Day surgery—Breast oncological surgery: A preliminary experience demonstrating safety and improved quality of recovery

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INTRODUCTION With the popularization of Enhanced Recovery after Surgery (ERAS) programs since its introduction in the early 2000s, significant benefits have been demonstrated in the realm of elective surgery,[1] especially for major abdominal operations.[2] Under such protocols, multidisciplinary approaches have been employed in managing the patient’s perioperative journey, including their expectations, postoperative pain, nutrition, analgesia, as well as postoperative wound and drain care.[3] Globally, numerous benefits have been demonstrated, including shorter length of stay, reduced postoperative pain, and earlier return to function.[1,4] While this approach has been adopted by select centers around the world for breast oncological surgeries (BOS) as early as 2002,[5-7] its uptake has been generally poor. Several small studies involving retrospective reviews of the experience of single centers have thus far demonstrated the safety of performing BOS as day surgery (DS) procedures.[8,9] For instance, Zeelst et al.[8] found no significant difference in unplanned return to care or complication rates between inpatient and outpatient mastectomies. Hejl et al.[9] also demonstrated no significant difference in quality of life, perioperative anxiety, and postoperative complications between patients who underwent ambulatory and nonambulatory BOS. Several barriers have been identified that account for the poor uptake of ERAS programs in the field of breast surgery. From the point of view of patients, those who experience postoperative nausea and vomiting (PONV), as well as postoperative pain, may be less confident of being able to recover at home.[10,11] From the surgeon’s point of view, some may be concerned regarding the ability to detect complications early, especially postoperative bleeding requiring emergent exploration.[8] The American Society of Breast Surgeons' multidisciplinary expert panel recommends the use of multimodal analgesia with appropriate nonopioid and opioid prescribing preoperatively and perioperatively, with the use of intraoperative adjuncts such as local analgesia and blocks.[12] This has been demonstrated to be effective in eliminating postoperative narcotic prescriptions while achieving adequate postoperative pain control with no increase in morbidities.[7,13] With the ongoing COVID-19 pandemic and a surge in demand for inpatient beds brought about with each new variant, establishing a DS-BOS protocol that minimizes unnecessary use of inpatient beds as well as allows for patients to recover at home safely is more pertinent than before.[8] In line with this, our center has piloted an initiative of performing BOS as DS for a well-selected group of patients between January and July 2022. Prior to this initiative, most oncological breast surgeries in the authors’ institution were performed on a 23-h ward (1-night stay) basis. The aim of this study was to compare the outcomes of patients who underwent BOS as a DS vs. inpatient procedure (IP), in particular, the safety and quality of recovery (QOR). To the best of our knowledge, this is the first study in the local context demonstrating the safety of DS-BOS along with an improved QOR score. MATERIALS AND METHODS Study protocol A prospective review of consecutive patients who underwent DS-BOS under the pilot initiative between January and July 2022 was performed. This study received exemption by the local Institutional Review Board by virtue of reviewing previously collected deidentified data. Patient selection Patients were included if they met the following criteria: they were able to understand the preoperative education and counseling, were able to reliably perform self-care independently with or without the assistance of reliable caregivers, were able to reliably assess wounds and drains, were suitable for teleconsultation, and met the hospital guidelines for DS, including being of ASA 1, 2 or well controlled ASA 3 status, have BMI less than 35 kg/m2, and have a responsible adult escorting them home after the operation and provide caregiving for 24 h postoperatively. Patients were excluded if they did not meet the above inclusion criteria, had major comorbidities that required longer postoperative monitoring, had pre-existing acute or chronic pain conditions or long-term analgesia, who would likely require more intraoperative and postoperative analgesia. BOS performed included unilateral or bilateral mastectomies without reconstruction, with or without axillary staging procedures (which included sentinel lymph node biopsy (SLNB), axillary sampling, or axillary dissection/clearance), as well as breast-conserving surgery (BCS), including those where oncoplastic techniques were involved, with or without axillary staging procedures. Both level 1 and 2 oncoplastic breast surgery techniques were performed. The duration of surgery included was 4 h or less, and surgeries had to be completed before 1 pm on the operating day to facilitate adequate postoperative monitoring (up to 6 h postoperatively) and discharge in the recovery ward during office hours. The cutoff limit of 1 pm was to avoid unnecessary nursing burden in view of reduced nursing manpower in the recovery ward after 7 pm. DS-BOS workflow Prior to surgery, patient and caregiver education and counseling were performed by the surgical team and BCNs. Wound and drain care was taught to patients and caregivers with the aid of a video presentation as well as pamphlet. Identification of red flags and when to seek medical attention was discussed and informed. A dedicated postoperative kit comprising the educational pamphlet in four languages (English, Chinese, Malay, and Tamil), two packets of gauze, and two packets of TegadermTM (3M, Minnesota, US) dressing was provided. Patients were informed on how to seek further advice from the dedicated BCN. On the day of surgery, a clear anesthesia plan was discussed between the anesthetist and surgeon with the aim of minimizing PONV, which was reported as one of the main factors impeding discharge after BOS.[10,11] Paracetamol was given preoperatively routinely when not contraindicated on arrival to the hospital as part of a multimodal approach. Intraoperatively, a combination of intravenous opioids, antiemetics, and dexamethasone was given by the anesthetist, and local infiltrative agents were given by the surgeon with the aim to minimize the use of opioids, including tumescent local anesthesia and pectoralis (PECS) nerve block. Postoperatively, paracetamol-based analgesia was prescribed. Patients were monitored in the DS ward and were reviewed by the surgical team prior to discharge. They were assessed to be fit for discharge if they had stable vital signs, were able to maintain pre-procedure mobility with minimal assistance, were able to retain feeds and void, and had a responsible adult accompanying them home. Discharge was postponed/converted to inpatient stay should the patient be deemed to have excessive pain not relieved by oral analgesia, excessive PONV not relieved by oral antiemetics, severe giddiness, shortness of breath, or bleeding from the surgical wound. They were given return advice prior to discharge and informed of the follow-up plan. They were also seen by the BCN prior to discharge and reminded on wound and drain management and how they might seek advice should they have concerns. Postdischarge, a video or physical consultation was scheduled on the morning of the first postoperative day with the operating surgeon to assess for any concerns in the early postoperative period. An in-person review was also scheduled on the fourth postoperative day to review the wound and drain. Outcome measures Basic demographics and clinicopathological data of patients, including their age, comorbidities, and tumor characteristics, were collected. Intraoperative variables such as nature of procedure, duration, and analgesia used were collected, and postoperative progress, such as complications

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