Enhanced recovery after surgery: A clinical review of implementation across multiple surgical subspecialties.

Enhanced recovery after surgery (ERAS) is a multimodal protocol applied towards perioperative patient care. ERAS programs are implemented by a multidisciplinary team centered around the patient, incorporating outpatient clinical staff, preoperative nurses, anesthesiologists, operative nurses, postoperative recovery staff, floor inpatient nurses, dieticians, physical therapists, social workers, and surgeons. Initial studies on perioperative care measures focused on cardiac surgery. Subsequently, the development of the ERAS Study Group in 2001 focused on colorectal surgery and postoperative outcome measures. Today, ERAS protocols have been implemented across many surgical subspecialties including: bariatric, breast, plastic, cardiac, colorectal, esophageal, head and neck, hepatic, gynecologic, neurosurgical, orthopedic, pancreatic, thoracic, and urologic surgery. The goal of ERAS programs is to promote rapid recovery as quantified by decreasing the length of hospital stay, complications, and cost of specific surgical interventions. In the setting of the opioid crisis in America, there is also an increasing focus on minimizing perioperative narcotic use. The purpose of this review is to compare ERAS protocols across surgical subspecialties, focusing on quantified metrics of improvement, and to provide a clear and concise summary of the literature in regards to current ERAS practices and success rates.

Considerations for sentinel lymph node biopsy in breast cancer patients with biopsy proven axillary disease prior to neoadjuvant treatment.

BACKGROUND: Axillary disease can be downstaged with neoadjuvant treatment for breast cancer. We attempted to identify factors to consider in determining whether to perform a sentinel lymph node biopsy in patients with biopsy proven axillary metastases (cN+) prior to neoadjuvant treatment. METHODS: A retrospective chart review was conducted on patients at a single tertiary care center who underwent neoadjuvant treatment followed by surgery between 9/2013 and 2/2017. RESULTS: 47% of patients with node positive disease prior to neoadjuvant treatment were downstaged to node negative (ypN0) disease. These patients were more likely to have triple negative or Her2 positive disease than those patients who remained node positive (ypN+) as these were more likely to have hormone receptor positive disease. These patients were also more likely to demonstrate complete clinical imaging response of the primary tumor and axilla on preoperative breast MRI. CONCLUSIONS: Tumor biology and clinical response noted on breast MRI can help guide the decision to perform sentinel lymph node biopsy in patients with axillary node positive disease prior to neoadjuvant treatment.