By Dr. Constance M Chen

Enhanced Recovery After Surgery (ERAS) is an evidence-based, patient-focused protocol that reduces hospital stays, minimizes postoperative pain, and speeds overall patient recovery after surgery. Frankly, ERAS has transformed the mentality of many health providers who used to just accept the status quo.

For breast surgery patients, we have implemented ERAS to put people on the “fast track” to recovery. ERAS programs can include the following:

● Enhanced patient preparation and education prior to surgery; 
● Greater use of advanced anesthesia protocols; 
● Removing Foley catheters and tubing within 24 hours after surgery to minimize infection risk and facilitate recovery; 
● Resuming solid food immediately after the operation; 
● Improved postoperative fluid management; 
● Better pain control; and 
● Fewer postoperative complications.

Almost all of our patients are up and walking 24 hours after surgery. Since they are not dependent on opioids for pain beyond the immediate postoperative period, they have shorter hospital stays overall.

Introduced in the 1990s, ERAS was initially implemented to better manage pain, minimize infection, and improve the overall recovery process for patients undergoing colorectal surgery. After formation of the ERAS® Society in 2010 and the Society’s release of surgery and anesthesia guidelines, however, application of ERAS expanded to include other major operations, including breast reconstruction.

In a pilot study of a breast surgery ERAS protocol designed to eliminate narcotic prescriptions at the time of a patient’s hospital discharge, researchers indicated that “employing opioid-sparing techniques successfully eliminated postoperative narcotic prescription without sacrificing perioperative pain control or increasing postoperative complications.” Their report was published in an October 2018 issue of Breast Cancer Research and Treatment.

A 2019 study published in the Journal of Neurosurgery indicates that an ERAS protocol developed to enhance care for patients before, during and after spinal and peripheral nerve surgery significantly reduced use of opioid medications. A pain management plan was personalized for each patient and designed to prevent opioid dependency following surgery.

The success of ERAS protocols is revolutionizing post-surgical care in general. The significant advances in breast reconstruction have resulted in a better and more comfortable patient experience with less postoperative pain. Key advancements in breast reconstruction include: 
● Pre-pectoral breast reconstruction, a minimally invasive technique in which a breast implant is placed above the pectoralis muscle and just under the skin in the same anatomic location as a normal breast. 
● Perforator flap breast reconstruction, a microsurgical technique that transfers a woman’s own fat and skin while preserving her muscle to reconstruct the breasts. Perforator flap breast reconstruction creates a breast composed of soft, warm, living tissue that is part of the patient’s body, and can restore sensation to breasts after mastectomy.

Of course, “selecting a qualified surgeon and care team is a critical first step to ensure a satisfactory patient experience”. Following are tips for patients: 
● Fully learn your options – and risks -- prior to breast reconstruction surgery; 
● Find out whether your surgical team uses an ERAS -”fast-track” protocol to improve the patient experience; 
● Balance your goals for breast reconstruction with the realities of your cancer treatment, such as need for follow-up and required adjuvant therapies like radiation or chemotherapy; 
● Learn as much as possible about your planned procedure before the operation and follow all care team-recommended guidelines before and after surgery; 
● Expect recovery to take time – even with a successfully shortened hospital stay.

Benefits from the ERAS fast-track protocol can create an easier surgical experience for patients. The goals of ERAS include less pain, reduced hospital stay, and fewer complications. At the end of the day,” says Dr. Chen, “it’s worth it to do some homework ahead of time to optimize your chances for the best possible overall outcome.