Implementation of a Multimodal Enhanced Recovery Protocol in Ambulatory Anorectal Surgery: A Randomized Trial

Area of Science:

• Anesthesiology
• Colorectal Surgery
• Surgical Outcomes

Background:

• Enhanced recovery pathways (ERPs) are understudied in ambulatory anorectal surgery.
• Multimodal analgesia may reduce postoperative opioid use in this setting.

Purpose of the Study:

• To compare postoperative opioid use in patients undergoing ambulatory anorectal surgery with multimodal analgesia versus standard care.
• To evaluate the efficacy of an enhanced recovery pathway in reducing opioid consumption.

Main Methods:

• Prospective randomized trial (September 2018 - May 2022) at an urban teaching hospital.
• Inclusion of adults aged 18-70 undergoing elective anal fistula or hemorrhoid surgery.
• Intervention: Multimodal ERP with non-opioid analgesia (acetaminophen, gabapentin, ketorolac); Control: Standard care.

Main Results:

• 89 patients completed the study; median age 38 years, 46% female.
• Opioid use (oral morphine milligram equivalents) in the first week was significantly lower in the ERP arm (8 mg) compared to the standard care arm (79 mg; p = 0.002).
• No significant differences in secondary outcomes (pain, nausea, adverse events, admissions) were observed.

Conclusions:

• Enhanced recovery pathways with multimodal analgesia effectively decrease postoperative opioid use in elective anal fistula and hemorrhoid surgery.
• These protocols should be considered for routine implementation in similar procedures.
• Findings are specific to fistula and hemorrhoid surgery and may not generalize to other anorectal procedures.