Decreased Postoperative Emesis and Opioid Use After Implementation of ERAS Protocol for Free Flap Surgery

Introduction: Enhanced Recovery After Surgery (ERAS) protocols are designed to improve surgical patient outcomes. In this study, we compare outcomes for patients undergoing head and neck free flap surgery at a tertiary care institution before and after an ERAS protocol was implemented.

Methods: Retrospective evaluation of outcome data from patients who underwent head and neck surgery with free flap reconstruction prior to ERAS (Jan 2018-Jun 2022, baseline) with patient outcomes after ERAS implementation (Jul 2022-Sep 2023, ERAS). Outcomes studied included length of stay, opioid utilization, post-operative emesis, readmission, and mortality.

Results: There were 329 patients in the baseline group and 115 patients in the ERAS group. ERAS patients had significantly lower opioid utilization (135 ± 217 MME vs. 266 ± 431, p< 0.01) as well as significantly lower rates of post-operative emesis (OR 0.05, p< 0.01). This difference in emesis remained significant in the subgroup of patients who underwent total laryngectomy. There was a marginally significant increase in 30-day readmission in the ERAS group (OR 1.9, p=0.046). We found no significant decrease in length of stay or mortality.

Conclusions: In the year after implementing an ERAS protocol for head and neck free flap surgery patients, we found significantly lower opioid utilization and the unique finding of lower post-operative emesis overall and in the laryngectomy subgroup for whom emesis-induced fistula is most impactful. No difference was noted in length of stay or mortality, likely due to pre-existing protocols that guide clinical workflow. To our knowledge this is the first study of an ERAS protocol for head and neck surgery to show a decrease in post-operative emesis.