An Enhanced Recovery After Surgery (ERAS) Protocol for Ambulatory Anorectal Surgery Reduced Postoperative Pain and Unplanned Returns to Care After Discharge

Abstract

Ambulatory surgery for anorectal procedures has been proven to be safe and effective. Specific perioperative pathways combining multiple interventions have been shown to optimize recovery and outcomes associated with inpatient colorectal surgery. However, there are no major studies describing and evaluating a standardized protocol for ambulatory anorectal surgery. The purpose of this study was to evaluate the outcomes of a modified enhanced recovery after surgery (ERAS) protocol for ambulatory anorectal surgery. This was a retrospective review of prospectively collected data from 14 Southern California Kaiser Permanente medical centers. An eight-item protocol including: preoperative education, preoperative distribution of prescriptions, preoperative carbohydrate treatment, multimodal analgesia, preferential use of monitored anesthesia care (MAC), routine use of local anesthesia/regional blocks, intraoperative restriction of intravenous fluids, and post-discharge phone call. Postoperative pain scores and preventable returns to the emergency department or urgent care were assessed. Postoperative pain scores were reduced when all eight elements of the protocol were delivered (p=0.005). On multivariate analysis, there was reduced postoperative pain when preoperative carbohydrate treatment was completed (p=0.002), with MAC (p=0.003), and when multimodal analgesia was used (p=0.02). There were decreased preventable returns to the emergency department or urgent care when MAC was used (p=0.03); there were more returns for constipation (p=0.04) but fewer returns for pain (p=0.002) after preoperative carbohydrate treatment. Local anesthesia was associated with fewer returns for constipation (p=0.01). Implementation of a standardized ERAS protocol for ambulatory anorectal surgery decreased postoperative pain and unplanned return visits to emergency care.