Evaluation of the Feasibility, Safety, and Effectiveness of a Tailored Enhanced Recovery After Surgery Protocol for Gastroepiploic Vascularized Lymph Node Transfer in Breast Cancer-Related Upper Extremity Lymphedema: A Preliminary Retrospective Comparative Study.

Abstract

Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative pathways designed to reduce surgical stress, accelerate recovery, and improve resource utilization. Although ERAS principles have been increasingly adopted in microsurgery, their application in vascularized lymph node transfer (VLNT), particularly using gastroepiploic flaps, remains poorly defined. The aim of this study was to evaluate the feasibility, safety, and effectiveness of a tailored ERAS protocol in patients undergoing gastroepiploic VLNT for breast cancer-related upper extremity lymphedema. A retrospective comparative study was conducted in patients with unilateral breast cancer-related upper extremity lymphedema (ISL Stage II-III) undergoing gastroepiploic vascularized lymph node transfer after failure of at least 6 months of conservative treatment. Patients were managed either with a conventional perioperative protocol, including nasogastric tube placement, delayed oral intake, delayed mobilization, opioid-based analgesia, and delayed initiation of complete decongestive therapy (CDT), or with a tailored ERAS-VLNT protocol incorporating early oral intake, early mobilization, opioid-sparing analgesia, avoidance of nasogastric decompression, and CDT initiation from postoperative Day 7. Outcomes included circumferential reduction rate, LYMQOL score, infection rate, flap-related complications, length of hospital stay, and hospitalization costs. A total of 45 patients were included, with 29 in the ERAS group and 16 in the conventional group. Baseline demographic and clinical characteristics were comparable between groups. The ERAS group demonstrated a significantly shorter hospital stay (2.34 ± 0.48 vs. 5.56 ± 0.51 days, p < 0.001) and lower estimated hospitalization costs (€1400 vs. €3300, p < 0.001). Flap survival was 100% in both groups, with no flap-related complications. Circumferential reduction rate was comparable between groups (44.39% ± 10.20% vs. 47.53% ± 8.26%, p = 0.278), as were LYMQOL scores at 12 months (8.21 ± 0.73 vs. 7.93 ± 0.70, p = 0.236) and infection rates (2.62 ± 0.90 vs. 2.73 ± 0.96 episodes/year, p = 0.71). An ERAS-based protocol tailored to VLNT is feasible and safe, and is associated with improved perioperative recovery and reduced healthcare costs without evidence of compromised surgical or functional outcomes. These findings support the integration of ERAS principles into lymphatic microsurgery and warrant further prospective validation.