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

Abstract

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.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.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.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 to enhance the advantages of laparoscopic surgery for live kidney donation through optimizing donor outcomes and perioperative patient satisfaction.

Department

Description

Provenance

Citation

Published Version (Please cite this version)

10.7759/cureus.889

Publication Info

Rege, Aparna, Harold Leraas, Deepak Vikraman, Kadiyala Ravindra, Todd Brennan, Tim Miller, Julie Thacker, Debra Sudan, et al. (2016). Could the Use of an Enhanced Recovery Protocol in Laparoscopic Donor Nephrectomy be an Incentive for Live Kidney Donation?. Cureus, 8(11). p. e889. 10.7759/cureus.889 Retrieved from https://hdl.handle.net/10161/17257.

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Scholars@Duke

Leraas

Harold Leraas

House Staff
Miller

Timothy Ellis Miller

Professor of Anesthesiology

Clinical and research interests are Enhanced Recovery and Perioperative Medicine; with particular interests in fluid management, and perioperative optimization of the high-risk non-cardiac surgery patient.

Sudan

Debra L Sudan

Professor of Surgery

I am interested clinically in all abdominal organ transplants (kidney, liver, pancreas and intestine).  I am specifically interested in intestine transplantation and improving intestine graft preservation and long-term graft function and patient survival.  In addition, I am interested in monitoring of patients to improve our ability to determine the etiology of graft dysfunction when there are complex interacting issues such as infection and rejection as well as examining better immunosuppressive regimens to maintain excellent graft function.  We have numerous research studies and trial to improve our knowledge in these areas and thereby contribute to improved patient outcomes!


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