Deep Inferior Artery Perforator Flap–Enhanced Recovery After Surgery: Perspectives From Australia's Only Public Cancer‐Specific Hospital

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways are increasingly utilised in autologous breast reconstruction (ABR) to improve patient outcomes. This Australian study evaluates the impact of our centre's newly standardised electronic ERAS pathway from 2023 to 2024 compared to a transitional ERAS cohort from 2017 to 2018. METHODS: A perioperative ERAS protocol was implemented for patients undergoing DIEP flap reconstruction for therapeutic or prophylactic mastectomies. Key components included comprehensive patient education, standardised perioperative surgical proformas, goal-directed fluid resuscitation, mitigation of opioid use, early mobilisation, and diet reintroduction. Outcomes from the 2023-2024 cohort were compared with the 2017-2018 cohort. The primary endpoint was length of stay (LoS), from admission to discharge. Secondary endpoints included daily and total oral morphine-equivalent daily dosage (oMEDD, mg), incidence and duration of patient-controlled analgesia (PCA, hours), Days 1-4 pain scores and rates of major and minor complications alongside standardised Clavien-Dindo classifications. RESULTS: A total of 102 patients were analysed (transitional ERAS, n = 48; standardised ERAS, n = 54). LoS for the whole cohort of unilateral and bilateral patients decreased from 5.8 days (5.0-6.6) to 4.5 days (4.1-5.0), p = 0.007. Total oMEDD reduced from 155.0 mg (134.3-175.5) to 111.6 mg (85.0-138.2), p = 0.011. PCA incidence remained unchanged at 16.7%, but duration decreased from 31.8 h (19.9-43.8) to 14.2 h (11.7-16.7), p = 0.010. These trends were consistent across subgroup analysis. No significant difference in major complication rate was observed. Minor complications showed a marginal decline. CONCLUSION: Our standardised ERAS pathway for DIEP flap reconstruction significantly reduced LoS and PCA duration without increasing major or minor complication rates. These findings underscore the value of multidisciplinary perioperative collaboration and establish a framework for best practices in ABR within the Australian healthcare context.