Effect of Enhanced Recovery after Surgery in Morbidly Obese Patients Undergoing Free Flap Breast Reconstruction.

Background:  Enhanced recovery after surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.

Methods:  A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), intensive care unit (ICU) utilization, opioid usage, cost, and flap outcomes were analyzed in patients with body mass index greater than 35 before and after ERAS implementation.

Results:  Thirty-five morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral versus bilateral or immediate versus delayed reconstruction. LOS decreased with ERAS (3.43 vs. 2.06 days, p < 0.0000001). ICU utilization decreased with ERAS (0.94 vs. 0.0 days, p < 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs. 17.9 morphine milligram equivalent [MME], p < 0.0001; 190.5 vs. 54.7 MME, p < 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs. $25,079, p = 0.0002) and increased cost margin ($4,458 vs. -$8,306, p = 0.004). There were no differences in donor or recipient site outcomes including flap loss, deep venous thrombosis/pulmonary embolism, hernia/bulge, delayed wound healing, revisions, and blood loss.

Conclusion:  ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased LOS, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.