Evidence-based review of enhancing postoperative recovery after breast surgery

Background: The introduction of enhanced recovery after surgery (ERAS) protocols has revolutionized preoperative and postoperative care. To date, however, the principles of enhanced recovery have not been applied specifically to patients undergoing breast surgery. Methods: Based on the core features of ERAS, individual aspects of postoperative care in breast surgery were defined. A comprehensive search of MEDLINE, PubMed, Embase and the Cochrane Library database was performed from 1980 to 2010 to determine the best evidence for perioperative care in oncological breast surgery. A graded recommendation based on the best level of evidence was then proposed for each feature of ERAS. Results: Twelve core features of enhanced recovery after breast surgery were identified. Use of the thoracic block, from both analgesic and anaesthetic viewpoints, is well supported by evidence and should be encouraged. Trials specific to breast surgery regarding aspects such as perioperative fasting, preanaesthetic medication, prevention of hypothermia and postdischarge support are scarce, and evidence was extrapolated from non-breast trials. Trials on postoperative analgesia and prevention of postoperative nausea and vomiting in breast surgery are generally of small numbers. In addition, there is heterogeneity between studies. Conclusion: This review suggests that the principles of enhanced recovery can be adopted in breast surgery. A 12-point protocol is proposed for prospective evaluation.