ORIGINAL SCIENTIFIC REPORT
An Enhanced Recovery After Surgery (ERAS) Protocol
for Ambulatory Anorectal Surgery Reduced Postoperative Pain
and Unplanned Returns to Care After Discharge
Aaron B. Parrish
Sean M. O’Neill
Steven R. Crain
Tara A. Russell
Deepak K. Sonthalia
Vu T. Nguyen
Published online: 9 January 2018
Internationale de Chirurgie 2018
Background Ambulatory surgery for anorectal procedures has been proven to be safe and effective. Speciﬁc peri-
operative pathways combining multiple interventions have been shown to optimize recovery and outcomes associ-
ated 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.
Methods 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.
Results 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).
Conclusions Implementation of a standardized ERAS protocol for ambulatory anorectal surgery decreased post-
operative pain and unplanned return visits to emergency care.
This manuscript was presented as a podium presentation at the
ASCRS Annual scientiﬁc meeting in Seattle, Washington, USA; June
& Armen Aboulian
Department of Surgery, Harbor-UCLA Medical Center,
Torrance, CA, USA
Department of Surgery, UCLA Medical Center, Los Angeles,
Veterans Affairs/Robert Wood Johnson Clinical Scholars
Program, Philadelphia, PA, USA
Department of Surgery, Southern California Permanente
Medical Group, Woodland Hills, CA, USA
Department of Anesthesia, Southern California Permanente
Medical Group, San Diego, CA, USA
Department of General Surgery, Southern California
Permanent Medical Group, Baldwin Park, CA 91367, USA
World J Surg (2018) 42:1929–1938