Breast Cancer Research and Treatment

, Volume 173, Issue 1, pp 65–77 | Cite as

Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature

  • Anaeze C. OffodileII
  • Cindy Gu
  • Stefanos Boukovalas
  • Christopher J. Coroneos
  • Abhishek Chatterjee
  • Rene D. Largo
  • Charles ButlerEmail author



Enhanced recovery after surgery (ERAS) pathways are increasingly promoted in post-mastectomy reconstruction, with several articles reporting their benefits and safety. This meta-analysis appraises the evidence for ERAS pathways in breast reconstruction.


A systematic search of Medline, EMBASE, and Cochrane databases was performed to identify reports of ERAS protocols in post-mastectomy breast reconstruction. Two reviewers screened studies using predetermined inclusion criteria. Studies evaluated at least one of the following end-points of interest: length of stay (LOS), opioid use, or major complications. Risk of bias was assessed for each study. Meta-analysis was performed via a mixed-effects model to compare outcomes for ERAS versus traditional standard of care. Surgical techniques were assessed through subgroup analysis.


A total of 260 articles were identified; 9 (3.46%) met inclusion criteria with a total of 1191 patients. Most studies had “fair” methodological quality and incomplete implementation of ERAS society recommendations was noted. Autologous flaps comprised the majority of cases. In autologous breast reconstruction, ERAS significantly reduces opioid use [Mean difference (MD) = − 183.96, 95% CI − 340.27 to 27.64, p = 0.02) and LOS (MD) = − 1.58, 95% CI − 1.99 to 1.18, p < 0.00001] versus traditional care. There is no significant difference in the incidence of complications (major complications, readmission, hematoma, and infection).


ERAS pathways significantly reduce opioid use and length of hospital stay following autologous breast reconstruction without increasing complication rates. This is salient given the current US healthcare climate of rising expenditures and an opioid crisis.


Breast reconstruction Enhanced recovery after surgery (ERAS) Fast-track surgery Length of stay Post-operative opioid consumption 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants and/or animals

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Not applicable.

Supplementary material

10549_2018_4991_MOESM1_ESM.docx (27 kb)
Supplementary material 1 (DOCX 27 KB)


  1. 1.
    Ljungqvist O, Scott M, Fearon KC (2017) Enhanced recovery after surgery. JAMA Surg 152(3):292–298Google Scholar
  2. 2.
    Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78(5):606–617Google Scholar
  3. 3.
    Alvarez A, Goudra BG, Singh PM (2016) Enhanced recovery after bariatric surgery. Curr Opin Anaesthesiol. Google Scholar
  4. 4.
    Wang MY, Chang PYGJ (2017) Development of an enhanced recovery after surgery (ERAS) approaach for lumbar spinal fusion. J Neurosurg Spine 26:411–418Google Scholar
  5. 5.
    Barton JG (2016) Enhanced recovery pathways in pancreatic surgery. Surg Clin North Am 96(6):1301–1312Google Scholar
  6. 6.
    Auyong DB, Allen CJ, Pahang JA, Clabeaux JJ, MacDonald KM, Hanson NA (2015) Reduced length of hospitalization in primary total knee arthroplasty patients using an updated enhanced recovery after orthopedic surgery (ERAS) pathway. J Arthroplasty 30(10):1705–1709Google Scholar
  7. 7.
    Nelson G, Kalogera E, Dowdy SC (2014) Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol 135(3):586–594Google Scholar
  8. 8.
    Fearon KCH, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24(3):466–477Google Scholar
  9. 9.
    Yamada T, Hayashi T, Cho H et al (2012) Usefulness of enhanced recovery after surgery protocol as compared with conventional perioperative care in gastric surgery. Gastric Cancer 15(1):34–41Google Scholar
  10. 10.
    Tatsuishi W, Kohri T, Kodera K et al (2012) Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm. Surg Today 42(12):1195–1200Google Scholar
  11. 11.
    Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38(6):1531–1541Google Scholar
  12. 12.
    Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146(5):571–577Google Scholar
  13. 13.
    American Society of Plastic Surgeons (2017) Plastic surgery statistics report. report-2017.pdf. Accessed 1 Apr 2018
  14. 14.
    Batdorf NJ, Lemaine V, Lovely JK et al (2015) Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 68(3):395–402Google Scholar
  15. 15.
    Astanehe A, Temple-Oberle C, Nielsen M, de Haas W, Lindsay R, Matthews J, McKenzie DC, Yeung JSC (2018) An enhanced recovery after surgery pathway for microvascular breast reconstruction is safe and effective. Plast Reconstr Surg Glob Open. Google Scholar
  16. 16.
    Bonde C, Khorasani H, Eriksen K, Wolthers M, Kehlet H, Elberg J (2015) Introducing the fast track surgery principles can reduce length of stay after autologous breast reconstruction using free flaps: A case control study. J Plast Surg Hand Surg 49(6):367–371Google Scholar
  17. 17.
    Temple-Oberle C, Shea-Budgell MA, Tan M et al (2017) Consensus review of optimal perioperative care in breast reconstruction: enhanced recovery after surgery (ERAS) society recommendations. Plast Reconstr Surg 139(5):1056e–1071eGoogle Scholar
  18. 18.
    Dumestre DO, Webb CE, Temple-Oberle C (2017) Improved recovery experience achieved for women undergoing implant-based breast reconstruction using an enhanced recovery after surgery model. Plast Reconstr Surg 139:550–559Google Scholar
  19. 19.
    Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Commun Health 52(6):377–384Google Scholar
  20. 20.
    Offodile AC, Aycart MA, Segal JB (2018) Comparative effectiveness of preoperative paravertebral block for post-mastectomy reconstruction: a systematic review of the literature. Ann Surg Oncol 25(3):818–828Google Scholar
  21. 21.
    Silverman SR, Schertz LA, Yuen HK, Lowman JD, Bickel CS (2012) Systematic review of the methodological quality and outcome measures utilized in exercise interventions for adults with spinal cord injury. Spinal Cord 50(10):718–727Google Scholar
  22. 22.
    Higgins J, Green S (2011) Cochrane handbook for systematic reviews of interventions. Vers 5.1. The cochrane collaboration. Accessed 11 April 2018
  23. 23.
    Cohen J (1988) Statistical power analysis for the behavioral sciences, 2nd edn. Lawrence Erlbaum, HillsdaleGoogle Scholar
  24. 24.
    Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ Br Med J 327(7414):557–560Google Scholar
  25. 25.
    Bonde CT, Khorasani H, Elberg J, Kehlet H (2016) Perioperative optimization of autologous breast reconstruction. Plast Reconstr Surg 137:411–414Google Scholar
  26. 26.
    Kaoutzanis C, Ganesh Kumar N, O’Neill D et al (2018) Enhanced recovery pathway in microvascular autologous tissue-based breast reconstruction. Plast Reconstr Surg 141(4):841–851Google Scholar
  27. 27.
    Armstrong KA, Davidge K, Morgan P, Brown M, Li M, Cunningham L, Clarke HSJ (2016) Determinants of increased acute postoperative pain after autologous breast reconstruction within an enhanced recovery after surgery protocol: a Prospective Cohort Study. J Plast Reconstr Aesthet Surg 69(8):1157–1160Google Scholar
  28. 28.
    Davidge KM, Brown M, Morgan P, Semple JL (2013) Processes of care in autogenous breast reconstruction with pedicled TRAM flaps: Expediting postoperative discharge in an ambulatory setting. Plast Reconstr Surg 132(3):339e–339e44eGoogle Scholar
  29. 29.
    Afonso A, Oskar S, Tan K, Disa J, Mehrara B, Dayan J (2017) Is enhanced recovery the new standard of care in microsurgical breast reconstruction? Plast Reconstr Surg 139(5):1053–1061Google Scholar
  30. 30.
    Ni TG, Yang HT, Zhang H, Meng HP, Li B (2015) Enhanced recovery after surgery programs in patients undergoing hepatectomy: a meta-analysis. World J Gastroenterol 21(30):9209–9216Google Scholar
  31. 31.
    Coolsen MME, Van Dam RM, Van Der Wilt AA, Slim K, Lassen K, Dejong CHC (2013) Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg 37(8):1909–1918Google Scholar
  32. 32.
    Stowers MDJ, Manuopangai L, Hill AG, Gray JR, Coleman B, Munro JT (2016) Enhanced recovery after surgery in elective hip and knee arthroplasty reduces length of hospital stay. ANZ J Surg 86(6):475–479Google Scholar
  33. 33.
    Malczak P, Pisarska M, Piotr M, Wysocki M, Budzynski A, Pedziwiatr M (2017) Enhanced recovery after bariatric surgery: systematic review and meta-analysis. Obes Surg 27:226–235Google Scholar
  34. 34.
    Gnaneswaran N, Perera M, Perera N (2016) Enhanced recovery after surgery (ERAS) pathways in autologous breast reconstruction: a systematic review. Eur J Plast Surg 39(3):165–172Google Scholar
  35. 35.
    Tong M, Pattakos G, He J et al (2015) Sequentially updated discharge model for optimizing hospital resource use and surgical patients’ satisfaction. Ann Thorac Surg 100(6):2174–2181Google Scholar
  36. 36.
    O’Donnell TF Jr, Gembarowicz RM, Callow AD, Pauker SG, Kelly JJ, Deterling RA (1980) The economic impact of acute variceal bleeding: cost-effectiveness implications for medical and surgical therapy. Surgery 88(5):693–701Google Scholar
  37. 37.
    Papanicolas I, Woskie LR, Jha AK (2018) Health care spending in the united states and other high-income countries. JAMA 319(10):1024–1039Google Scholar
  38. 38.
    Parikh RP, Sharma K, Guffey R, Myckatyn TM (2016) Preoperative paravertebral block improves postoperative pain control and reduces hospital length of stay in patients undergoing autologous breast reconstruction after mastectomy for breast cancer. Ann Surg Oncol 23(13):4262–4269Google Scholar
  39. 39.
    Koehler RM, Okoroafor UC, Cannada LK (2018) A systematic review of opioid use after extremity trauma in orthopedic surgery. Injury 49(6):1003–1007Google Scholar
  40. 40.
    Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S (2016) Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Med (United States) 17(1):85–98Google Scholar
  41. 41.
    Lassen K, Hannemann P, Ljungqvist O et al (2005) Patterns in current perioperative practice: Survey of colorectal surgeons in five northern European countries. Br Med J 330(7505):1420–1421Google Scholar
  42. 42.
    Ahmed O, Rogers A, Bolger J, Mastrosimone A, Robb W (2018) Meta-analysis of enhanced recovery protocols in bariatric surgery. J Gastrointest Surg 22:964–972Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Anaeze C. OffodileII
    • 1
  • Cindy Gu
    • 2
  • Stefanos Boukovalas
    • 1
    • 5
  • Christopher J. Coroneos
    • 3
  • Abhishek Chatterjee
    • 4
  • Rene D. Largo
    • 1
  • Charles Butler
    • 1
    Email author
  1. 1.Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.University of Texas McGovern Medical SchoolHoustonUSA
  3. 3.Division of Plastic SurgeryMcMaster UniversityHamiltonCanada
  4. 4.Division of Plastic SurgeryTufts Medical CenterBostonUSA
  5. 5.Division of Plastic SurgeryUniversity of Texas Medical Branch- GalvestonGalvestonUSA

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