• May 2020

    Enhanced recovery protocols may ease burden of living donor nephrectomy

A patient undergoing any major surgery, including laparoscopic donor nephrectomy, experiences a temporary decline in their functional capacity. The goal of an enhanced recovery after surgery (ERAS) program is to return a patient to baseline functional status as soon as possible without sacrificing safety, quality, comfort or long-term outcomes.

“The main objective of an enhanced recovery program is to decrease the symptom burden,” says Eric Martinez, MD, a transplant surgeon on the medical staff at Baylor University Medical Center at Dallas, part of Baylor Scott & White Health. “ERAS proposes ways we can manage patients perioperatively to help return them to their prior function sooner.”

More than 30 randomized controlled trials and more than 20 meta-analyses have validated ERAS efficacy. A 2015 study of liver resections at MD Anderson Cancer Center compared a traditional recovery approach with enhanced recovery protocols. Results showed greater early pain control, fewer complications and decreased length of stay with the ERAS approach.1 When using a patient’s “life interference” as a measure of recovery – such as mobility, driving, ability to care for oneself or others – life interference scores were much lower when ERAS protocols were implemented.2

ERAS protocols focus on pre-operative, intraoperative and post-operative factors that can be implemented to improve and increase the speed of a patient’s recovery. In the setting of laparoscopic donor nephrectomy, pre-op factors may include patient education, limitation of bowel prep, reduced fasting, carbohydrate loading to improve muscle function and minimize protein loss, use of non-narcotic analgesic medications, such as tramadol and pregabalin, and withholding of sedative medications.

“The most important pre-op factor by far is patient education and setting expectations,” says Dr. Martinez. “If you tell patients they’re going to be in the hospital for five days after nephrectomy, you can bet they will be here five days. It is up to us as surgeons to help them through this process and discharge them when we are convinced they are ready to go home.”

Intraoperative steps that may be considered include using low-pressure pneumoperitoneum during laparoscopic or robotic donor nephrectomy to optimize live donors’ comfort. While it requires a lengthier procedure due to less space for the surgeon to operate in, studies show patients report less overall pain and less referred pain with no change in donor serum creatinine, complications or quality of life.3

Other ERAS options are a single intraoperative injection of dexamethasone to decrease nausea, vomiting and pain after LDN. A 2017 study concluded that a higher dose (8-14 mg) decreases anti-emetic requirements for post-op nausea and vomiting by 20 percent.4 A transverse abdominis plane (TAP) block between the internal oblique muscle and the transverse abdominis muscle blocks several nerves along the majority of the three incisions used in LDN, including the midline and extraction site.

“A TAP block can result in a 50 percent reduction in opioid use, decreased use of anti-emetics, earlier resumption of food and decreased length of stay. Preemptive analgesia is an effective and standard way of targeting post-op pain in LDN,” says Dr. Martinez.

ERAS elements to consider in the post-operative setting include nausea /vomiting prophylaxis, fluid restriction, routine laxative or pro-kinetic use, protein and carbohydrate supplements, early diet and early mobilization, and scheduled non-narcotic analgesia.

During the last 10 years, transplant surgeons at Baylor Dallas and Baylor Scott & White All Saints Medical Center – Fort Worth have performed 517 live donor nephrectomies, 99.2 percent laparoscopically or robotically. Although attending dependent, ERAS  protocols generally include clear liquid diet on POD#0, lactated ringers at 125mL/Hr, removal of Foley on POD#1, administration of Lovenox on POD#1 and administration of oral Tylenol with codeine and tramadol with morphine administered on a PRN basis. “We believe ERAS should become the standard of care,” Dr. Martinez says. “Instead of ERAS, it should be called ‘optimal care’ because this should be applied to all our patients, potentially even the transplant recipient population. We need patients to understand that pain is part of living donation, but it can be very well controlled. And when they meet certain discharge criteria, we’ll be ready to send them home.”

 1Day, Aloia. JACS. 2015

Day, Aloia. BJS 2015

2 Aloia. 2015

3 Berkers et. al. Clin Translant. 2013

4 Yamanaga et. al. J. Transplantation 2017