Breast Surgery in the Time of Global Pandemic: Benefits of Same-Day Surgery for Breast Cancer Patients Undergoing Mastectomy with Immediate Reconstruction during COVID-19

Sir:

I read with interest the Viewpoint published in the October 2020 issue by Perez-Alvarez et al.¹ describing their preliminary experience with same-day surgery after mastectomy and immediate implant-based reconstruction during the coronavirus disease of 2019 (COVID-19) pandemic. Their group began offering patients same-day surgery in 2018 and began enrolling patients in a prospective clinical trial comparing same-day surgery with inpatient admission in 2019. While not providing extensive details about their protocol and results, they describe an enhanced recovery after anesthesia protocol and the use of intraoperative liposomal bupivacaine blocks to facilitate same-day surgery. They do mention that the majority of these reconstructions were performed in the prepectoral plane, as these patients would be expected to have significantly less immediate postoperative pain. Preliminarily, their results demonstrate no emergency room admissions or readmissions and no increased need for postoperative opioid prescriptions. While these findings have important implications for our general approach to immediate implant-based breast reconstruction, the authors correctly point out that their findings have even more relevance during the COVID-19 pandemic. Same-day surgery reduces strain on hospital resources and staff utilization, both of which are in short supply as the pandemic intensifies. They also cite data from publications looking at same-day surgery for mastectomy alone that demonstrate improved psychological well-being, decreased exposure to nosocomial infections, and decreased burden on the health care system, and extrapolate that same-day surgery for mastectomy and immediate implant-based reconstruction would likely provide these benefits as well.²

I am in agreement with these findings and recently published results for 106 consecutive patients (183 breasts) who underwent mastectomy and immediate implant-based reconstruction and same-day discharge from my institution’s ambulatory surgery center.³ My experience started in July of 2017 and is currently ongoing, now with more than 200 patients undergoing same-day surgery. I utilize preoperative celecoxib, gabapentin, and acetaminophen⁴ and perform intraoperative pectoral nerve blocks to minimize narcotic requirements and to facilitate same-day surgery. While my recent publication described tissue expander reconstruction, my current standard is to go direct to implant. I demonstrated no difference in complications between patients who underwent same-day surgery in the ambulatory surgery center versus those patients who were admitted to the hospital. As Perez-Alvarez et al. found, I also noted no unplanned readmissions for pain, nausea, or vomiting. I also found improved patient satisfaction for patients who had surgery in the ambulatory surgery center, as the process is more efficient and personal, with only two operating rooms, increased privacy, and more dedicating nursing staff. Interestingly, I also found a significantly reduced rate of major infectious complications requiring reoperation for implant salvage or removal when retrospectively compared to a similar cohort of my patients operated on in the hospital with or without admission.

My article discussed the relevance of the findings given the COVID-19 pandemic with regard to cost savings, decreased utilization of health care resources, and increased patient safety. I pointed out that surgery in the ambulatory surgery center with same-day discharge is almost certainly safer for immunocompromised patients who have or will be receiving chemotherapy, as there will be less exposure to nosocomial infections in the hospital. I concluded that as ambulatory surgery centers are inherently more cost-effective and have a possibly reduced infection rate, shifting surgery to the ambulatory surgery center with same-day discharge will have the most pronounced impact on reducing costs and decreasing utilization of resources during this critical time. Finally, I noted that surgery in an ambulatory surgery center also frees up hospital beds and operating rooms for the more acutely ill. I acknowledge that not all surgeons have access to an ambulatory surgery center where breast reconstruction can be performed. Regardless, I strongly urge surgeons to at least consider same-day discharge after mastectomy and implant-based reconstruction in the hospital during these critical times, as Perez-Alvarez et al. and I have shown that it is safe. I again maintain that admission after mastectomy and immediate prepectoral reconstruction should be the exception and not the rule.

DISCLOSURE

The author has no financial interest to disclose in relation to the content of this communication.

Jean-Claude Schwartz, M.D., Ph.D.
Northside Hospital
Northside Gwinnett Surgical Associates
631 Professional Drive, Suite 300
Lawrenceville, Ga. 30046
gabreastsurgery@gmail.com

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