POSTOPERATIVE PAIN CONTROL IN THE SURGERY OF CROHN’S DISEASE

Background. Crohn’s disease (CD) is a chronic, granulomatous, inflammatory disease of the gastrointestinal tract and of yet unidentified etiology. The majority of CD patients require surgery during their clinical history, to manage both the disease complications and medical treatment failures1. Patients may experience visceral pain during the chronic phase of the disease and may perceive an amplified acute postoperative pain due to abnormal pain reactions developed secondary to the chronic pain2,3. Aims. The aim of our study was to critically evaluate the efficacy of the methods used in our practice for postoperative pain control in patients undergoing surgery for complications of CD. Methods. This observational and retrospective study included 197 consecutive patients with CD who underwent surgery between September 2011 and September 2012 and that were followed for postoperative pain control by the Acute Pain Service (APS) of Sant’Orsola-Malpighi teaching Hospital of Bologna. Pain ratings were made by instructed anesthesia residents using a 0-10 numerical rating scale (NRS) both under static (NRSs) and dynamic (NRSd) conditions. Our in-house postoperative pain management protocols are: Protocol A, intravenous administration of NSAIDs or paracetamol at fixed hours (not considered for this analysis), Protocol B, continuous intravenous administration of morphine chlorhydrate or tramadol, Protocol C, Patient Controlled Analgesia (PCA) with morphine chlorhydrate and Protocol D, Results.Among all protocols the median of NRSs was higher in patients treated with Protocol D; from the 48^ postoperative also the latter got comparable with the other two protocols considered. Similar trend was found also for the NRSd. dynamic conditions, at 8^ postoperative hour significant differences were found between Protocol C and D, showing a better effectiveness of the PCA (8^h: p=0,004). At 16^, 24^, 32^, 40^ and 48^ hours epidural analgesia was found to be less effective than both PCA and continuous intravenous analgesia. Conclusions. Our data support the assumption that the PCA represent the best analgesic choice for the treatment of postoperative pain in CD patients. The median trend of NRSs and NRSd with PCA was lower in most of evaluations, suggesting a major patient’s satisfaction with pain management. This has been explained by the ‘theory of locus of control’2,4. Satisfactory results were also obtained using intravenous opioid analgesia; they were comparable to the PCA at all evaluations. We also demonstrated that in CD patients epidural infusion was less effective for postoperative pain control. This limited efficacy of epidural analgesia may be explained by the limited size of the anesthetic block as compared to the size of the surgical incision. Bibliography. 1. Poggioli G, Pierangeli F, Laureti S et al. Review article: indication and type of surgery in Crohn's disease. Aliment.Pharmacol.Ther. 2002;16 Suppl 4:59-64 2. Cameron CA, Sawatzky JA. Postoperative pain management: the challenges of the patient with Crohn's disease. Medsurg.Nurs. 2008;17:85-91. 3. McCance K.L., Huether S.E. Pathophysiology: The biological basis for disease in adults and children. 5 ed. St. Louis: Elsevier Mosby, 2006. 4. Lackner JM, Quigley BM, Blanchard EB. Depression and abdominal pain in IBS patients: the mediating role of catastrophizing. Psychosom.Med. 2004;66:435-41.