on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures. Breast J. 2012;18:312317.
67. Olsen MA, Nickel KB, Fox IK, et al. Incidence of surgical site infection following mastectomy with and without immediate reconstruction using private insurer claims data. Infect Control Hosp Epidemiol. 2015;36:907914.
68. Winocour S, Martinez-Jorge J, Habermann E, Thomsen K, Lemaine V. Early surgical site infection following tissue expander breast reconstruction with or without acellular dermal matrix: National benchmarking using National Surgical Quality Improvement Program. Arch Plast Surg. 2015;42:194200.
69. Jones DJ, Bunn F, Bell-Syer SV. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev. 2014;3:CD005360.
70. Huang N, Liu M, Yu P, et al. Antibiotic prophylaxis in prosthesis-based mammoplasty: A systematic review. Int J Surg. 2015;15:3137.
71. Hardwicke JT, Bechar J, Skillman JM. Are systemic antibiotics indicated in aesthetic breast surgery? A systematic review of the literature. Plast Reconstr Surg. 2013;131:13951403.
72. Cabaluna ND, Uy GB, Galicia RM, Cortez SC, Yray MD, Buckley BS. A randomized, double-blinded placebo-controlled clinical trial of the routine use of preoperative antibiotic prophylaxis in modified radical mastectomy. World J Surg. 2013;37:5966.
73. Collins JB, Verheyden CN, Mahabir RC. Core measures: Implications for plastic surgery. Plast Reconstr Surg. 2013;131:12661271.
74. Thomas R, Alvino P, Cortino GR, et al. Long-acting versus short-acting cephalosporins for preoperative prophylaxis in breast surgery: A randomized double-blind trial involving 1,766 patients. Chemotherapy 1999;45:217223.
75. Drury KE, Lanier ST, Khavanin N, et al. Impact of postoperative antibiotic prophylaxis duration on surgical site infections in autologous breast reconstruction. Ann Plast Surg. 2016;76:174179.
76. Craft RO, Damjanovic B, Colwell AS. Evidence-based protocol for infection control in immediate implant-based breast reconstruction. Ann Plast Surg. 2012;69:446450.
77. Dumville JC, McFarlane E, Edwards P, et al. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2015;4:CD003949.
78. Drinane JJ, Bergman RS, Folkers BL, Kortes MJ. Revisiting triple antibiotic irrigation of breast implant pockets: A placebo-controlled single practice cohort study. Plast Reconstr Surg Glob Open 2013;1:e55.
79. Singhal AK, Kannan S, Gota VS. 5HT3 antagonists for prophylaxis of postoperative nausea and vomiting in breast surgery: A meta-analysis. J Postgrad Med. 2012;58:2331.
80. Olanders KJ, Lundgren GA, Johansson AM. Betamethasone in prevention of postoperative nausea and vomiting following breast surgery. J Clin Anesth. 2014;26:461465.
81. Gómez-Hernández J, Orozco-Alatorre AL, Domínguez-Contreras M, et al. Preoperative dexamethasone reduces postoperative pain, nausea and vomiting following mastectomy for breast cancer. BMC Cancer 2010;10:692.
82. Gupta P, Jain S. Postoperative nausea and vomiting prophylaxis: A comparative study of ondansetron, granisetron and granisetron and dexamethasone combination after modified radical mastectomy. Saudi J Anaesth. 2014;8(Suppl 1):S67S71.
83. Diemunsch P, Gan TJ, Philip BK, et al.; Aprepitant-PONV Protocol 091 International Study Group. Single-dose aprepitant vs ondansetron for the prevention of postoperative nausea and vomiting: A randomized, double-blind phase III trial in patients undergoing open abdominal surgery. Br J Anaesth. 2007;99:202211.
84. Habib AS, Gan TJ. CON: Postoperative nausea and vomiting database research: Limitations and opportunities. Anesth Analg. 2010;110:412414.
85. Jung WS, Kim YB, Park HY, Choi WJ, Yang HS. Oral administration of aprepitant to prevent postoperative nausea in highly susceptible patients after gynecological laparoscopy. J Anesth. 2013;27:396401.
86. Sinha AC, Singh PM, Williams NW, Ochroch EA, Goudra BG. Aprepitant’s prophylactic efficacy in decreasing postoperative nausea and vomiting in morbidly obese patients undergoing bariatric surgery. Obes Surg. 2014;24:225231.
87. Vallejo MC, Phelps AL, Ibinson JW, et al. Aprepitant plus ondansetron compared with ondansetron alone in reducing postoperative nausea and vomiting in ambulatory patients undergoing plastic surgery. Plast Reconstr Surg. 2012;129:519526.
88. Habib AS, Keifer JC, Borel CO, White WD, Gan TJ. A comparison of the combination of aprepitant and dexamethasone versus the combination of ondansetron and dexamethasone for the prevention of postoperative nausea and vomiting in patients undergoing craniotomy. Anesth Analg. 2011;112:813818.
89. Grover VK, Mathew PJ, Yaddanapudi S, Sehgal S. A single dose of preoperative gabapentin for pain reduction and requirement of morphine after total mastectomy and axillary dissection: Randomized placebo-controlled double-blind trial. J Postgrad Med. 2009;55:257260.
90. Dirks J, Fredensborg BB, Christensen D, Fomsgaard JS, Flyger H, Dahl JB. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and morphine consumption after mastectomy. Anesthesiology 2002;97:560564.
91. Kim SY, Song JW, Park B, Park S, An YJ, Shim YH. Pregabalin reduces post-operative pain after mastectomy: A double-blind, randomized, placebo-controlled study. Acta Anaesthesiol Scand. 2011;55:290296.
92. Priya V, Divatia JV, Sareen R, Upadhye S. Efficacy of intravenous ketoprofen for pre-emptive analgesia. J Postgrad Med. 2002;48:109112.
93. Sun M, Liao Q, Wen L, Yan X, Zhang F, Ouyang W. Effect of perioperative intravenous flurbiprofen axetil on chronic postmastectomy pain. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2013;38:653660.
94. Riest G, Peters J, Weiss M, et al. Does perioperative administration of rofecoxib improve analgesia after spine, breast and orthopaedic surgery? Eur J Anaesthesiol. 2006;23:219226.
95. Zielinski J, Jaworski R, Smietanska I, Irga N, Wujtewicz M, Jaskiewicz J. A randomized, double-blind, placebo-controlled trial of preemptive analgesia with bupivacaine in patients undergoing mastectomy for carcinoma of the breast. Med Sci Monit. 2011;17:CR589CR597.
96. Segerdahl M, Ekblom A, Sandelin K, Wickman M, Sollevi A. Peroperative adenosine infusion reduces the requirements for isoflurane and postoperative analgesics. Anesth Analg. 1995;80:11451149.
97. De Oliveira GS, Bialek J, Fitzgerald P, Kim JY, McCarthy RJ. Systemic magnesium to improve quality of post-surgical recovery in outpatient segmental mastectomy: A randomized, double-blind, placebo-controlled trial. Magnes Res. 2013;26:156164.
98. Amr YM, Yousef AA. Evaluation of efficacy of the perioperative administration of Venlafaxine or gabapentin on acute and chronic postmastectomy pain. Clin J Pain 2010;26:381385.
99. Imai Y, Mammoto T, Murakami K, et al. The effects of preanesthetic oral clonidine on total requirement of propofol for general anesthesia. J Clin Anesth. 1998;10:660665.
100. Adam F, Libier M, Oszustowicz T, Lefebvre D, Beal J, Meynadier J. Preoperative small-dose ketamine has no preemptive analgesic effect in patients undergoing total mastectomy. Anesth Analg. 1999;89:444447.
101. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology 2006;105:660664.
102. Buckley A, McQuaid S, Johnson P, Buggy DJ. Effect of anaesthetic technique on the natural killer cell anti-tumour activity of serum from women undergoing breast cancer surgery: A pilot study. Br J Anaesth. 2014;113(Suppl 1):i56i62.
103. Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ. Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: A retrospective analysis. Anesthesiology 2008;109:180187.
104. Gupta A, Björnsson A, Fredriksson M, Hallböök O, Eintrei C. Reduction in mortality after epidural anaesthesia and analgesia in patients undergoing rectal but not colonic cancer surgery: A retrospective analysis of data from 655 patients in central Sweden. Br J Anaesth. 2011;107:164170.
105. The Cleveland Clinic. Regional Anesthesia and Breast Cancer Recurrence. ClinicalTrials.gov identification number NCT00418457. Available at: https://clinicaltrials.gov/ct2/show/NCT00418457. Accessed April 3, 2015.
106. Glissmeyer C, Johnson W, Sherman B, Glissmeyer M, Garreau J, Johnson N. Effect of paravertebral nerve blocks on narcotic use after mastectomy with reconstruction. Am J Surg. 2015;209:881883.
107. Zhong T, Ojha M, Bagher S, et al. Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: A double-blind, placebo-controlled, randomized trial. Plast Reconstr Surg. 2014;134:870878.
108. Karmakar MK, Samy W, Li JW, et al. Thoracic paravertebral block and its effects on chronic pain and health-related quality of life after modified radical mastectomy. Reg Anesth Pain Med. 2014;39:289298.
109. Hong JY, Kang YS, Kil HK. Anaesthesia for day case excisional breast biopsy: Propofol-remifentanil compared with sevoflurane-nitrous oxide. Eur J Anaesthesiol. 2008;25:460467.
110. Chen HP, Hsu YH, Hua KC, Lin CC, Lo YF, Yu HP. Comparison of sevoflurane versus propofol under auditory evoked potential monitoring in female patients undergoing breast surgery. Biomed J. 2013;36:125131.
111. National Institute for Health and Care Excellence. Clinical practice guideline: The management of inadvertent perioperative hypothermia in adults. National Collaborating Centre for Nursing and Supportive care commissioned by National Institute for Health and Care Excellence (NICE): April 2008. Available at: http://guidance.nice.org.uk/CG65. Accessed April 3, 2015.
112. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:12091215.
113. Huh J, Cho YB, Yang MK, Yoo YK, Kim DK. What influence does intermittent pneumatic compression of the lower limbs intraoperatively have on core hypothermia? Surg Endosc. 2013;27:20872093.
114. Roberson MC, Dieckmann LS, Rodriguez RE, Austin PN. A review of the evidence for active preoperative warming of adults undergoing general anesthesia. AANA J. 2013;81:351356.
115. Brandes IF, Müller C, Perl T, Russo SG, Bauer M, Bräuer A. Efficacy of a novel warming blanket: Prospective randomized trial (in German). Anaesthesist 2013;62:137142.
116. Deren ME, Machan JT, DiGiovanni CW, Ehrlich MG, Gillerman RG. Prewarming operating rooms for prevention of intraoperative hypothermia during total knee and hip arthroplasties. J Arthroplasty 2011;26:13801386.
117. Munday J, Hines S, Wallace K, Chang AM, Gibbons K, Yates P. A systematic review of the effectiveness of warming interventions for women undergoing cesarean section. Worldviews Evid Based Nurs. 2014;11:383393.
118. Röder G, Sessler DI, Roth G, Schopper C, Mascha EJ, Plattner O. Intra-operative rewarming with Hot Dog resistive heating and forced-air heating: A trial of lower-body warming. Anaesthesia 2011;66:667674.
119. Engelen S, Himpe D, Borms S, et al. An evaluation of underbody forced-air and resistive heating during hypothermic, on-pump cardiac surgery. Anaesthesia 2011;66:104110.
120. Poveda Vde B, Martinez EZ, Galvão CM. Active cutaneous warming systems to prevent intraoperative hypothermia: A systematic review. Rev Lat Am Enfermagem. 2012;20:183191.
121. Moysés AM, dos Santos Trettene A, Navarro LH, Ayres JA. Hypothermia prevention during surgery: Comparison between thermal mattress and thermal blanket (in Portuguese). Rev Esc Enferm USP 2014;48:228235.
122. Egan C, Bernstein E, Reddy D, et al. A randomized comparison of intraoperative PerfecTemp and forced-air warming during open abdominal surgery. Anesth Analg. 2011;113:10761081.
123. Pu Y, Cen G, Sun J, et al. Warming with an underbody warming system reduces intraoperative hypothermia in patients undergoing laparoscopic gastrointestinal surgery: A randomized controlled study. Int J Nurs Stud. 2014;51:181189.
124. Hasegawa K, Negishi C, Nakagawa F, Ozaki M. Core temperatures during major abdominal surgery in patients warmed with new circulating-water garment, forced-air warming, or carbon-fiber resistive-heating system. J Anesth. 2012;26:168173.
125. Andrzejowski JC, Turnbull D, Nandakumar A, Gowthaman S, Eapen G. A randomised single blinded study of the administration of pre-warmed fluid vs active fluid warming on the incidence of peri-operative hypothermia in short surgical procedures. Anaesthesia 2010;65:942945.
126. Oh JH, Kim JY, Chung SW, et al. Warmed irrigation fluid does not decrease perioperative hypothermia during arthroscopic shoulder surgery. Arthroscopy 2014;30:159164.
127. Han SB, Gwak MS, Choi SJ, et al. Effect of active airway warming on body core temperature during adult liver transplantation. Transplant Proc. 2013;45:251254.
128. Inoue S, Shinjo T, Kawaguchi M, Nakajima Y, Furuya H. Amino acid infusions started after development of intraoperative core hypothermia do not affect rewarming but reduce the incidence of postoperative shivering during major abdominal surgery: A randomized trial. J Anesth. 2011;25:850854.
129. Gozdemir M, Usta B, Demircioglu RI, Muslu B, Sert H, Karatas OF. Magnesium sulfate infusion prevents shivering during transurethral prostatectomy with spinal anesthesia: A randomized, double-blinded, controlled study. J Clin Anesth. 2010;22:184189.
130. Brandstrup B, Tønnesen H, Beier-Holgersen R, et al.; Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: Comparison of two perioperative fluid regimens. A randomized assessor-blinded multicenter trial. Ann Surg. 2003;238:641648.
131. Varadhan KK, Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: Getting the balance right. Proc Nutr Soc. 2010;69:488498.
132. Taniguchi H, Sasaki T, Fujita H, et al. Preoperative fluid and electrolyte management with oral rehydration therapy. J Anesth. 2009;23:222229.
133. Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia 2008;63:4451.
134. Funk D, Bohn J, Mutch W, Hayakawa T, Buchel EW. Goal-directed fluid therapy for microvascular free flap reconstruction following mastectomy: A pilot study. Plast Surg (Oakv.) 2015;23:231234.
135. Rollins KE, Lobo DN. Intraoperative goal-directed fluid therapy in elective major abdominal surgery: A meta-analysis of randomized controlled trials. Ann Surg. 2016;263:465476.
136. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Changes in central venous saturation after major surgery, and association with outcome. Crit Care 2005;9:R694R699.
137. Nelson JA, Fischer JP, Grover R, et al. Intraoperative perfusion management impacts postoperative outcomes: An analysis of 682 autologous breast reconstruction patients. J Plast Reconstr Aesthet Surg. 2015;68:175183.
138. Soni N. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP): Cassandra’s view. Anaesthesia 2009;64:235238.
139. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: A meta-analysis of randomized controlled trials. Br J Anaesth. 2009;103:637646.
140. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: A randomised controlled trial. Lancet 2002;359:18121818.
141. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005;103:2532.
142. Zhong T, Neinstein R, Massey C, et al. Intravenous fluid infusion rate in microsurgical breast reconstruction: Important lessons learned from 354 free flaps. Plast Reconstr Surg. 2011;128:11531160.
143. Booi DI. Perioperative fluid overload increases anastomosis thrombosis in the free TRAM flap used for breast reconstruction. Eur J Plast Surg. 2011;34:8186.
144. Franklin J, Yoo J, Matthews TW, et al. Morbidity associated with perioperative fluid management in free flap reconstruction of the head and neck. Western Section Triological Society Meeting. Laryngoscope 2002;112:765766.
145. Clark JR, McCluskey SA, Hall F, et al. Predictors of morbidity following free flap reconstruction for cancer of the head and neck. Head Neck 2007;29:10901101.
146. Chen C, Nguyen MD, Bar-Meir E, et al. Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction. Ann Plast Surg. 2010;65:2831.
147. Kelly DA, Reynolds M, Crantford C, Pestana IA. Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg. 2014;72:S135S138.
148. Harris L, Goldstein D, Hofer S, Gilbert R. Impact of vasopressors on outcomes in head and neck free tissue transfer. Microsurgery 2012;32:1519.
149. Suominen S, Svartling N, Silvasti M, Niemi T, Kuokkanen H, Asko-Seljavaara S. The effect of intravenous dopamine and dobutamine on blood circulation during a microvascular TRAM flap operation. Ann Plast Surg. 2004;53:425431.
150. Disa JJ, Polvora VP, Pusic AL, Singh B, Cordeiro PG. Dextran-related complications in head and neck microsurgery: Do the benefits outweigh the risks? A prospective randomized analysis. Plast Reconstr Surg. 2003;112:15341539.
151. McNicol ED, Tzortzopoulou A, Cepeda MS, et al. Single-dose intravenous paracetamol or propacetamol for prevention or treatment of postoperative pain: A systematic review and meta-analysis. Br J Anaesth. 2011;106:764775.
152. Hein A, Norlander C, Blom L, Jakobsson J. Is pain prophylaxis in minor gynaecological surgery of clinical value? A double-blind placebo controlled study of paracetamol 1 g versus lornoxicam 8 mg given orally. Ambul Surg. 2001;9:9194.
153. Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. Cochrane Database Syst Rev. 2013;6:CD010210.
154. Hall PE, Derry S, Moore RA, et al. Single dose oral lornoxicam for acute postoperative pain in adults. Cochrane Database Syst Rev. 2009;4:CD007441.
155. Barden J, Derry S, McQuay HJ, et al. Single dose oral ketoprofen and dexketoprofen for acute postoperative pain in adults. Cochrane Database Syst Rev. 2009;4:CD007355.
156. Legeby M, Sandelin K, Wickman M, Olofsson C. Analgesic efficacy of diclofenac in combination with morphine and paracetamol after mastectomy and immediate breast reconstruction. Acta Anaesthesiol Scand. 2005;49:13601366.
157. Sharma S, Chang DW, Koutz C, et al. Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction. Plast Reconstr Surg. 2001;107:352355.
158. Gobble RM, Hoang HL, Kachniarz B, Orgill DP. Ketorolac does not increase perioperative bleeding: A meta-analysis of randomized controlled trials. Plast Reconstr Surg. 2014;133:741755.
159. Jarupongprapa S, Ussavasodhi P, Katchamart W. Comparison of gastrointestinal adverse effects between cyclooxygenase-2 inhibitors and non-selective, non-steroidal anti-inflammatory drugs plus proton pump inhibitors: A systematic review and meta-analysis. J Gastroenterol. 2013;48:830838.
160. Padol IT, Hunt RH. Association of myocardial infarctions with COX-2 inhibition may be related to immunomodulation towards a Th1 response resulting in atheromatous plaque instability: An evidence-based interpretation. Rheumatology (Oxford) 2010;49:837843.
161. Seib RK, Paul JE. Preoperative gabapentin for postoperative analgesia: A meta-analysis. Can J Anaesth. 2006;53:461469.
162. Engelman E, Cateloy F. Efficacy and safety of perioperative pregabalin for post-operative pain: A meta-analysis of randomized-controlled trials. Acta Anaesthesiol Scand. 2011;55:927943.
163. Zhang J, Ho KY, Wang Y. Efficacy of pregabalin in acute postoperative pain: A meta-analysis. Br J Anaesth. 2011;106:454462.
164. Heller L, Kowalski AM, Wei C, Butler CE. Prospective, randomized, double-blind trial of local anesthetic infusion and intravenous narcotic patient-controlled anesthesia pump for pain management after free TRAM flap breast reconstruction. Plast Reconstr Surg. 2008;122:10101018.
165. Morrison JE Jr, Jacobs VR. Reduction or elimination of postoperative pain medication after mastectomy through use of a temporarily placed local anesthetic pump vs. control group. Zentralbl Gynakol. 2003;125:1722.
166. Boehmler JH IV, Venturi ML, Nahabedian MY. Decreased narcotic use with an implantable local anesthetic catheter after deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg. 2009;62:618620.
167. Zhong T, Ojha M, Bagher S, et al. Abstract 16: The analgesic efficacy of the transversus abdominis plane (TAP) block on the abdominal donor site following autologous tissue breast reconstruction: A double-blind, placebo-controlled randomized trial. Plast Reconstr Surg. 2014;133(Suppl):2526.
168. Dasta J, Ramamoorthy S, Patou G, Sinatra R. Bupivacaine liposome injectable suspension compared with bupivacaine HCl for the reduction of opioid burden in the postsurgical setting. Curr Med Res Opin. 2012;28:16091615.
169. Rohde CH, Taylor EM, Alonso A, Ascherman JA, Hardy KL, Pilla AA. Pulsed electromagnetic fields reduce postoperative interleukin-1β, pain, and inflammation: A double-blind, placebo-controlled study in TRAM flap breast reconstruction patients. Plast Reconstr Surg. 2015;135:808e817e.
170. Lambert E, Carey S. Practice guideline recommendations on perioperative fasting: A systematic review. JPEN J Parenter Enteral Nutr. 2016;40:11581165.
171. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: Systematic review and meta-analysis of controlled trials. BMJ 2001;323:773776.
172. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: Indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119:20922100.
173. Chang EI, Carlsen BT, Festekjian JH, Da Lio AL, Crisera CA. Salvage rates of compromised free flap breast reconstruction after recurrent thrombosis. Ann Plast Surg. 2013;71:6871.
174. Masoomi H, Clark EG, Paydar KZ, et al. Predictive risk factors of free flap thrombosis in breast reconstruction surgery. Microsurgery 2014;34:589594.
175. Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: A review of the process and considerations when choosing medications. Ann Pharmacother. 2014;48:6276.
176. Nahabedian MY, Momen B, Manson PN. Factors associated with anastomotic failure after microvascular reconstruction of the breast. Plast Reconstr Surg. 2004;114:7482.
177. Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: Predicting salvage versus failure. Plast Reconstr Surg. 2012;130:579589.
178. Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: An 11-year experience in 750 consecutive cases. Plast Reconstr Surg. 1999;104:97101.
179. Schmulder A, Gur E, Zaretski A. Eight-year experience of the Cook-Swartz Doppler in free-flap operations: Microsurgical and reexploration results with regard to a wide spectrum of surgeries. Microsurgery 2011;31:16.
180. Rozen WM, Chubb D, Whitaker IS, Acosta R. The efficacy of postoperative monitoring: A single surgeon comparison of clinical monitoring and the implantable Doppler probe in 547 consecutive free flaps. Microsurgery 2010;30:105110.
181. Whitaker IS, Rozen WM, Chubb D, et al. Postoperative monitoring of free flaps in autologous breast reconstruction: A multicenter comparison of 398 flaps using clinical monitoring, microdialysis, and the implantable Doppler probe. J Reconstr Microsurg. 2010;26:409416.
182. Smit JM, Werker PM, Liss AG, et al. Introduction of the implantable Doppler system did not lead to an increased salvage rate of compromised flaps: A multivariate analysis. Plast Reconstr Surg. 2010;125:17101717.
183. Um GT, Chang J, Louie O, et al. Implantable Cook-Swartz Doppler probe versus Synovis Flow Coupler for the post-operative monitoring of free flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2014;67:960966.
184. Pelletier A, Tseng C, Agarwal S, Park J, Song D. Cost analysis of near-infrared spectroscopy tissue oximetry for monitoring autologous free tissue breast reconstruction. J Reconstr Microsurg. 2011;27:487494.
185. Lin SJ, Nguyen MD, Chen C, et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg. 2011;127:10801085.
186. Duteille F, Rouif M, Alfandari B, et al. Reduction of skin closure time without loss of healing quality: A multicenter prospective study in 100 patients comparing the use of Insorb absorbable staples with absorbable thread for dermal suture. Surg Innov. 2013;20:7073.
187. Williams N, Sweetland H, Goyal S, Ivins N, Leaper DJ. Randomized trial of antimicrobial-coated sutures to prevent surgical site infection after breast cancer surgery. Surg Infect (Larchmt.) 2011;12:469474.
188. Zhang ZT, Zhang HW, Fang XD, et al. Cosmetic outcome and surgical site infection rates of antibacterial absorbable (Polyglactin 910) suture compared to Chinese silk suture in breast cancer surgery: A randomized pilot research. Chin Med J (Engl.) 2011;124:719724.
189. Nipshagen MD, Hage JJ, Beekman WH. Use of 2-octyl-cyanoacrylate skin adhesive (Dermabond) for wound closure following reduction mammaplasty: A prospective, randomized intervention study. Plast Reconstr Surg. 2008;122:1018.
190. Gennari R, Rotmensz N, Ballardini B, et al. A prospective, randomized, controlled clinical trial of tissue adhesive (2-octylcyanoacrylate) versus standard wound closure in breast surgery. Surgery 2004;136:593599.
191. Blondeel PN, Richter D, Stoff A, Exner K, Jernbeck J, Ramakrishnan V. Evaluation of a new skin closure device in surgical incisions associated with breast procedures. Ann Plast Surg. 2014;73:631637.
192. Richter D, Stoff A, Ramakrishnan V, Exner K, Jernbeck J, Blondeel PN. A comparison of a new skin closure device and intradermal sutures in the closure of full-thickness surgical incisions. Plast Reconstr Surg. 2012;130:843850.
193. Kerrigan CL, Homa K. Evaluation of a new wound closure device for linear surgical incisions: 3M Steri-Strip S Surgical Skin Closure versus subcuticular closure. Plast Reconstr Surg. 2010;125:186194.
194. Veiga DF, Veiga-Filho J, Damasceno CA, et al. Dressing wear time after breast reconstruction: Study protocol for a randomized controlled trial. Trials 2013;14:58.
195. Nahabedian MY. Achieving ideal donor site aesthetics with autologous breast reconstruction. Gland Surg. 2015;4:145153.
196. Kim JY, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. 2012;129:2841.
197. Kostaras EK, Tansarli GS, Falagas ME. Use of negative-pressure wound therapy in breast tissues: Evaluation of the literature. Surg Infect (Larchmt.) 2014;15:679685.
198. Henriksen MG, Jensen MB, Hansen HV, Jespersen TW, Hessov I. Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery. Nutrition 2002;18:147152.
199. Brower RG. Consequences of bed rest. Crit Care Med. 2009;37(Suppl):S422S428.
200. Blom RL, van Heijl M, Bemelman WA, et al. Initial experiences of an enhanced recovery protocol in esophageal surgery. World J Surg. 2013;37:23722378.
201. Jones C, Kelliher L, Dickinson M, et al. Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg. 2013;100:10151024.
202. van Dam RM, Hendry PO, Coolsen MM, et al.; Enhanced Recovery After Surgery (ERAS) Group. Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection. Br J Surg. 2008;95:969975.
203. Ramírez JM, Blasco JA, Roig JV, et al.; Spanish working group on fast track surgery. Enhanced recovery in colorectal surgery: A multicentre study. BMC Surg. 2011;11:9.
204. Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA; Collaborative LAFA Study Group. Which fast track elements predict early recovery after colon cancer surgery? Colorectal Dis. 2012;14:10011008.
205. Bartolo M, Zucchella C, Pace A, et al. Early rehabilitation after surgery improves functional outcome in inpatients with brain tumours. J Neurooncol. 2012;107:537544.
206. Convertino VA. Cardiovascular consequences of bed rest: Effect on maximal oxygen uptake. Med Sci Sports Exerc. 1997;29:191196.
207. Paddon-Jones D, Sheffield-Moore M, Cree MG, et al. Atrophy and impaired muscle protein synthesis during prolonged inactivity and stress. J Clin Endocrinol Metab. 2006;91:48364841.
208. Testa A, Iannace C, Di Libero L. Strengths of early physical rehabilitation programs in surgical breast cancer patients: Results of a randomized controlled study. Eur J Phys Rehabil Med. 2014;50:275284.
209. Scaffidi M, Vulpiani MC, Vetrano M, et al. Early rehabilitation reduces the onset of complications in the upper limb following breast cancer surgery. Eur J Phys Rehabil Med. 2012;48:601611.
210. Davidge KM, Brown M, Morgan P, Semple JL. Processes of care in autogenous breast reconstruction with pedicled TRAM flaps: Expediting postoperative discharge in an ambulatory setting. Plast Reconstr Surg. 2013;132:339e344e.
211. Cho HS, Davis GC, Paek JE, et al. A randomised trial of nursing interventions supporting recovery of the postmastectomy patient. J Clin Nurs. 2013;22:919929.
212. Hill O, White K. Exploring women’s experiences of TRAM flap breast reconstruction after mastectomy for breast cancer. Oncol Nurs Forum 2008;35:8188.
213. Holtzmann J, Timm H. The experiences of and the nursing care for breast cancer patients undergoing immediate breast reconstruction. Eur J Cancer Care (Engl.) 2005;14:310318.
214. Armstrong KA, Semple JL, Coyte PC. Replacing ambulatory surgical follow-up visits with mobile app home monitoring: Modeling cost-effective scenarios. J Med Internet Res. 2014;16:e213.
215. Temple-Oberle CF, Cook EF, Bettger-Hahn M, Mychailyshyn N, Naeem H, Macdermid J. Development of a breast reconstruction satisfaction questionnaire (BRECON-31): Principal components analysis and clinimetric properties. J Surg Oncol. 2012;106:799806.
216. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124:345353.
217. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clin Nutr. 2010;29:434440.
218. Ren L, Zhu D, Wei Y, et al. Enhanced Recovery After Surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: A prospective randomized controlled trial. World J Surg. 2012;36:407414.
219. Gustafsson UO, Scott MJ, Schwenk W, et al.; Enhanced Recovery After Surgery Society. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2012;31:783800.
220. Nygren J, Thacker J, Carli F, et al.; Enhanced Recovery After Surgery Society. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2012;31:801816.
221. Dumestre D, Webb C, Temple-Oberle C. Improved recovery experience achieved for women undergoing implant-based breast reconstruction using an Enhanced Recovery After Surgery (ERAS) model. Plast Reconstr Surg. 2017;139:550559.
222. Stark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: The QoR-15. Anesthesiology 2013;118:13321340.
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