{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T02:49:14Z","timestamp":1786502954639,"version":"build-2736575974"},"reference-count":58,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2025,9,28]],"date-time":"2025-09-28T00:00:00Z","timestamp":1759017600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.mdpi.com"],"crossmark-restriction":true},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Our objective was to evaluate the clinical feasibility and sustainability of an awake breast conserving surgery (BCS) protocol integrating opioid-free anesthesia, telemedicine, and environmental sustainability compared to standard care. Methods: A prospective, monocentric, non-inferiority randomized controlled trial (133.24 CET2 ptv; NCT06624917) named Breast Green Surgery (BuGS) was planned. Women aged 18\u201375 years eligible for level I BCS were randomized to either the BuGS group\u2014comprising opioid-free monitored anesthesia care (MAC), a telehealth follow-up, and intraoperative waste reduction\u2014or the control. The primary endpoint was postoperative pain at rest (PPR) and during movement (PPD) both at 24 h, measured with the Numeric Pain Rating Scale (NPRS). Secondary exploratory endpoints included SF-36, PSQ-18, TSQ test, LOS, and KgCO2 equivalent (KgCO2e) from surgical waste, patient transport, and complications. The interim analysis included patients completing a 30-day follow-up by 31 December 2024. Results: A total of 45 patients were enrolled (BuGS n = 18, control n = 27). While disproportionate, no significant differences were observed in PPR\/PPD at 24 h (4.75 (3.725\u20135.875) vs. 4.5 (4.15\u20135.35); p = 0.626; 4 (3.10\u20134.75) vs. 4.6 (3.90\u20135.2); p = 0.130), confirmed using group ANOVA analysis (p = 0.515; p = 0.779, respectively). The BuGS group reported a reduced surgical room occupation (80.03 (64.84\u2013101.87) vs. 133.23 (95.47\u2013144.25) min; p = 0.002) and length of stay (0 (0\u20131) vs. 1 (1\u20132); p = 0.0001), without hospital unplanned admissions. Reduced KgCO2e emissions from waste disposal were reported, with no difference in SF-36, PSQ-18, and complication rates. Conclusions: If confirmed after complete accrual, BuGS could potentially promote a clinically equivalent, environmentally sustainable, and hospital efficient surgery without affecting the QoL of our patients. Further multicentric validation is warranted.<\/jats:p>","DOI":"10.3390\/jcm14196881","type":"journal-article","created":{"date-parts":[[2025,9,30]],"date-time":"2025-09-30T09:12:23Z","timestamp":1759223543000},"page":"6881","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Feasibility of a Green Breast Surgery Protocol to Reduce Carbon Footprint of Care: BuGS Trial Interim Results"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3006-5855","authenticated-orcid":false,"given":"Gianluca","family":"Vanni","sequence":"first","affiliation":[{"name":"Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, 00133 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3599-061X","authenticated-orcid":false,"given":"Marco","family":"Materazzo","sequence":"additional","affiliation":[{"name":"Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, 00133 Rome, Italy"},{"name":"PhD Program in Applied Medical-Surgical Sciences, Department of Surgical Science, Tor Vergata University, 00133 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Pellicciaro","sequence":"additional","affiliation":[{"name":"Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, 00133 Rome, Italy"},{"name":"PhD Program in Applied Medical-Surgical Sciences, Department of Surgical Science, Tor Vergata University, 00133 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan","family":"Caspi","sequence":"additional","affiliation":[{"name":"Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, 00133 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-6067-277X","authenticated-orcid":false,"given":"Giordana","family":"Di Mauro","sequence":"additional","affiliation":[{"name":"School of Specialization in Medical Oncology, Department of Human Pathology \u201cG. Barresi\u201d, University of Messina, 98125 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federico","family":"Tacconi","sequence":"additional","affiliation":[{"name":"Unit of Thoracic Surgery, Department of Surgical Sciences, Tor Vergata University, 00133 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denisa","family":"Eskiu","sequence":"additional","affiliation":[{"name":"PhD Program in Applied Medical-Surgical Sciences, Department of Surgical Science, Tor Vergata University, 00133 Rome, Italy"},{"name":"Faculty of Medicine, Universit\u00e0 Cattolica Nostra Signora Del Buon Consiglio, 1000 Tirana, Albania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8671-0609","authenticated-orcid":false,"given":"Benedetto","family":"Longo","sequence":"additional","affiliation":[{"name":"Plastic Surgery, Department of Surgical Sciences, University of Rome \u201cTor Vergata\u201d, 00133 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valerio","family":"Cervelli","sequence":"additional","affiliation":[{"name":"Plastic Surgery, Department of Surgical Sciences, University of Rome \u201cTor Vergata\u201d, 00133 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9837-9148","authenticated-orcid":false,"given":"Massimiliano","family":"Berretta","sequence":"additional","affiliation":[{"name":"Division of Medical Oncology, AOU \u201cG.Martino\u201d Hospital, University of Messina, 98166 Messina, Italy"},{"name":"Department of Clinical and Experimental Medicine, University of Messina, 98166 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oreste Claudio","family":"Buonomo","sequence":"additional","affiliation":[{"name":"Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, 00133 Rome, Italy"},{"name":"General Surgery Program, Department of Health Science, University of Basilicata (UNIBAS), 85100 Potenza, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"on behalf of BuGS Study Group","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1016\/j.breast.2022.08.010","article-title":"Current and Future Burden of Breast Cancer: Global Statistics for 2020 and 2040","volume":"66","author":"Arnold","year":"2022","journal-title":"Breast"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"628","DOI":"10.1001\/jamasurg.2021.1438","article-title":"Survival After Breast Conservation vs Mastectomy Adjusted for Comorbidity and Socioeconomic Status: A Swedish National 6-Year Follow-up of 48 986 Women","volume":"156","author":"Szulkin","year":"2021","journal-title":"JAMA Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"7463","DOI":"10.1245\/s10434-024-15711-0","article-title":"Comparing Costs: Does Extreme Oncoplastic Breast-Conserving Surgery Confer a Cost Benefit When Compared with Mastectomy and Reconstruction?","volume":"31","author":"Millen","year":"2024","journal-title":"Ann. Surg. Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1412","DOI":"10.21873\/invivo.13225","article-title":"Awake Breast Surgery: A Systematic Review","volume":"37","author":"Vanni","year":"2023","journal-title":"In Vivo"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1928","DOI":"10.1007\/s12630-023-02567-3","article-title":"Comparison of the Quality of Recovery-15 Score in Patients Undergoing Oncoplastic Breast-Conserving Surgery under Monitored Anesthesia Care versus General Anesthesia: A Prospective Quality Improvement Study","volume":"70","author":"Rajaee","year":"2023","journal-title":"Can. J. Anesth.\/J. Can. D\u2019anesth\u00e9sie"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Buonomo, O.C., Vinci, D., De Carolis, G., Pellicciaro, M., Petracca, F., Sadri, A., Buonomo, C., Dauri, M., and Vanni, G. (2022). Role of Breast-Conserving Surgery on the National Health System Economy From and to SARS-COVID-19 Era. Front. Surg., 8.","DOI":"10.3389\/fsurg.2021.705174"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"12738","DOI":"10.1007\/s10668-021-01240-3","article-title":"Positive Environmental Effects of the Coronavirus 2020 Episode: A Review","volume":"23","author":"Mousazadeh","year":"2021","journal-title":"Environ. Dev. Sustain."},{"key":"ref_8","first-page":"e2830","article-title":"Revolutionizing Women\u2019s Health Care with a Sustainable Change: Breast Green Surgery (BuGS) Protocol","volume":"11","author":"Vanni","year":"2024","journal-title":"World Cancer Res. J."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"115859","DOI":"10.1016\/j.envpol.2020.115859","article-title":"Links between Air Pollution and COVID-19 in England","volume":"268","author":"Travaglio","year":"2021","journal-title":"Environ. Pollut."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e04965","DOI":"10.1016\/j.heliyon.2020.e04965","article-title":"Environmental Effects of COVID-19 Pandemic and Potential Strategies of Sustainability","volume":"6","author":"Rume","year":"2020","journal-title":"Heliyon"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Ihsan, F.R., Bloomfield, J.G., and Monrouxe, L.V. (2024). Triple Planetary Crisis: Why Healthcare Professionals Should Care. Front. Med., 11.","DOI":"10.3389\/fmed.2024.1465662"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1097\/SLA.0000000000003951","article-title":"The Carbon Footprint of Surgical Operations: A Systematic Review","volume":"272","author":"Rizan","year":"2020","journal-title":"Ann. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1308\/rcsbull.2020.148","article-title":"Using Surgical Sustainability Principles to Improve Planetary Health and Optimise Surgical Services Following the COVID-19 Pandemic","volume":"102","author":"Rizan","year":"2020","journal-title":"Bull. R. Coll. Surg. Engl."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1867","DOI":"10.21873\/invivo.13278","article-title":"From Patient Reported Outcome Measure (PROM) to Environment Related Outcome Measure (EROM): Towards \u201cGreen Breast Surgery\u201d","volume":"37","author":"Vanni","year":"2023","journal-title":"In Vivo"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e081123","DOI":"10.1136\/bmj-2024-081123","article-title":"CONSORT 2025 Statement: Updated Guideline for Reporting Randomised Trials","volume":"389","author":"Hopewell","year":"2025","journal-title":"BMJ"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1308\/rcsbull.2023.25","article-title":"The Intercollegiate Green Theatre Checklist","volume":"105","author":"Robb","year":"2023","journal-title":"Bull. R. Coll. Surg. Engl."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1056e","DOI":"10.1097\/PRS.0000000000003242","article-title":"Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations","volume":"139","author":"Tan","year":"2017","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_18","unstructured":"Royal College of Pathologists (2021). Guidelines for Non-Operative Diagnostic Procedures and Reporting in Breast Cancer Screening, The Royal College of Pathologists."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"109448","DOI":"10.1016\/j.ejso.2024.109448","article-title":"Assessing the Efficacy of Clavien-Dindo Classification and Comprehensive Complication Index (CCI) in Reporting Post Operative Complications Following Breast Surgery. Do We Need a Breast Specific Complication System?","volume":"50","author":"Khatun","year":"2024","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e170","DOI":"10.1111\/ajd.13522","article-title":"Carbon Footprint of Dermatologic Surgery","volume":"62","author":"Tan","year":"2021","journal-title":"Australas. J. Dermatol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"125446","DOI":"10.1016\/j.jclepro.2020.125446","article-title":"The Carbon Footprint of Waste Streams in a UK Hospital","volume":"286","author":"Rizan","year":"2021","journal-title":"J. Clean. Prod."},{"key":"ref_22","first-page":"825","article-title":"Landfilling of Waste: Accounting of Greenhouse Gases and Global Warming Contributions","volume":"27","author":"Manfredi","year":"2009","journal-title":"Waste Manag. Res. J. Sustain. Circ. Econ."},{"key":"ref_23","unstructured":"DEFRA (2025, July 29). Experimental Statistics on the Carbon Impact of Waste from Households Managed by Local Authorities in England, Available online: https:\/\/www.gov.uk\/government\/statistics\/experimental-statistics-on-the-carbon-impact-of-waste-from-households-managed-by-local-authorities-in-england."},{"key":"ref_24","unstructured":"Institute for Applied Ecology (2022). Climate Impact of Pyrolysis of Waste Plastic Packaging in Comparison with Reuse and Mechanical Recycling, Institute for Applied Ecology."},{"key":"ref_25","unstructured":"European Commission (2021). Joint Research Centre. Environmental Effects of Plastic Waste Recycling, Publications Office."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1991","DOI":"10.1007\/s00345-020-03432-4","article-title":"Preliminary Assessment of Patient and Physician Satisfaction with the Use of Teleconsultation in Urology during the COVID-19 Pandemic","volume":"39","author":"Pinar","year":"2021","journal-title":"World J. Urol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1486","DOI":"10.1038\/s41416-021-01555-y","article-title":"Multicenter Evaluation of Breast Cancer Patients\u2019 Satisfaction and Experience with Oncology Telemedicine Visits during the COVID-19 Pandemic","volume":"125","author":"Bizot","year":"2021","journal-title":"Br. J. Cancer"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1007\/s11136-014-0785-6","article-title":"A Methodological Review of the Short Form Health Survey 36 (SF-36) and Its Derivatives among Breast Cancer Survivors","volume":"24","author":"Treanor","year":"2015","journal-title":"Qual. Life Res."},{"key":"ref_29","unstructured":"Marshall, G., and Hays, R. (1994). The Patient Satisfaction Questionnaire Short-Form (PSQ-18), Rand."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1038\/s41523-022-00383-4","article-title":"De-Escalation in Breast Cancer Surgery","volume":"8","author":"Shubeck","year":"2022","journal-title":"Npj Breast Cancer"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"704","DOI":"10.1245\/s10434-014-3481-4","article-title":"Society of Surgical Oncology\u2013American Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery with Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer","volume":"21","author":"Moran","year":"2014","journal-title":"Ann. Surg. Oncol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e203025","DOI":"10.1001\/jamasurg.2020.3025","article-title":"Changes in Reoperation After Publication of Consensus Guidelines on Margins for Breast-Conserving Surgery: A Systematic Review and Meta-Analysis","volume":"155","author":"Marinovich","year":"2020","journal-title":"JAMA Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"918","DOI":"10.1001\/jama.2017.11470","article-title":"Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial","volume":"318","author":"Giuliano","year":"2017","journal-title":"JAMA"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1303","DOI":"10.1016\/S1470-2045(14)70460-7","article-title":"Radiotherapy or Surgery of the Axilla after a Positive Sentinel Node in Breast Cancer (EORTC 10981-22023 AMAROS): A Randomised, Multicentre, Open-Label, Phase 3 Non-Inferiority Trial","volume":"15","author":"Donker","year":"2014","journal-title":"Lancet Oncol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"108843","DOI":"10.1016\/j.surg.2024.08.047","article-title":"Implementation of Choosing Wisely Guidelines: Omission of Lymph Node Surgery","volume":"179","author":"Whitrock","year":"2025","journal-title":"Surgery"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1720","DOI":"10.1200\/JCO-25-00099","article-title":"Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer: ASCO Guideline Update","volume":"43","author":"Park","year":"2025","journal-title":"J. Clin. Oncol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1557","DOI":"10.1001\/jamaoncol.2023.3759","article-title":"Sentinel Lymph Node Biopsy vs No Axillary Surgery in Patients with Small Breast Cancer and Negative Results on Ultrasonography of Axillary Lymph Nodes: The SOUND Randomized Clinical Trial","volume":"9","author":"Gentilini","year":"2023","journal-title":"JAMA Oncol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1056\/NEJMoa2207586","article-title":"Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer","volume":"388","author":"Kunkler","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Ivascu, R., Torsin, L.I., Hostiuc, L., Nitipir, C., Corneci, D., and Dutu, M. (2024). The Surgical Stress Response and Anesthesia: A Narrative Review. J. Clin. Med., 13.","DOI":"10.3390\/jcm13103017"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"759","DOI":"10.23736\/S0375-9393.24.18125-4","article-title":"Opioid-Free Anesthesia Improves Postoperative Recovery Quality of Small and Medium-Sized Surgery: A Prospective, Randomized Controlled Study","volume":"90","author":"Wang","year":"2024","journal-title":"Minerva Anestesiol."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Choi, H., and Hwang, W. (2024). Anesthetic Approaches and Their Impact on Cancer Recurrence and Metastasis: A Comprehensive Review. Cancers, 16.","DOI":"10.3390\/cancers16244269"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1048","DOI":"10.1111\/aas.13644","article-title":"Survival after Primary Breast Cancer Surgery Following Propofol or Sevoflurane General Anesthesia\u2014A Retrospective, Multicenter, Database Analysis of 6305 Swedish Patients","volume":"64","author":"Enlund","year":"2020","journal-title":"Acta Anaesthesiol. Scand."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Xie, S., Li, L., Meng, F., and Wang, H. (2024). Regional Anesthesia Might Reduce Recurrence and Metastasis Rates in Adult Patients with Cancers after Surgery: A Meta-Analysis. BMC Anesthesiol., 24.","DOI":"10.1186\/s12871-023-02400-w"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1243","DOI":"10.2147\/JPR.S252377","article-title":"Acute Cytokine Response During Breast Cancer Surgery: Potential Role of Dexamethasone and Lidocaine and Relationship with Postoperative Pain and Complications\u2014Analysis of Three Pooled Pilot Randomized Controlled Trials","volume":"13","author":"Bronkhorst","year":"2020","journal-title":"J. Pain Res."},{"key":"ref_45","first-page":"158","article-title":"Pain Therapy to Reduce Perioperative Complications","volume":"4","author":"Freys","year":"2019","journal-title":"Innov. Surg. Sci."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Ghadimi, D.J., Looha, M.A., Akbari, M.E., and Akbari, A. (2023). Predictors of Postoperative Pain Six Months after Breast Surgery. Sci. Rep., 13.","DOI":"10.1038\/s41598-023-35426-8"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"zrae040","DOI":"10.1093\/bjsopen\/zrae040","article-title":"Overall Survival after Mastectomy versus Breast-Conserving Surgery with Adjuvant Radiotherapy for Early-Stage Breast Cancer: Meta-Analysis","volume":"8","author":"Rajan","year":"2024","journal-title":"BJS Open"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Magnoni, F., Sacchini, V., Veronesi, P., Bianchi, B., Bottazzoli, E., Tagliaferri, V., Mazzotta, E., Castelnovo, G., Deguidi, G., and Rossi, E.M.C. (2022). Surgical Management of Inherited Breast Cancer: Role of Breast-Conserving Surgery. Cancers, 14.","DOI":"10.3390\/cancers14133245"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"101779","DOI":"10.1016\/j.suronc.2022.101779","article-title":"Comparison of Surgical and Oncological Outcomes between Oncoplastic Breast-Conserving Surgery versus Conventional Breast-Conserving Surgery for Treatment of Breast Cancer: A Systematic Review and Meta-Analysis of 31 Studies","volume":"42","author":"Mohamedahmed","year":"2022","journal-title":"Surg. Oncol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1016\/j.eururo.2022.01.027","article-title":"Climate-Smart Actions in the Operating Theatre for Improving Sustainability Practices: A Systematic Review","volume":"83","author":"Pradere","year":"2023","journal-title":"Eur. Urol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1213\/ANE.0b013e3181e058d7","article-title":"Global Warming Potential of Inhaled Anesthetics: Application to Clinical Use","volume":"111","author":"Ryan","year":"2010","journal-title":"Anesth. Analg."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1007\/s00268-018-4850-0","article-title":"Enhanced REVENUE After Surgery? A Cost-Standardized Enhanced Recovery Pathway for Mastectomy Decreases Length of Stay","volume":"43","author":"Ackerman","year":"2019","journal-title":"World J. Surg."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"485","DOI":"10.1001\/jamasurg.2022.8388","article-title":"Reexamining Time from Breast Cancer Diagnosis to Primary Breast Surgery","volume":"158","author":"Wiener","year":"2023","journal-title":"JAMA Surg."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"An, D., Choi, J., Lee, J., Kim, J.-Y., Kwon, S., Kim, J., Lee, S., Jeon, S., Lee, C., and Lee, S. (2022). Time to Surgery and Survival in Breast Cancer. BMC Surg., 22.","DOI":"10.1186\/s12893-022-01835-1"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1879","DOI":"10.21873\/invivo.11681","article-title":"Impact of Awake Breast Cancer Surgery on Postoperative Lymphocyte Responses","volume":"33","author":"Vanni","year":"2019","journal-title":"In Vivo"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1177\/15589447231220412","article-title":"Greening Hand Surgery: Targeted Measures to Reduce Waste in Ambulatory Trigger Finger and Carpal Tunnel Decompression","volume":"20","author":"Tevlin","year":"2023","journal-title":"HAND"},{"key":"ref_57","first-page":"e2656","article-title":"Awake Breast Surgery and De-Escalation Treatment: Strategies for Frail and Elderly Breast Cancer Patients","volume":"10","author":"Vanni","year":"2023","journal-title":"World Cancer Res. J."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"e040316","DOI":"10.1136\/bmjopen-2020-040316","article-title":"Surgical Treatment for Colorectal Cancer: Analysis of the Influence of an Enhanced Recovery Programme on Long-Term Oncological Outcomes\u2014A Study Protocol for a Prospective, Multicentre, Observational Cohort Study","volume":"10","year":"2020","journal-title":"BMJ Open"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/19\/6881\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,30]],"date-time":"2025-09-30T09:45:47Z","timestamp":1759225547000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/19\/6881"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,28]]},"references-count":58,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["jcm14196881"],"URL":"https:\/\/doi.org\/10.3390\/jcm14196881","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,28]]}}}