Background/Introduction: Enhanced recovery programs (ERPs) in colorectal surgery have decreased the duration of postoperative ileus and 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 benefits of ERAS protocols in living kidney donors undergoing laparoscopic nephrectomy.

Methods: This is a single-center retrospective analysis comparing the outcomes of the first 40 live kidney donors subjected to laparoscopic nephrectomy with ERAS protocol to 40 donors operated prior to ERAS with traditional standard of care. Our ERP includes reduced duration of fasting with preoperative carbohydrate loading, intraoperative fluid restriction to 3ml/kg/hr., target urine output of 0.5 ml/kg/hr., use of sub fascial Exparel injection (Bupivacaine liposome suspension) and postoperative narcotic free pain regimen with Acetaminophen, ketorolac, tramadol.

Results: ERAS protocol reduced 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 3.00 vs 7.00; p = 0.005, lowest pain score 0.0 vs 2.0; p= 0.016) without any narcotic use. Average duration of surgery was shorter with the ERP (248 vs 304 min; p<0.001). Average amount of intraoperative fluid used was significantly lower in the ERAS group (2500ml vs 3525ml; p < 0.001), without affecting the donor urine output intraoperatively or the percent change in donor serum creatinine on postop day 1(25% ERP vs 21.1% SCP; p=0.911). Incidence of delayed graft function was similar in the two groups (p=0.541). A trend towards 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 ERAS protocol in laparoscopic living donor nephrectomy was associated with reduced length of hospitalization and improved pain scores likely related to intraoperative use of sub fascial Exparel and shorter duration of ileus. Restricted use of intraoperative fluids prevents excessive third spacing & 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.

CITATION INFORMATION: Rege A, Vikraman D, Ravindra K, Brennan T, Leraas H, Sudan D. Influence of an Enhanced Recovery Protocol in Laparoscopic Living Donor Nephrectomy. Am J Transplant. 2017;17 (suppl 3).

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