Original Clinical Science
Building the Case for Enhanced Recovery Protocols in Living Kidney Donors Seth A Waits,1 Paul Hilliard,2 Kyle H Sheetz,1 Randall S. Sung,1 and Michael J. Englesbe1 Background. Enhanced recovery protocols align with the current advantages of laparoscopic donor nephrectomy and may continue to decrease disincentives to donation. Methods. In this single-center retrospective analysis, we compare the outcomes of the first 60 living kidney donors enrolled in our enhanced recovery program (ERP) to those patients treated before implementation of the protocol. In addition to improved coordination of care, highlights of the ERP bundle included the use of transversus abdominus plane block, preoperative carbohydrate loading and narcotic free pain regimens. Chi-square and Student t test were used where appropriate. Results. Postoperative median length of stay decreased from 2.0 to 1.0 days (P < 0.01) after protocol initiation. Overall narcotic use also decreased by nearly 50% (45.6 vs. 21.3; P < 0.01), whereas pain scores remained similar (3.97 vs. 3.87; P = ns). Average time to incision was longer in the enhanced recovery group as compared to the standard protocol group (51 vs 42 min; P < 0.05) by 9 min. Conclusion. Implementation of an ERP for living kidney donors was associated with reduced LOS and decreased narcotic use after donor nephrectomy. This study suggests that ERPs may offer a framework for decreasing disincentives for donation and optimize patient satisfaction.
(Transplantation 2015;99: 405–408)
T
he laparoscopic donor nephrectomy has transformed the practice of living kidney donation.1 By decreasing the burden of disincentives, the minimally invasive approach to organ donation sparked a nationwide spike that eventually peaked at 6,647 nephrectomies in 2004.2-4 Despite the early success, donation rates decreased, falling by over 15% through 2012. To combat this decline, several innovative approaches have been developed, most notably through the use of paired kidney donation, social media outreach, and the National Living Donor Assistance Center.5-7 By continuing to optimize the patient-centered experience for donors, further gains in donation rates may be achievable. Potentially, enhanced recovery programs (ERPs) could offer an innovative addition to current care protocols. Initially developed in Europe to address prolonged length of stay after colorectal resections, ERP programs have been shown to decrease the length of stay while showing equivalent morbidity, Received 28 April 2014. Revision requested 5 May 2014. Accepted 27 May 2014. 1
Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
2
Department of Anesthesia, University of Michigan, Ann Arbor, MI.
The authors declare no funding and conflicts of interest. S.A.W., K.H.S., R.S.S., and M.J.E. participated in research design. All authors participated in the writing of the article. S.A.W, K.H.S., and P.H. participated in the performance of the research. S.A.W. and K.H.S. participated in data analysis. All authors gave their final approval. Correspondence: Seth Waits, MD, Department of Surgery, University of Michigan Medical School, 2926A Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5331. ([email protected]) Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0041-1337/15/9902-405 DOI: 10.1097/TP.0000000000000328
Transplantation
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February 2015
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Volume 99
■
Number 2
mortality, and readmission rates.8 Enhanced recovery program's build on the advantages of the laparoscopic approach, through a combination of physiologic readiness and pain minimization.9 These principles align with the current advantages of laparoscopic donor nephrectomy, creating the opportunity for gains in patient satisfaction, pain management, and length of stay (Figure 1). In this single-center retrospective analysis, we investigate the utility of an ERP in living kidney donors. We describe the outcomes of the first 60 participants enrolled at our institution and consider the implications for widespread implementation. RESULTS Demographics
A total of 120 live donor nephrectomies were performed during the study period. Sixty of these cases represented those that were included in the ERP group, and 60 were performed with the standard care protocol (SCP). No significant differences were found between the cohorts, including age (ERP 43.1 vs. SCP 39.2; P = 0.13), male sex (33.3 vs. 50.0; P = 0.06), weight (80.7 vs. 77.7; P = 0.39), body mass index (27.4 vs. 25.9; P = −0.39), and relation to the transplant recipient (46.6 vs. 56.6; P = 0.27). Demographic characteristics are described in Table 1. Outcomes
Our primary outcome was length of stay after donor nephrectomy. Length of hospital stay varied from 1 to 5 days during the study period. After implementation of the ERP, median length of stay dropped from 2 to 1 days (P < 0.01). Average time to incision was longer by 9 min in the ERP cohort versus the SCP cohort (51 min vs. 42, P < 0.05). Total operative www.transplantjournal.com
405
Waits et al
© 2015 Wolters Kluwer
education in the area of preoperative nutrition and adopted a policy of clear liquid carbohydrate loading 2 hr before surgery. Our pain control regimen was also considerably different. The introduction of bilateral TAP block and preoperative acetaminophen loading contrast with the old regimen which included a patient-controlled morphine pump that transitioned to oral hydromorphone at discharge. We believe that the TAP block provided improved pain control immediately after the operation, allowing the patient to ambulate, resume an oral diet, and remove the urinary catheter much more quickly. The confidence in performing these tasks on the day of the surgery provides reinforcement to their ability to do well at home. Although this study offers the results of a single center trial of an ERP in living kidney donors, it highlights the possibilities of widespread implementation. Because our ERP was not designed to be a randomized trial, our inpatient care team was aware of the protocol change. This introduces the possibility that decisions to discharge the patients on postoperative day 1 may have been influenced by the focus on improving postoperative length of stay. It is unclear how much our results may be affected by this bias. Another significant consideration is our increases in operating room time attributable to the addition of a TAP block. From a cost perspective, if you compare the average daily cost of hospitalization (~U.S. $1,200) to the additional operating room costs (~U.S. $200) incurred during the TAP block, there is still a financial benefit from implementation.14,15 Finally, we postulate that decreased length of stay and decreased narcotic use will translate to improved patient satisfaction scores; however, we did not collect this data during the implementation period, and our assumptions may prove to be false. The gift of kidney donation is unmatched in altruism and impact. With this in mind, donor safety and satisfaction should be the top priority for transplant programs. Enhanced recovery programs appear to be a safe and feasible opportunity to target these goals. By providing care from a patient-centered approach, positive patient experiences may be translated to positive word of mouth regarding the donation process. For transplant programs, reduced hospital resource use and improved patient satisfaction can have important financial implications to counter the rapidly changing landscape of cost and quality in health care. In all, the implementation of ERPs in living kidney donors makes sense for patients, providers, and payers alike. Through pain minimization, physiologic readiness, and optimal preparation, enhanced recovery protocols in the living donor population may further decrease disincentives to donation and optimize patient satisfaction. These data provide the basis for study of subjective, patient-centered outcomes in the setting of a randomized controlled interventional trial. Further attempts to refine enhanced recovery protocols in the living-donor population will be beneficial for all stakeholders.
MATERIALS AND METHODS
407
and institutional review board approval was obtained before chart review. Enhanced Recovery Bundle
Preoperative Care All ERP interventions are described in Table 2. Patients were given information regarding the enhanced recovery bundle at their preoperative appointment. Each patient was offered smoking cessation counseling and a preoperative carbohydrate drink (Welches Apple Juice 10 oz, 36 g carbohydrates; Welch’s Foods Inc., Concord, MA) to be consumed 2 hr before the scheduled operative time. This drink was in accordance with the published guidelines from the American Society of Anesthesiologists that suggest patients may consume clear, nonprotein containing beverages until 2 hr before the surgery. Additionally, detailed information regarding the perioperative stay was outlined during the appointment. On the day of the operation, patients were instructed arrive 2 hr before their scheduled operative time. They were asked to consume their preoperative beverage before arrival. In a change from the control population, patients were given 1 g of acetaminophen and consented for nerve block in the preoperative holding area. Intraoperative Care All patients underwent a bilateral TAP block immediately after induction. Transversus abdominus plane block was completed under ultrasound guidance using a hydrodissection technique with normal saline followed by 15 to 20 mL of 0.5% ropivacaine per side. No additives were used. After TAP block and patient positioning, specific fluid goals were relayed to the presiding anesthesia staff. In general, patients weighing less than 90 kg were given 3 to 4 L of intravenous fluid and donors weighing greater than 90 kg were given 4 to 5 L. Additionally, the protocol included administration of 15 mg intravenous ketorolac before the termination of the case. Postoperative Care On arrival to the postoperative anesthesia care unit, patients were encouraged to initiate oral intake with liquids and solids when appropriate. Patients were also encouraged to ambulate if possible before leaving for the general care floor. Scheduled acetaminophen and ketorolac (first 48 hr),
TABLE 2.
Summary of measures included in the enhanced recovery bundle
Preoperative measures
Intraoperative measures
Data Source and Study Population
Postoperative measures
As part of a quality improvement initiative for living kidney, every donor operation from March 2013 to January 2014 received the ERP protocol.16 The section of transplant surgery approved the ERP protocol as a standard of care change
TAP, transversus abdominus plane.
• Smoking cessation • Carbohydrate loading • Acetaminophen loading • TAP block • Standardized fluid administration • Ketorolac administration • Scheduled nonnarcotic pain medications • Early ambulation • Early regular diet • Improved discharge planning
408
Transplantation
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February 2015
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Volume 99
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Number 2
and as needed, hydrocodone were given as pain adjuncts on the general care floor. Postdischarge Follow-Up
Every patient was scheduled for a 2-week clinic follow-up visit. At this visit, patients were given detailed medical records, a copy of their preoperative computerized tomographic scan, and a donation t-shirt. Outcome Measures
Our primary endpoint for this study was length of stay after the nephrectomy operation. Secondary endpoints included overall narcotic use, pain scores, and time to incision. Overall narcotic use was recorded for all routes of administration and converted to intravenous morphine equivalents. These were recorded from discharge in postanesthesia care unit to discharge from the hospital. Pain scores were requested of patients at regular intervals and based on a visual analog score of 0 to 10. Time to incision was calculated as time when patient arrived to the operating room to time of incision. Readmission is considered readmission for complication relating the operation within 30 days of hospital discharge. Data Collection and Statistical Analysis
All patient data were collected retrospectively after completion of the cases enrolled in the ERP. Data on a cohort of similar size were collected from cases immediately before initiation of the protocol for comparative purposes. All study staff were blinded to the identity of the study subjects and the date of the operation. Data were analyzed using an intention to treat approach. To compare patient characteristics, we used chi-square and t tests where appropriate. For all statistical tests, P values are two-tailed, and alpha is set at 0.05. Analyses were performed using STATA version 13.1 (StataCorp, College Station, TX. USA).
www.transplantjournal.com
REFERENCES 1. Vavallo A, Lucarelli G, Bettocchi C, et al. Allograft nephrectomy: what is the best surgical technique? Transplant Proc 2012;44:1922. 2. Ratner LE, Hiller J, Sroka M, et al. Laparoscopic live donor nephrectomy removes disincentives to live donation. Transplant Proc 1997;29:3402. 3. Ratner LE, Kavoussi LR, Schulam PG, Bender JS, Magnuson TH, Montgomery R. Comparison of laparoscopic live donor nephrectomy versus the standard open approach. Transplant Proc 1997;29:138. 4. Matas AJ, Smith JM, Skeans MA, et al. OPTN/SRTR 2012 annual data report: kidney. Am J Transplant 2014;14:11. 5. NLDAC: National Living Donor Assistance Center. 2014; Available from: http://www.livingdonorassistance.org/newsupdates/default.aspx. 6. Chang A, Anderson EE, Turner HT, Shoham D, Hou SH, Grams M. Identifying potential kidney donors using social networking web sites. Clin Transplant 2013;27:E320. 7. Segev DL, Gentry SE, Warren DS, Reeb B, Montgomery RA. Kidney paired donation and optimizing the use of live donor organs. JAMA 2005;293:1883. 8. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 2014;38:1531. 9. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS ((R))) Society recommendations. World J Surg 2013;37:259. 10. Hosgood SA, Thiyagarajan UM, Nicholson HF, Jeyapalan I, Nicholson ML. Randomized clinical trial of transversus abdominis plane block versus placebo control in live-donor nephrectomy. Transplantation 2012;94:520. 11. Cannon RM, Eng M, Marvin MR, Buell JF. Laparoscopic living kidney donation at a single center: an examination of donor outcomes with increasing experience. Am Surg 2011;77:911. 12. Hausel J, Nygren J, Lagerkranser M, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg 2001;93:1344. 13. Nygren J. The metabolic effects of fasting and surgery. Best Pract Res Clin Anaesthesiol 2006;20:429. 14. Foundation KF. Hospital Adjusted Expenses per Inpatient Day by Ownership. 2011 [cited 2014 03/7/14]; Available from: http://kff.org/ other/state-indicator/expenses-per-inpatient-day-by-ownership/. 15. Macario A. What does one minute of operating room time cost? J Clin Anesth 2010;22:233. 16. Waits SA, Reames BN, Krell RW, et al. Development of team action projects in surgery (TAPS): a multilevel team-based approach to teaching quality improvement. J Surg Educ 2014;71:166.
Building the Case for Enhanced Recovery Protocols in Living Kidney Donors Seth A Waits,1 Paul Hilliard,2 Kyle H Sheetz,1 Randall S. Sung,1 and Michael J. Englesbe1 Background. Enhanced recovery protocols align with the current advantages of laparoscopic donor nephrectomy and may continue to decrease disincentives to donation. Methods. In this single-center retrospective analysis, we compare the outcomes of the first 60 living kidney donors enrolled in our enhanced recovery program (ERP) to those patients treated before implementation of the protocol. In addition to improved coordination of care, highlights of the ERP bundle included the use of transversus abdominus plane block, preoperative carbohydrate loading and narcotic free pain regimens. Chi-square and Student t test were used where appropriate. Results. Postoperative median length of stay decreased from 2.0 to 1.0 days (P < 0.01) after protocol initiation. Overall narcotic use also decreased by nearly 50% (45.6 vs. 21.3; P < 0.01), whereas pain scores remained similar (3.97 vs. 3.87; P = ns). Average time to incision was longer in the enhanced recovery group as compared to the standard protocol group (51 vs 42 min; P < 0.05) by 9 min. Conclusion. Implementation of an ERP for living kidney donors was associated with reduced LOS and decreased narcotic use after donor nephrectomy. This study suggests that ERPs may offer a framework for decreasing disincentives for donation and optimize patient satisfaction.
(Transplantation 2015;99: 405–408)
T
he laparoscopic donor nephrectomy has transformed the practice of living kidney donation.1 By decreasing the burden of disincentives, the minimally invasive approach to organ donation sparked a nationwide spike that eventually peaked at 6,647 nephrectomies in 2004.2-4 Despite the early success, donation rates decreased, falling by over 15% through 2012. To combat this decline, several innovative approaches have been developed, most notably through the use of paired kidney donation, social media outreach, and the National Living Donor Assistance Center.5-7 By continuing to optimize the patient-centered experience for donors, further gains in donation rates may be achievable. Potentially, enhanced recovery programs (ERPs) could offer an innovative addition to current care protocols. Initially developed in Europe to address prolonged length of stay after colorectal resections, ERP programs have been shown to decrease the length of stay while showing equivalent morbidity, Received 28 April 2014. Revision requested 5 May 2014. Accepted 27 May 2014. 1
Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
2
Department of Anesthesia, University of Michigan, Ann Arbor, MI.
The authors declare no funding and conflicts of interest. S.A.W., K.H.S., R.S.S., and M.J.E. participated in research design. All authors participated in the writing of the article. S.A.W, K.H.S., and P.H. participated in the performance of the research. S.A.W. and K.H.S. participated in data analysis. All authors gave their final approval. Correspondence: Seth Waits, MD, Department of Surgery, University of Michigan Medical School, 2926A Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5331. ([email protected]) Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0041-1337/15/9902-405 DOI: 10.1097/TP.0000000000000328
Transplantation
■
February 2015
■
Volume 99
■
Number 2
mortality, and readmission rates.8 Enhanced recovery program's build on the advantages of the laparoscopic approach, through a combination of physiologic readiness and pain minimization.9 These principles align with the current advantages of laparoscopic donor nephrectomy, creating the opportunity for gains in patient satisfaction, pain management, and length of stay (Figure 1). In this single-center retrospective analysis, we investigate the utility of an ERP in living kidney donors. We describe the outcomes of the first 60 participants enrolled at our institution and consider the implications for widespread implementation. RESULTS Demographics
A total of 120 live donor nephrectomies were performed during the study period. Sixty of these cases represented those that were included in the ERP group, and 60 were performed with the standard care protocol (SCP). No significant differences were found between the cohorts, including age (ERP 43.1 vs. SCP 39.2; P = 0.13), male sex (33.3 vs. 50.0; P = 0.06), weight (80.7 vs. 77.7; P = 0.39), body mass index (27.4 vs. 25.9; P = −0.39), and relation to the transplant recipient (46.6 vs. 56.6; P = 0.27). Demographic characteristics are described in Table 1. Outcomes
Our primary outcome was length of stay after donor nephrectomy. Length of hospital stay varied from 1 to 5 days during the study period. After implementation of the ERP, median length of stay dropped from 2 to 1 days (P < 0.01). Average time to incision was longer by 9 min in the ERP cohort versus the SCP cohort (51 min vs. 42, P < 0.05). Total operative www.transplantjournal.com
405
Waits et al
© 2015 Wolters Kluwer
education in the area of preoperative nutrition and adopted a policy of clear liquid carbohydrate loading 2 hr before surgery. Our pain control regimen was also considerably different. The introduction of bilateral TAP block and preoperative acetaminophen loading contrast with the old regimen which included a patient-controlled morphine pump that transitioned to oral hydromorphone at discharge. We believe that the TAP block provided improved pain control immediately after the operation, allowing the patient to ambulate, resume an oral diet, and remove the urinary catheter much more quickly. The confidence in performing these tasks on the day of the surgery provides reinforcement to their ability to do well at home. Although this study offers the results of a single center trial of an ERP in living kidney donors, it highlights the possibilities of widespread implementation. Because our ERP was not designed to be a randomized trial, our inpatient care team was aware of the protocol change. This introduces the possibility that decisions to discharge the patients on postoperative day 1 may have been influenced by the focus on improving postoperative length of stay. It is unclear how much our results may be affected by this bias. Another significant consideration is our increases in operating room time attributable to the addition of a TAP block. From a cost perspective, if you compare the average daily cost of hospitalization (~U.S. $1,200) to the additional operating room costs (~U.S. $200) incurred during the TAP block, there is still a financial benefit from implementation.14,15 Finally, we postulate that decreased length of stay and decreased narcotic use will translate to improved patient satisfaction scores; however, we did not collect this data during the implementation period, and our assumptions may prove to be false. The gift of kidney donation is unmatched in altruism and impact. With this in mind, donor safety and satisfaction should be the top priority for transplant programs. Enhanced recovery programs appear to be a safe and feasible opportunity to target these goals. By providing care from a patient-centered approach, positive patient experiences may be translated to positive word of mouth regarding the donation process. For transplant programs, reduced hospital resource use and improved patient satisfaction can have important financial implications to counter the rapidly changing landscape of cost and quality in health care. In all, the implementation of ERPs in living kidney donors makes sense for patients, providers, and payers alike. Through pain minimization, physiologic readiness, and optimal preparation, enhanced recovery protocols in the living donor population may further decrease disincentives to donation and optimize patient satisfaction. These data provide the basis for study of subjective, patient-centered outcomes in the setting of a randomized controlled interventional trial. Further attempts to refine enhanced recovery protocols in the living-donor population will be beneficial for all stakeholders.
MATERIALS AND METHODS
407
and institutional review board approval was obtained before chart review. Enhanced Recovery Bundle
Preoperative Care All ERP interventions are described in Table 2. Patients were given information regarding the enhanced recovery bundle at their preoperative appointment. Each patient was offered smoking cessation counseling and a preoperative carbohydrate drink (Welches Apple Juice 10 oz, 36 g carbohydrates; Welch’s Foods Inc., Concord, MA) to be consumed 2 hr before the scheduled operative time. This drink was in accordance with the published guidelines from the American Society of Anesthesiologists that suggest patients may consume clear, nonprotein containing beverages until 2 hr before the surgery. Additionally, detailed information regarding the perioperative stay was outlined during the appointment. On the day of the operation, patients were instructed arrive 2 hr before their scheduled operative time. They were asked to consume their preoperative beverage before arrival. In a change from the control population, patients were given 1 g of acetaminophen and consented for nerve block in the preoperative holding area. Intraoperative Care All patients underwent a bilateral TAP block immediately after induction. Transversus abdominus plane block was completed under ultrasound guidance using a hydrodissection technique with normal saline followed by 15 to 20 mL of 0.5% ropivacaine per side. No additives were used. After TAP block and patient positioning, specific fluid goals were relayed to the presiding anesthesia staff. In general, patients weighing less than 90 kg were given 3 to 4 L of intravenous fluid and donors weighing greater than 90 kg were given 4 to 5 L. Additionally, the protocol included administration of 15 mg intravenous ketorolac before the termination of the case. Postoperative Care On arrival to the postoperative anesthesia care unit, patients were encouraged to initiate oral intake with liquids and solids when appropriate. Patients were also encouraged to ambulate if possible before leaving for the general care floor. Scheduled acetaminophen and ketorolac (first 48 hr),
TABLE 2.
Summary of measures included in the enhanced recovery bundle
Preoperative measures
Intraoperative measures
Data Source and Study Population
Postoperative measures
As part of a quality improvement initiative for living kidney, every donor operation from March 2013 to January 2014 received the ERP protocol.16 The section of transplant surgery approved the ERP protocol as a standard of care change
TAP, transversus abdominus plane.
• Smoking cessation • Carbohydrate loading • Acetaminophen loading • TAP block • Standardized fluid administration • Ketorolac administration • Scheduled nonnarcotic pain medications • Early ambulation • Early regular diet • Improved discharge planning
408
Transplantation
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February 2015
■
Volume 99
■
Number 2
and as needed, hydrocodone were given as pain adjuncts on the general care floor. Postdischarge Follow-Up
Every patient was scheduled for a 2-week clinic follow-up visit. At this visit, patients were given detailed medical records, a copy of their preoperative computerized tomographic scan, and a donation t-shirt. Outcome Measures
Our primary endpoint for this study was length of stay after the nephrectomy operation. Secondary endpoints included overall narcotic use, pain scores, and time to incision. Overall narcotic use was recorded for all routes of administration and converted to intravenous morphine equivalents. These were recorded from discharge in postanesthesia care unit to discharge from the hospital. Pain scores were requested of patients at regular intervals and based on a visual analog score of 0 to 10. Time to incision was calculated as time when patient arrived to the operating room to time of incision. Readmission is considered readmission for complication relating the operation within 30 days of hospital discharge. Data Collection and Statistical Analysis
All patient data were collected retrospectively after completion of the cases enrolled in the ERP. Data on a cohort of similar size were collected from cases immediately before initiation of the protocol for comparative purposes. All study staff were blinded to the identity of the study subjects and the date of the operation. Data were analyzed using an intention to treat approach. To compare patient characteristics, we used chi-square and t tests where appropriate. For all statistical tests, P values are two-tailed, and alpha is set at 0.05. Analyses were performed using STATA version 13.1 (StataCorp, College Station, TX. USA).
www.transplantjournal.com
REFERENCES 1. Vavallo A, Lucarelli G, Bettocchi C, et al. Allograft nephrectomy: what is the best surgical technique? Transplant Proc 2012;44:1922. 2. Ratner LE, Hiller J, Sroka M, et al. Laparoscopic live donor nephrectomy removes disincentives to live donation. Transplant Proc 1997;29:3402. 3. Ratner LE, Kavoussi LR, Schulam PG, Bender JS, Magnuson TH, Montgomery R. Comparison of laparoscopic live donor nephrectomy versus the standard open approach. Transplant Proc 1997;29:138. 4. Matas AJ, Smith JM, Skeans MA, et al. OPTN/SRTR 2012 annual data report: kidney. Am J Transplant 2014;14:11. 5. NLDAC: National Living Donor Assistance Center. 2014; Available from: http://www.livingdonorassistance.org/newsupdates/default.aspx. 6. Chang A, Anderson EE, Turner HT, Shoham D, Hou SH, Grams M. Identifying potential kidney donors using social networking web sites. Clin Transplant 2013;27:E320. 7. Segev DL, Gentry SE, Warren DS, Reeb B, Montgomery RA. Kidney paired donation and optimizing the use of live donor organs. JAMA 2005;293:1883. 8. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 2014;38:1531. 9. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS ((R))) Society recommendations. World J Surg 2013;37:259. 10. Hosgood SA, Thiyagarajan UM, Nicholson HF, Jeyapalan I, Nicholson ML. Randomized clinical trial of transversus abdominis plane block versus placebo control in live-donor nephrectomy. Transplantation 2012;94:520. 11. Cannon RM, Eng M, Marvin MR, Buell JF. Laparoscopic living kidney donation at a single center: an examination of donor outcomes with increasing experience. Am Surg 2011;77:911. 12. Hausel J, Nygren J, Lagerkranser M, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg 2001;93:1344. 13. Nygren J. The metabolic effects of fasting and surgery. Best Pract Res Clin Anaesthesiol 2006;20:429. 14. Foundation KF. Hospital Adjusted Expenses per Inpatient Day by Ownership. 2011 [cited 2014 03/7/14]; Available from: http://kff.org/ other/state-indicator/expenses-per-inpatient-day-by-ownership/. 15. Macario A. What does one minute of operating room time cost? J Clin Anesth 2010;22:233. 16. Waits SA, Reames BN, Krell RW, et al. Development of team action projects in surgery (TAPS): a multilevel team-based approach to teaching quality improvement. J Surg Educ 2014;71:166.
