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British Journal of Healthcare and Medical Research - Vol. 11, No. 5
Publication Date: October 25, 2024
DOI:10.14738/bjhmr.115.17714.
Mahmood, A., Yaakovian, M., Ahmed, K., & Mahmood, A. M. (2024). Post Operative Pain Control Following Colon Resection – and
the Pendulum that has Swung from One Extreme to the Other. British Journal of Healthcare and Medical Research, Vol - 11(5). 129-
133.
Services for Science and Education – United Kingdom
Post Operative Pain Control Following Colon Resection – and the
Pendulum that has Swung from One Extreme to the Other
Ali Mahmood
Underwood Digestive Disease Center, Houston Methodist Hospital
Department of Surgery, Texas A&M School of Medicine 16605
Southwest Freeway, Suite 430, Sugar Land, TX 77479, USA
Michael Yaakovian
Houston Methodist Hospital, Department of Surgery
Houston Methodist Hospital, Institute of Academic Medicine
16605 Southwest Freeway, Suite 450, Sugar Land, TX 77479, USA
Kamran Ahmed
Houston Methodist Hospital, Department of Medicine
Kelsey, Seybold Clinic 11555 University Blvd, Sugar Land,
TX 77478, USA
Aiva Mariam Mahmood
Houston Methodist Hospital, Department of Surgery
16605 Southwest Freeway Suite 430, Sugar Land, TX 77479
USA
ABSTRACT
The mitigation and limitation of narcotics following colon resection procedures has
had many positive outcomes. The quicker return of bowel function has enabled
many patients to be discharged from the hospital sooner. Earlier return to home not
only provides the patients with a familiar environment to heal expediently, but also
limits their exposure to nosocomial infections and provides a financial savings to
healthcare. However, has the pendulum swung to far? Colon resection is a
tremendous trauma to the patient. Even laparoscopy requires a small incision to
extract the resected specimen, severing skin, muscle, fascia and peritoneum,
inciting visceral and somatic pain. While the volume of narcotics has been markedly
decreased, there is a role for narcotic usage in the post surgical colon resection
patient. There is real pain that is incurred by the patient following a laparoscopic
colon resection. Adequate control of this pain fosters an environment where the
patient is willing to ambulate more, motivated to push themselves to recovery and
build trust with their surgeons and caregivers. The purpose of our study was to
evaluate the efficacy of pain medication, in particular the pain medication
prescribed upon discharge. Our hypothesis centered around adequate and robust
pain control would result in a motivated patient enabling a faster return to pre- surgical quality of life and fewer narcotic refills. Appropriate care with potent
narcotics yields a more robust and faster recovery, with less refills on pain
medication and a shorter path to recovery.
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130
British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 05, October-2024
Services for Science and Education – United Kingdom
Keyword: Pain, Narcotics, Post-operative, Post-surgical, Enhanced Recovery
RESEARCH DESIGN
From January 2015 to January 2024, all patients that underwent a segmental colon resection
were identified. Patients that underwent an open procedure (laparoscopic converted to open)
were excluded from the study.
The type of pain management was identified. The duration of the PCA was recorded. The return
of bowel function and length of stay was recorded. The prescription for pain medication was
identified. The amount of refills authorized was reviewed. The patient’s return to work and/or
daily functional activity was extracted from the records.
RESULTS
There were 1608 colon resections identified. 62 (3.8%) were excluded due to them being
converted to an open procedure from a laparoscopic procedure. Patients were given a PCA.
1300 hundred patients had a dilaudid PCA for the first 24 hours. 244 had a morphine PCA. 2
patients had a fentanyl PCA. There were 2 patients that did not have their PCA discontinued in
the first 24 hours and they were excluded from the study.
Patients had a mean return of bowel function at 60.2 hours post operative ± 24 hours. Their
average length of stay was 4.3 days.
970 Patients that were given Norco 5/325 as their discharge pain medication. 322 patients
were given tramadol as their discharge pain medication. 248 patients were given Tylenol with
codeine (T3) as their discharge paid medication. 4 patients were given a regimen by their pain
management physician. They were excluded from the study.
Patients that received the Norco 5/325 had a much faster recovery. They returned to the work
setting, walking better and feeling better. The number of refills for the patient population
receiving robust pain control was markedly lower. Table 1 There were 0 patients that were
given a refill on the Norco. The patients on tramadol were not as progressive at the Norco
cohort. Of the 322, 52 patients (16%) asked for and received refills on their pain medication.
An additional 8 (2.5%) asked for a second refill. In the T3 patient cohort, 48 patients (19%)
asked for a refill upon return to their clinic follow up. An additional 12 (4.9%) patients
requested a second refill. From the Tramadol and T3 patient populations, of the 570 patients,
there were 12 patients, 2%, that asked for their leave of work to be extended. There were 0
patients from the Norco cohort that asked for a extension from returning to work.
The cohort of patients that received Norco 5/325 had an earlier return to daily functional
activity and/or work. The average time period from operation to returning to their occupation
was 19 days ± 3 days. There were two patients that were back to work 6 days after their
operation. These were excluded from the data because they were significant outliers. Patients
that were given tramadol returned to their daily functional activity, without any sequelae, 22
days ± 4 days, after their surgery. Patients that were given T3 had an average return to work
23 days ± 4 days.
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131
Mahmood, A., Yaakovian, M., Ahmed, K., & Mahmood, A. M. (2024). Post Operative Pain Control Following Colon Resection – and the Pendulum
that has Swung from One Extreme to the Other. British Journal of Healthcare and Medical Research, Vol - 11(5). 129-133.
URL: http://dx.doi.org/10.14738/bjhmr.115.17714.
DISCUSSION
The use of narcotics has been severely mitigated in the medical realm. While this has been
received with much positivity, there are instances and occurrences where the pendulum has
swung too far. Patients are expected to have pain following a major abdominal operation, with
an incision. While the authors of this study are not advocating for pain medicine to be
prescribed and dispensed blindly and carelessly, there definitely is an advantage to addressing
pain early and successfully following a colon resection.
Opioid dependency became an epidemic in healthcare. Some studies reported a 30% opioid
dependency stemming from hospital prescribed opioids. [1] There is also a cohort of patients
that enters the operation already on scheduled pain medication. These patients fare worse than
opioid naïve patients.[2] The tolerance to pain medication results in larger doses having to be
administered with poorer control. Younger patients have also been shown to report increased
pain, following major abdominal surgery.[3]
The use of laparoscopy has certainly helped with curtailing pain. The collective length at the
hospital has been shorter, along with the use of narcotics. [4] Some studies have shown that
using a Pfannenstiel incision, for colon extraction, versus a midline incision has reduced the
demand of narcotics. [5] The demand for opioids did not differ for benign versus malignant
pathology, for patients undergoing the same type of operation.[6]
Enhanced recovery after surgery (ERAS) protocols have played a monumental role in patients
leaving the hospital faster, requiring less pain medication and assimilating back into their daily
functional routine quicker. [7] One study showed the length of stay decreased from 6.7 to 3.7
days, the use of patient-controlled analgesia decreased from 63.2% to 15% and the duration of
narcotic usage decreased from 67.8 hours to 47.1 hours.[8] Some surgeons have used epidural
analgesia to augment narcotics, citing reduced postoperative pain. [9,10] Another study
advocated the use of intravenous lidocaine as an alternative to epidural bupivacaine in reducing
ileus duration, length of stay and post operative pain following colon resection. [11] The
authors of this study have not used epidural analgesia due to its potential for adverse effects,
complicating post operative recovery. The introduction of bupivacaine at the port sites has seen
some benefit with decreasing post operative narcotic usage, however these studies are varying
in their results. [12,13] Ultrasound and laparoscopic guided transversus abdominis plane
blocks received popularity in post operative pain control, mitigating the use of opioids. [14,15]
The Cochrane Database of Systemic Review illustrated that the use of ERAS with laparoscopy
decreased length of time for a bowel movement by 21.0%, with a 12.6% reduction in pain
scores. There was earlier resumption of an oral diet – (28.3% sooner) and patients were
discharged home 19.1% earlier.[16]
The results of our study showed that appropriate pain control early led to patients ambulating
better, assimilating back into their routines faster and gaining their confidence sooner. It is
paramount that patients ambulate early in the post operative course. Benefits include
prevention of blood clots, subsequent embolisms, pneumonia and aids in the bowel recovery
process, to name a few. The return to daily functional high functional activities, returning to
their profession, builds confidence and reinforces a successful recovery form a major operation.
Our study clearly demonstrated that return to work amongst the Norco cohort was faster on
average, when compared to tramadol or T3. Achieving robust pain control immediately upon