Introduction of an enhanced recovery protocol into a laparoscopic living donor nephrectomy programme

Abstract

Introduction Living-donor renal transplantation is the optimal treatment for patients with end-stage renal disease. The rate of living donation in the UK is sub-optimal, and potential donor concerns regarding postoperative recovery may be contributory. Enhanced recovery programmes are well described for a number of surgical procedures, but experience in living-donor surgery is sparse. This study reports the impact of introducing an enhanced recovery protocol into a living-donor renal transplant programme. Materials and methods All consecutive patients undergoing laparoscopic living-donor nephrectomy over a 25-month period were included. The principles of enhanced recovery were fluid restriction, morphine sparing and expectation management. Outcome measures were postoperative pain scores and complications for donor and recipients. Results Standard care was provided for 24 (30%) patients and 57 (70%) followed an enhanced recovery pathway. The latter group received significantly less preoperative intravenous fluid (0ml vs 841ml p < 000.1) and opiate medication (14.83mg vs 23.85mg p = 0.001). Pain scores, postoperative complications and recipient transplant outcomes were comparable in both groups. Conclusions Enhanced recovery for living-donor nephrectomy is a safe approach for donors and recipients. Application of these techniques and further refinement should be pursued to enhance the experience of living donors.

Feasibility, Safety and Efficacy of Enhanced Recovery after Living Donor Nephrectomy: Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…Of these, 103 articles were excluded (10 studies involving ERAS protocols for renal transplant recipients; 27 conference abstracts with either insufficient information or duplicated data; 8 commentaries, systematic reviews, study protocols; 3 because patients with major complications were excluded; 3 because the relevant outcome data were not reported; 1 because there was no comparator; 3 because paediatric patients were enrolled; 3 because patients undergoing nephrectomy for cancer were included; 45 because they involved solitary interventions). Overall, 11 studies, 4 RCTs and 7 non-randomized cohort studies were included in the present systematic review [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ].…”

“…With regard to preoperative interventions, outpatient consultation for setting recovery goals [ 10 , 12 , 13 , 17 , 19 , 20 ], carbohydrate loading (with avoidance of peri-operative fasting) [ 10 , 12 , 13 , 15 , 19 , 20 ] and pre-emptive analgesia loading [ 11 , 19 , 20 ] were the most common ERAS elements encountered. Intraoperatively, the infiltration of local anaesthetic in the epidural space [ 12 , 13 , 15 , 16 ], the use of Transversus Abdominis Plane (TAP) blocks [ 19 , 20 ], and the insertion of local anaesthetic wound infiltration catheters [ 10 , 18 ] were the three most prominent ERAS interventions. Postoperatively, initiation of nutrition [ 10 , 12 , 13 , 17 , 19 , 20 ] and mobilization [ 10 , 12 , 13 , 17 , 20 ] from POD0 were common ERAS elements.…”

“…Intraoperatively, the infiltration of local anaesthetic in the epidural space [ 12 , 13 , 15 , 16 ], the use of Transversus Abdominis Plane (TAP) blocks [ 19 , 20 ], and the insertion of local anaesthetic wound infiltration catheters [ 10 , 18 ] were the three most prominent ERAS interventions. Postoperatively, initiation of nutrition [ 10 , 12 , 13 , 17 , 19 , 20 ] and mobilization [ 10 , 12 , 13 , 17 , 20 ] from POD0 were common ERAS elements. With regard to postoperative pain management, nonsteroid anti-inflammatory drugs (NSAIDs) were the basic ERAS analgesic regime [ 11 , 13 , 14 , 16 , 19 , 20 ].…”

“…With regard to postoperative pain management, nonsteroid anti-inflammatory drugs (NSAIDs) were the basic ERAS analgesic regime [ 11 , 13 , 14 , 16 , 19 , 20 ]. The administration of local anaesthetic through an epidural catheter [ 12 , 13 , 15 ] or through a wound infiltration catheter [ 10 , 15 , 18 ] was used to complement analgesic medications in the included studies. Three out of the eleven studies included in our systematic review defined specific clinical discharge criteria in their ERAS protocols [ 12 , 13 , 20 ].…”

Hyperamylasemia Post Living Donor Nephrectomy Does Not Relate to Pain

“…Our centre routinely conducts a TAP block prior to nephrectomy [7]. We did not analyse this further due to the time when the first pain scores were collected being 24 hours after surgery by which time the TAP block would have worn off.…”