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Same-Day Approach to Mastectomy with Immediate Reconstruction
Michelle C. Specht1, Bridget Kelly1, Alexandra J. Webster1, Olivia Abbate2, Nikki Rosado2, Caroline McGugin1, Barbara L. Smith1, Michele A. Gadd1, Suzanne B. Coopey1, Eric Liao2
1Division of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts, United States, 2Division of Plastic and Reconstructive Surgery, Massachusetts General Hopsital, Boston, Massachusetts, United States

Objective
Our team developed a comprehensive protocol for same-day mastectomy and immediate breast reconstruction in patients with breast cancer or breast cancer risk. This protocol emphasizes early recovery and includes pre-operative patient education, paravertebral nerve blocks, minimization of opioids, and utilization of visiting nurses. We compared patients under the same-day protocol to a historical cohort admitted post-operatively at our institution to determine how same-day pathway affects mastectomy patient outcomes.
Design
Retrospective cohort study.
Setting
High-volume academic center.
Patients
A total of 927 patients who underwent mastectomy with immediate implant-based reconstruction were identified: 611 patients from 04/2016 - 05/2018 and 316 from 02/2020 - 02/2021.
Intervention
N/A
Main Outcome Measures
Length of stay, post-operative IV opioid administration, time to last IV opioid dose
Results
Of 316 mastectomy patients treated between 2020-2021, 192 (60.7%) were discharged on the day of their mastectomy, and 274 (86.7%) were discharged within 24 hours of surgery. Mean length of stay decreased from 24 hours in 2016-2018 to 6 hours in 2020-2021 following implementation of a same-day protocol (p<0.001) without increase in 30-day readmission rate (4.1% vs 6.0%, p=0.192). From 2016-2018, 68.7% of patients required IV opioids with last dose at 1.4 hours, compared to 48.7% of patients in 2020-2021 with last dose at 0.9 hours (p<0.001). 2020-2021 patients were more likely to stay at least one night if they underwent bilateral mastectomies (p<0.001) or tissue expander reconstruction (p=0.020).
Conclusion
Introduction of a same-day protocol for mastectomy patients with immediate reconstruction significantly decreased length of stay, postoperative IV opioid administration, and time to last IV opioid. Implementation and success of this protocol was critical to treating patients during the COVID 19 pandemic.

 Historical Cohort
(2016-2018)
n=611
Contemporary Cohort
(2020-2021)
n=316
p-value
Length of Stay, hours, median (range)   
Overall24 (16-95)6 (2-77)<0.001
Laterality   
Unilateral24 (16-57)5 (2-77)<0.001
Bilateral24 (16-95)7 (2-73)<0.001
Reconstruction   
Direct Implant24 (16-95)6 (2-45)<0.001
Tissue Expander25 (16-72)7 (2-77)<0.001
Requiring IV opioids, n (%)420 (68.7%)154 (48.7%)<0.001
Time to last IV opioid dose, hours, median (range)   
Overall1.4 (0.1-42.5)0.9 (0.1-35.3)<0.001
Laterality   
Unilateral1.7 (0.1-10.2)0.9 (0.2-16)0.162
Bilateral1.6 (0.1-42.5)1.0 (0.1-35.3)<0.001
Reconstruction   
Direct Implant1.4 (0.1-21.5)0.9 (0.1-25.2)<0.001
Tissue Expander1.5 (0.2-42.5)1.0 (0.2-35.3)0.01


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