The Quality of Plastic Surgery Enhanced Recovery After Surgery (ERAS) Studies: A Systematic Review

SDCC 

Purpose: In an effort to improve post-operative outcomes and optimize patient recovery, Enhanced Recovery After Surgery (ERAS) protocols have gained popularity.[1] The objective of this systematic review was to assess the reporting and methodological quality of plastic surgery ERAS studies.

Methods: All plastic surgery ERAS studies, published between January 2021 to November 2023 were assessed for reporting quality, and those published between January 2020 to November 2023 were assessed for methodological quality. Time-periods were selected based on publication dates of The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist[2] (reporting quality) and Recommendations from the ERAS® Society for the development of ERAS guidelines[1] (methodological quality). The primary outcome was reporting quality (The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist[1] (40 points)). Secondary outcomes included methodological quality. For Autologous Breast Reconstruction and Head and Neck (H&N) studies, methodological quality was assessed through the appraisal of adherence to ERAS® Society guidelines.[3, 4] The methodological quality of other sub-specialty ERAS studies was appraised through adherence to Recommendations from the ERAS® Society for the development of ERAS guidelines[1] (9 points).

Results: Fifty studies were included (Breast Reconstruction: 29, 58%; H&N: 7, 14%; Craniofacial: 7, 14%; Aesthetic: 5, 10%; Other: 3, 6%). Mean reporting quality was 22.6/40 (56.5%; SD: 4.7). ERAS protocol elements least adhered to included: patient warming strategy (8/50, 16%), post-operative analgesia/anti-emetic plans (14/50, 28%), and post-discharge outcome tracking (14/50, 28%). Evaluation of the methodological quality of Autologous Breast Reconstruction studies revealed mean compliance of 8.0/18 (44.4%, SD: 3.5). Least complied with elements included: preoperative CTA (4/23, 17.4%), intra-operative warming (6/23, 26.1%), and post-operative wound management (2/23, 8.7%). For H&N studies, average compliance was 9.2/24 (38.3%, SD: 5.2). Least complied with elements included: pre-anesthesia pain medications (1/7, 14.3%), post-operative wound care (0/7, 0%) and post-operative pulmonary therapy (1/7, 14.3%). Least complied with elements for other sub-specialties included: multidisciplinary ERAS development (3/16, 18.8%), and evaluation plans (3/16, 18.8%).

Conclusions: ERAS studies in plastic surgery are variable, with overall low reporting and methodological quality. Plastic surgeons should critically appraise ERAS protocols before adopting them to their practice.

1. Brindle M, Nelson G, Lobo DN, Ljungqvist O, Gustafsson UO (2020) Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines. BJS Open 4:157–163
2. Elias KM, Stone AB, McGinigle K, et al (2019) The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS® and ERAS® USA Societies. World J Surg 43:1–8
3. Temple-Oberle C, Shea-Budgell MA, Tan M, Semple JL, Schrag C, Barreto M, Blondeel P, Hamming J, Dayan J, Ljungqvist O (2017) Consensus review of optimal perioperative care in breast reconstruction: Enhanced recovery after surgery (ERAS) society recommendations. Plast Reconstr Surg 139:1056e–1071e
4. Dort JC, Farwell DG, Findlay M, et al (2017) Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society. JAMA Otolaryngology–Head & Neck Surgery 143:292–303

Practice Management

PSTM 2024