Discussion: Consensus Review of Optimal Perioperative Care in Breast Reconstruction

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I had the pleasure of reviewing “Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations” by Temple-Oberle et al. The concept of enhanced recovery programs, enhanced recovery after surgery, and fast track protocols has its roots in the 1990s.1 Its beginnings were in colorectal surgery, general surgery, and urology.2,3 These early perioperative programs centered around the medical optimization of the patient, and the goal of these programs was to reduce perioperative morbidity and length of hospital stay.
Regarding preadmission information, education, and counseling, the paradigm of preoperative counseling for this group of patients has significantly changed in only the past few years with social media and the level of available support from the patient community, and so I wondered what detailed preoperative counseling entailed specifically. Certainly, before-and-after photographs are important, but how does a practitioner navigate the nuances of a paternalistic approach versus shared decision-making in breast reconstruction?4,5
Regarding preadmission optimization, the panel reviews poor glycemic control as a well-known risk factor but does not make a recommendation regarding patients with diabetes. One suggestion is an acceptable preoperative hemoglobin A1C level for an ideal preoperative candidate.
Next, perforator flap planning is reviewed. We all know colleagues who use mapping all the time and those who do not, and there are certainly pros and cons to each view. Regardless, incidental findings on preoperative computed tomographic angiography may change the course of a patient’s treatment while potentially valuable information is being gathered for perforator surgery.6 Regarding preoperative fasting, I agree that the evidence may be strong for this recommendation; however, it may take a significant culture change, and primarily time, on the part of our anesthesiology colleagues to allow for patients undergoing an all-day bilateral perforator flap breast reconstruction to be given nothing by mouth for 6 hours and clears only up until 2 hours.
On a related topic, the panel reviewed preoperative carbohydrate loading and recommended preoperative maltodextrin-based drinks given 2 hours before surgery, citing the benefits of presurgical carbohydrate loading. However, I also would posit that carbohydrate loading even earlier, perhaps the night before a major operation, might also be beneficial.
Regarding prophylaxis against venous thromboembolism, the authors recommend extended venous thromboembolism prophylaxis with the use of low-molecular-weight heparin or unfractionated heparin until the patient is ambulatory or discharged along with mechanical extremity compression. Indeed, in our practice we routinely give unfractionated heparin until discharge and low-molecular-weight heparin in patients with hematologic conditions.
The panel reviewed antimicrobial prophylaxis and placed a priority on chlorhexidine skin preparation, with intravenous antibiotics given within 1 hour of incision. I do not believe there is much controversy regarding the timing of preincision antibiotics, but there are differences in practice patterns regarding the length of postoperative antibiotic use, which commonly involve antibiotic administration until the drains are removed.
Preoperative and intraoperative prophylaxis against postoperative nausea and vomiting recommendations for preoperative and intraoperative multimodal medications make sense, along with multimodal therapy (e.g., nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, gabapentin) for preoperative and intraoperative analgesia. The maintenance of core body temperature in preventing intraoperative hypothermia above 36°C was advocated by the authors by preoperative and intraoperative measures such as forced air along with the avoidance of overresuscitation or underresuscitation of fluids in perioperative intravenous fluid management. The use of vasopressors to support fluid balance and blood pressure was recommended even in free tissue transfer cases. Pain management has progressed significantly in recent years—both the availability of newer medications that last longer (e.g., liposomal bupivacaine) and regional blocks (e.g.

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