Prospective Randomized Controlled Trial of an Enhanced Recovery Protocol for Anorectal Surgery

Although pain is a predictable part of the postoperative experience, inadequate management of
pain is common and can have profound implications Most patients who undergo surgical
procedures experience acute postoperative pain, but evidence suggests that less than half
report adequate postoperative pain relief. Many preoperative, intraoperative, and
postoperative interventions and management strategies are available for reducing and managing
postoperative pain. Mostly, pain is treated with opioids which are narcotics. medically they
are primarily used for pain relief and these are historically considered "safe" drugs as they
do not impose an increased risk of bleeding, kidney, or stomach problems. However, many
patients taking high dose opioids have a higher risk of constipation. Unrelieved
postoperative pain may result in economic and medical implications such as extended lengths
of stay, readmissions, and patient dissatisfaction with medical care. With the rising concern
over narcotic use, physicians are increasingly seeking alternative ways to help patients
manage pain throughout their hospital stay and beyond However, few studies in anorectal
surgery have shown that using an aggressive postoperative non-narcotic pain regimen (ERAS)
can help reduce postoperative pain and decreased returns to emergency care.

Inclusion Criteria:

- 1. Able to freely give written informed consent to participate in the study and have
signed the Informed Consent Form; 2. Males or females, age 18 to 70 years old at the
time of study screening; 3. American Society of Anesthesiologists (ASA) Class I-III
(Appendix III) undergoing elective anorectal surgery 4. Patients undergoing the
following hemorrhoid surgeries will be included:

1. Excisional single column or multiple column hemorrhoidectomy including internal
and external component

2. Stapled hemorrhoidpexy (aka procedure for prolapsed hemor-rhoids with or without
excision of external hemorrhoid or skin tag)

3. Trans anal hemorrhoidal dearterialization with mucopexy (THD) with or without
excision of external hemorrhoid or skin tag 5. Patients undergoing the following
anal fistula surgery will be included:

1. Anal fistulotomy or fistulectomy of intersphincteric or tran-sphincteric fistula
with wound > 1 cm

2. Endorectal or anocutaneous advancement flap for anal fistula re-pair

Exclusion Criteria:

- 1. Unable or unwilling to provide informed consent or comply with study procedures 2.
American Society of Anesthesiologists (ASA) Class IV or V; emergency surgeries 3.
Children <18 4. Patients over age 70 due to small risk of altered mental status with
gabapentin in elderly6 5. Patients with impaired renal clearance (baseline creatinine
1.5mg/dL, creatinine clearance < 60ml/min or known renal dysfunction) 6. Patients with
known liver dysfunction (Childs class A, B, or C) 7. Patients with prior liver or
kidney transplant 4. Pregnant patients 5.Patients requiring emergency surgery 6.
Patients taking narcotics or steroids at the time of surgery 7. Patients having
external hemorrhoidectomy or skin anal tag excision only 8. Patients having anal
abscess drainage, seton placement without definitive fistula repair, or ligation of
intersphincteric fistula tract, subcutaneous fistulotomy or fistulotomy with wound <1
cm