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The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015–March 2017) and after OSMMAP implementation (April 2017–March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/ robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.

Definitive draining seton (DDS) alone is an accepted treatment for complex refractory anal fistulas in Crohn’s disease (CD). We evaluated the long-term success of DDS in CD patients. DDS was defined as draining seton placed definitively for at least 12 months. Primary end point was clinical response (CR) defined as a lack of induration, pain, swelling, abscess recurrence, or unintended dislodgement. The study cohort of 23 patients had a median age of 29 (range; 9-61) years and included 14 males (61%). Reasons for DDS included anal stenosis (n = 9; 39%), active proctitis (n = 9; 39%), and/or anal canal ulceration (n = 9; 39%). Median number of setons was 2 (range; 1-6) and 65% had multiple fistula tracts. Almost all patients (n = 22; 96%) were on a biologic postoperatively. At 12-month follow-up, only 39% (n = 9) had a CR. The remaining 14 patients failed due to new abscess formation (n = 6; 26%), new fistula formation (n = 6; 26%), and seton dislodgement (n = 2; 9%). Six (26%) patients required fecal diversion. No patients required proctectomy. DDS for complex CD fistula results in a mediocre CR with many patients developing recurrent abscess/fistula or requiring diversion despite biologic therapy.