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Preemptive Analgesia Decreases Pain Following Anorectal Surgery

A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial

Van Backer, Justin T. M.D.1,2; Jordan, Matthew R. M.D., LT., M.C., U.S.N.2,3; Leahy, Danielle T. M.D.2,4; Moore, Jesse S. M.D.2; Callas, Peter Ph.D.2,5; Dominick, Timothy M.D.4; Cataldo, Peter A. M.D.2

Diseases of the Colon & Rectum: July 2018 - Volume 61 - Issue 7 - p 824–829
doi: 10.1097/DCR.0000000000001069
Original Contributions: Anorectal
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BACKGROUND: Postoperative pain is a frequent cause for delayed discharge following outpatient procedures, including anorectal surgery. Both central and peripheral pain receptor sensitization are thought to contribute to postoperative pain. Blocking these receptors and preempting sensitization prevents hyperalgesia leading to lower pain medication requirements. Studies in the orthopedic, urologic, and gynecologic literature support this practice, but the use of preemptive analgesia in anorectal surgery is understudied.

OBJECTIVE: This study aimed to evaluate the effectiveness of preemptive analgesia in decreasing postoperative pain.

DESIGN: This is a randomized, double-blinded, placebo-controlled trial.

SETTING: This study was conducted at the University of Vermont Medical Center, a tertiary care referral center in Burlington, Vermont.

PATIENTS: Patients who were over 18 years of age, ASA Physical Status Classes I, II, or III, and undergoing surgery for anal fissure, fistula or condyloma or hemorrhoids were selected.

INTERVENTIONS: Preoperative oral acetaminophen and gabapentin followed by intravenous ketamine and dexamethasone were given before incision compared with oral placebos.

MAIN OUTCOME MEASURES: The primary outcomes measured were postoperative pain scores, percentage of patients utilizing breakthrough narcotics, and rates of side effects.

RESULTS: Ninety patients were enrolled. Because of patient withdrawal, screen failures, and loss to follow-up, 61 patients were analyzed (30 in the preemptive analgesia group and 31 in the control group). Patients in the active group had significantly less pain in the postanesthesia care unit and at 8 hours postoperatively. Significantly fewer participants in the active group used narcotics in the postanesthesia care unit and at 8 hours postoperatively. Average pain scores were excellent for both groups. There was no difference in the number of medication-related side effects between the 2 groups.

LIMITATIONS: This study was limited by the small sample size and excellent pain control in both groups.

CONCLUSIONS: Preemptive analgesia is safe and results in decreased pain in the early postoperative period following anorectal surgery. It should be implemented by surgeons performing these procedures. See Video Abstract at

1 Department of General Surgery, Albany Medical Center, Albany, New York

2 Department of Surgery, University of Vermont Medical Center, Burlington, Vermont

3 Department of Emergency Medicine, Naval Medical Center, Portsmouth, Virginia

4 Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont

5 Department of Statistics, University of Vermont, Burlington, Vermont

Funding/Support: This research was supported by the Eugene Salvati Grant #097 from the Research Foundation of the American Society of Colon and Rectal Surgeons.

Financial Disclosures: None reported.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Research data derived from an approved University of Vermont IRB protocol, number 00000485.

Trial Registration Number: registration number NCT 02402543.

Podium presentation at the New England Surgical Society Resident and Fellow Research Day on May 8, 2018. Presented at the meeting of the New England Society of Colon and Rectal Surgeons, York, ME, May 20 to May 21, 2017. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to June 14, 2017.

Correspondence: Peter A. Cataldo, M.D., Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401. E-mail:

© 2018 The American Society of Colon and Rectal Surgeons