Could the Use of an Enhanced Recovery Protocol in Laparoscopic Donor Nephrectomy Be an Incentive for Live Kidney Donation?

Abstract

Introduction and Background: Gastrointestinal (GI) recovery after major abdominal surgery can be delayed from an ongoing need for narcotic analgesia thereby prolonging hospitalization. Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to facilitate early recovery after major surgery by maintaining preoperative body composition and physiological organ function and modifying the stress response induced by surgical exposure. Enhanced recovery programs (ERPs) in colorectal surgery have decreased the duration of postoperative ileus and the hospital stay while showing equivalent morbidity, mortality, and readmission rates in comparison to the traditional standard of care. This study is a pilot trial to evaluate the benefits of ERAS protocols in living kidney donors undergoing laparoscopic nephrectomy.Methods: This is a single-center, non-randomized, retrospective analysis comparing the outcomes of the first 40 live kidney donors subjected to laparoscopic nephrectomy under the ERAS protocol to 40 donors operated prior to ERAS with traditional standard of care. Our ERAS protocol includes reduced duration of fasting with preoperative carbohydrate loading, intraoperative fluid restriction to 3 ml/kg/hr, target urine output of 0.5 ml/kg/hr, use of subfascial Exparel injection (bupivacaine liposome suspension), and postoperative narcotic-free pain regimen with acetaminophen, ketorolac, or tramadol. Short-term patient outcomes were compared using Pearsons’s Chi-Squared test for categorical variables and the Kruskal-Wallis test for continuous variables. Additionally, a multivariate analysis was conducted to evaluate factors influencing patient length of stay and likelihood of readmission.Results: ERAS protocol reduced the postoperative median length of stay decreased from 2.0 to 1.0 days (p=0.001). Overall pain scores were significantly lower in the ERAS group (peak pain score 6.0 vs. 8.00, p< 0.001; morning after surgery pain score 3.0 vs. 7.0, p=0.001; lowest pain score 0.0 vs. 2.0, p=0.016) despite the absence of postoperative narcotics. The average duration of surgery was shorter in the ERAS group (248 vs. 304 minutes, p<0.001). The average amount of intraoperative fluid used was significantly lower in the ERAS group (2500 ml vs. 3525 ml, p<0.001) without affecting the donor renal function. The incidence of delayed graft function was similar in the two groups (p=0.541). A trend toward lower readmission was noted with the ERAS protocol (12.8% vs. 27.5%, p=0.105). GI dysfunction was the most common reason for readmission.Conclusion: Application of an ERAS protocol in a laparoscopic living donor nephrectomy was associated with reduced length of hospitalization and improved pain scores related likely to intraoperative use of subfascial Exparel and a shorter duration of ileus. Restricted use of intraoperative fluids prevents excessive third spacing and bowel edema, enhancing gut recovery without adversely impacting recipient graft function. This study suggests that ERAS has the potential...

Pain expectancy, prevalence, severity, and patterns following donor nephrectomy: Findings from the KDOC Study

“…All KDOC study centers used narcotic‐based pain management protocols. More recently, however, enhanced recovery after surgery (ERAS) protocols have emerged and have been shown to reduce narcotic use, length of stay, and pain following donor nephrectomy, 27,28 as well as many other postoperative complications following intra‐abdominal surgery 29 . Counterintuitively, however, we found that more intense exercise predonation was associated with higher likelihood of CPSP.…”

Comparison of the Impact of Propofol and Sevoflurane on Early Postoperative Recovery in Living Donors After Laparoscopic Donor Nephrectomy: A Prospective Randomized Controlled Study

“…All donors were classi ed as Clavien-Dindo grade 1 and discharge was uneventful in all cases. The length of hospital stay after surgery was signi cantly shorter in the IV propofol group than in the IH sevo urane group (3 [3][4] days in the IV propofol group versus 4 [3][4][5] days in the IH sevo urane group; p=0.013).…”

Laparoscopic Live Donor Nephrectomy: Techniques and Results

“…Novelties in this management were associated with reduced length of hospital stay, better pain control, and increased patient satisfaction. It has become evident that ERAS would potentially enhance the benefits of laparoscopic surgery for kidney donors [59].…”