PURPOSE: Enhanced recovery after surgery (ERAS) is increasingly being used in breast reconstruction. It is a multidisciplinary approach to surgical patient care that aims to decrease preoperative stress and postoperative pain, increase quality of care, and expedite patient recovery. The benefits of ERAS for patients are manifold; however, it still remains to be determined which components of the ERAS pathway are most responsible for improvement in outcomes in the setting of microvascular free tissue transfer (FTT) breast reconstruction.
METHODS: A retrospective chart review was performed for 42 FTT breast reconstruction patients at a single institution. Electronic medical records were used to assess demographics; pre-, intra-, and postoperative medications; and subjective pain scores. Outcomes of interest included average milligram morphine equivalents used per day, average self-reported pain, and number of antiemetic doses given during hospital stay. Linear regression was used to determine which ERAS medications correlated to these outcomes. We examined preoperative acetaminophen, gabapentin, and celecoxib; intraoperative lidocaine, ketorolac, and liposomal bupivacaine; and postoperative ketorolac, gabapentin, and acetaminophen.
RESULTS: Postoperative gabapentin, a cortical neuronal calcium channel modulator, showed significant correlation with study variables. All else equal, gabapentin use was associated with a 59.8 mg decrease in average postoperative milligram morphine equivalents used per day (P = 0.001; −93.36 to −26.30); a 2.1-point decrease in average pain (P = 0.031; −4.01 to −0.21); and a 2.5 dose decrease in the number of antiemetic doses (P = 0.045; −4.88 to −0.056). Gabapentin decreased the odds of a patient receiving over 50 mg of oral morphine equivalent per day by 8.3 times (P = 0.0321; 1.255–54.707) and reduced the chances of average pain above 5 by 16 times (P = 0.0079; 2.186–117.094). It was also associated with 8.5 times decreased odds of a patient requiring over 5 antiemetic doses (P = 0.0910; 0.926–78.0261).
CONCLUSIONS: In this single-center retrospective study, postoperative gabapentin use had the largest effect of all ERAS pathway analgesics on postoperative opioid use, pain, and antiemetic use. Gabapentin should therefore be especially considered for all FTT breast reconstruction patients. The effects of the other ERAS pathway analgesic medications may require larger sample sizes to evaluate. Further studies are required to further understand the effects of each component of the ERAS pathway on breast reconstruction patient outcomes.