title: Could the Use of an Enhanced Recovery Protocol in Laparoscopic Donor Nephrectomy be an Incentive for Live Kidney Donation?
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Surgery, Duke University Medical Center.
authors.forename: Aparna
authors.initials: A
authors.lastname: Rege
authors.affiliation: School of Medicine, Duke Univeristy Medical Center.
authors.forename: Harold
authors.initials: H
authors.lastname: Leraas
authors.affiliation: Surgery, Duke University Medical Center ; Division of Abdominal Transplantation, Duke University Medical Center.
authors.forename: Deepak
authors.initials: D
authors.lastname: Vikraman
authors.affiliation: Surgery, Duke University Medical Center ; Division of Abdominal Transplantation, Duke University Medical Center.
authors.forename: Kadiyala
authors.initials: K
authors.lastname: Ravindra
authors.affiliation: Surgery, Duke University Medical Center ; Division of Abdominal Transplantation, Duke University Medical Center.
authors.forename: Todd
authors.initials: T
authors.lastname: Brennan
authors.affiliation: Anesthesia, Duke University Medical Center.
authors.forename: Tim
authors.initials: T
authors.lastname: Miller
authors.affiliation: Surgery, Duke University Medical Center.
authors.forename: Julie
authors.initials: J
authors.lastname: Thacker
authors.affiliation: Surgery, Duke University Medical Center ; Division of Abdominal Transplantation, Duke University Medical Center.
authors.forename: Debra
authors.initials: D
authors.lastname: Sudan
keywords: donor readmission rates; enhanced recovery after surgery (eras); enhanced recovery programs (erps); laparoscopic living donor nephrectomy; length of stay (los); postoperative pain scores