TRANSformed Anesthesia: Examining a Novel ERAS Pathway for Gender-Affirming Chest Reconstruction Surgery
Michael Brule MD (he/him), Travis Reece-Nguyen MD, MPH, FAAP (he/him)
The Gender-Affirming Surgical Perioperative Program (GASPP) at Boston Children’s Hospital was established in November 2019 to provide a safe and affirming environment for transgender and gender-diverse (TGD) patients while addressing their unique perioperative care needs.1 The GASPP Team recently published a novel ERAS pathway for TGD patients undergoing chest reconstruction surgery. Firstly, we wish to commend the extensive effort the GASPP Team put into this research and for the incredible perioperative gender-affirming care they provide. Secondly, we want to note that – to our knowledge - this is the first suggested ERAS pathway specifically for TGD patients undergoing chest reconstruction surgery and establishes a major milestone in furthering the progression of safe and effective care for TGD patients. We’ve chosen to discuss this article because many aspects of the proposed ERAS pathway closely mirror those found in the cisgender surgical literature and can be easily adapted across surgery centers; however, the proposed novel ERAS pathway is notable for two main deviations: the addition of intraoperative tranexamic acid and the lack of regional anesthesia use.
Original article:
Aquino NJ, Goobie SM, Staffa SJ, Eastburn E, Ganor O, Jones CT. Implementation of an Enhanced Recovery after Surgery Pathway for Transgender and Gender-Diverse Individuals Undergoing Chest Reconstruction Surgery: An Observational Cohort Study. J Clin Med. 2023 Nov 14;12(22):7083. doi: 10.3390/jcm12227083. PMID: 38002695; PMCID: PMC10672389.
It is well-established that providing gender-affirming care (GAC) leads to improved mental health outcomes and can ultimately be a life-saving treatment for TGD patients.2 According to a recent 2023 article, the most common gender-affirming surgery completed for TGD adolescents was chest reconstruction surgery, also known as chest masculinization/feminization, chest contouring, or more colloquially as “top surgery.”3 These procedures aim to augment or remove breast tissue, reshape the remaining tissues to achieve a more masculine or feminine chest contour, and finally reposition the nipple-areolar complex resulting in a chest appearance better aligned with the patient’s gender identity. Chest reconstruction surgeries for TGD patients have relatively low complication rates and are associated with improved body dysphoria, gender congruence, body image satisfaction, and a low-likelihood of post-surgical regret.4,5
Among anesthesiology providers, there is often a lack of education and/or understanding about the needs of transgender patients, even if providers’ attitudes toward and intent to understand TGD patients are positive.6,7 Furthermore, anesthetic management for these surgeries can vary wildly across institutions and there is little consensus on what constitutes best practice. Transmasculine and non-binary patients presenting for chest masculinization surgery often have distinct psychosocial and physiologic factors that require diligence on the part of the anesthesiology team. For instance, unique to many transmasculine and non-binary patients is the practice of chest binding to compress breast tissue, which helps improve mental health and gender congruency, but may simultaneously result in negative physical health symptoms, such as impaired respiratory mechanics, chronic pain or neurologic sequelae.8 Anesthesiology teams must also think critically about whether or not their transmasculine patients need preoperative pregnancy testing and/or counseling regarding use of birth control after sugammadex administration.
When looking at chest reconstruction for cisgender women, various ERAS pathways exist and highlight the importance of psychosocial support, promotion of wound healing, decreasing bleeding risk, using TIVA when appropriate, PONV mitigation, and multimodal analgesia versus regional anesthesia (including paravertebral, erector-spinae, serratus and pectoralis blocks (PECS I/II) delivered as either single shot or via a continuous catheter) to decrease postoperative opioid consumption and hospital length of stay.9 Multiple studies in the adult literature concluded that PECS II blocks are superior to erector-spinae for chest surgeries.10,11,12 Data on whether these practices can be extrapolated to chest masculinization surgery, however, is unfortunately lacking. Interestingly, a 2021 study did compare regional techniques used specifically in gender-affirming chest reconstructions and showed that patients who received ultrasound-guided PECS II blocks reported less pain and used fewer opioids in the PACU compared to those that received the conventional, blind intercostal nerve block.13 Notably, the GASPP Team ERAS pathway being discussed does not utilize or recommend any specific regional anesthesia techniques.
Overall, most of the authors’ findings were consistent with other published reports of ERAS pathways used in cisgender chest reconstruction surgeries. The implementation of their pathway and the use of intraoperative TXA was associated with a shorter length of stay (1.1 to 0.3 days; p < 0.001), although this finding cannot be directly attributed to their ERAS pathway given the confounding impact COVID-19 had on scheduling practices, which the authors appropriately discuss as a study limitation. While their recommendations for a TIVA, multimodal pain control, and aggressive PONV prophylaxis echo other ERAS pathways, the authors’ recommendations to utilize an intraoperative TXA bolus and infusion, as well as routinely avoid regional anesthesia, are novel. When analyzing their outcomes data, the most common adverse events reported were hematoma formation and return to the OR within 24hrs, which prompted the proposed intervention of TXA. Interestingly, the rate of hematoma formation remained similar and not statistically different from the traditional cohort after instituting the use of intraoperative TXA. With that being said, the use of TXA in their pathway was associated with higher rates of discharge home (p < 0.001), decreased PACU and 24hr JP drainage (p < 0.001), and a lower volume of cases returning to the OR within 24hr for hematoma evacuation (p < 0.047). Despite not lowering the rate of hematoma formation, it does appear that TXA might improve patient care as evidenced by these secondary outcome measures. Also worth noting, the incidence of inpatient PONV was 12% lower in the ERAS groups when compared to the traditional cohort, which can be attributed to their comprehensive PONV prophylaxis regimen (combination of TIVA techniques, dexamethasone, ondansetron, and scopolamine).
We want to again express our gratitude for the authors’ dedication to advancing the field of gender-affirming perioperative care and addressing the healthcare disparities experienced by TGD patients. This novel ERAS pathway not only contributes to improving the perioperative experiences of TGD patients, but it also has the potential to foster greater acceptance and understanding among healthcare providers, thus reducing disparities and promoting more compassionate care throughout our specialty. By shedding light on these issues and exploring innovative solutions, the authors are actively contributing to the betterment of healthcare practices and paving the way for a more inclusive and equitable healthcare system.
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References:
1: Aquino NJ, Boskey ER, Staffa SJ, et al. A Single Center Case Series of Gender-Affirming Surgeries and the Evolution of a Specialty Anesthesia Team. J Clin Med. 2022;11(7):1943. Published 2022 Mar 31. doi:10.3390/jcm11071943
2: Almazan AN, Keuroghlian AS. Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surg. 2021, 156, 611.
3: Uffman JC, Willer BL, Mpody C, et al. Characteristics of Transgender and Gender-Diverse Youth Presenting for Surgery in the United States. Anesth Analg. 2023 Oct 1;137(4):882-886. doi: 10.1213/ANE.0000000000006618. Epub 2023 Jul 20. PMID: 37471293.
4: Bustos VP, Bustos SS, Mascaro A, et al. Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence. Plast Reconstr Surg Glob Open. 2021 Mar 19;9(3):e3477. doi: 10.1097/GOX.0000000000003477. Erratum in: Plast Reconstr Surg Glob Open. 2022 Apr 28;10(4):e4340. PMID: 33968550; PMCID: PMC8099405.
5: Ascha M, Sasson DC, Sood R, et al. Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults. JAMA Pediatr. 2022 Nov 1;176(11):1115-1122. doi: 10.1001/jamapediatrics.2022.3424. PMID: 36156703; PMCID: PMC9513704.
6: Roque, R.A., O’Reilly-Shah, V., Lorello, G.R. et al. Transgender patient care: a prospective survey of pediatric anesthesiologist attitudes and knowledge. Can J Anesth/J Can Anesth 68, 1723–1726 (2021). https://doi.org/10.1007/s12630-021-02089-w
7: Blanchard E, Evans R, Abdullatif H, et al. Beliefs and Intentions of Anesthesia Physicians Toward Providing Culturally Competent Care to Transgender Patients. Transgend Health. 2023 Dec 13;8(6):542-549. doi: 10.1089/trgh.2022.0041. PMID: 38130981; PMCID: PMC10732157.
8: Jarrett BA, Corbet AL, Gardner IH, et al. Chest Binding and Care Seeking Among Transmasculine Adults: A Cross-Sectional Study. Transgend Health. 2018 Dec 14;3(1):170-178. doi: 10.1089/trgh.2018.0017. PMID: 30564633; PMCID: PMC6298447.
9: Temple-Oberle C, Shea-Budgell M, Tan M, et al. Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plastic and Reconstructive Surgery 139(5):p 1056e-1071e, May 2017. | DOI: 10.1097/PRS.0000000000003242
10: Schwemmer U. Breast surgery and peripheral blocks. Is it worth it? Curr Opin Anaesthesiol. 2020 Jun;33(3):311-315. doi: 10.1097/ACO.0000000000000863. PMID: 32324660.
11: Sinha C, Kumar A, Kumar A, et al. Pectoral nerve versus erector spinae block for breast surgeries: A randomised controlled trial. Indian J Anaesth. 2019 Aug;63(8):617-622. doi: 10.4103/ija.IJA_163_19. PMID: 31462806; PMCID: PMC6691635.
12: Hong B, Bang S, Oh C, et al. Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group. J Anesth. 2021 Oct;35(5):723-733. doi: 10.1007/s00540-021-02923-x. Epub 2021 Mar 30. PMID: 33786681.
13: Rokhtabnak F, Sayad S, Izadi M, et al. Pain Control After Mastectomy in Transgender Patients: Ultrasound-guided Pectoral Nerve Block II Versus Conventional Intercostal Nerve Block: A Randomized Clinical Trial. Anesth Pain Med. 2021 Nov 10;11(5):e119440. doi: 10.5812/aapm.119440. PMID: 35070905; PMCID: PMC8771815.