Effectiveness of Etoricoxib as an Additive Analgesic to Epidural Analgesia in Colon or Rectal Fast-track Surgery

• Primary end point of the study is the average pain level (scale 0-10) in the area of surgery during movement (walking a fixed number of steps) under active epidural analgesia, at the third day following laparoscopic colon or rectal surgery. [ Time Frame: third postoperative day ] [ Designated as safety issue: Yes ]
  To demonstrate that the administration of etoricoxib 120mg additionally to the clinical routine therapy (epidural catheter) reduces the post-operative pain level during movement at the thrid day after laparoscopic colon or rectal surgery in the fast-track design.
  
  

• Post-operative pain level during movement in the first 2 days after laparoscopic colon or rectal surgery. [ Time Frame: in the first 2 days after laparoscopic colon or rectal surgery ] [ Designated as safety issue: Yes ]
  
• Post-operative pain level during rest in the first 2 days after laparoscopic colon or rectal surgery. [ Time Frame: in the first 2 days after laparoscopic colon or rectal surgery ] [ Designated as safety issue: Yes ]
  
• Post-operative pain level during rest and movement from the third until the fifth day after laparoscopic colon or rectal surgery (one day after epidural catheter removal) [ Time Frame: one day after epidural catheter removal ] [ Designated as safety issue: Yes ]
  
• Incidence of pain events and the average pain intensity in body parts outside of the area of operations. [ Time Frame: study period ] [ Designated as safety issue: Yes ]
  
• Incidence of new organ dysfunctions, side effects, frequency and amount of intake of rescue medication. [ Time Frame: study period ] [ Designated as safety issue: Yes ]
  
• Postoperative LOS [ Time Frame: period of hospital stay ] [ Designated as safety issue: No ]
  
• Patients level of satisfaction [ Time Frame: study period ] [ Designated as safety issue: No ]
  

A fast-track program is an evidence-based, multimodal approach for patients undergoing surgery to reduce perioperative morbidity, hospital stay and cost and to increase patient centered well-being. Particularly in visceral surgery of the colon it is gaining widespread acceptance (Schwenk 2009). Optimized pain relief is a core component of any fast-track regimen (Kehlet and Wilmore 2008). In this context epidural analgesia has become the standard of care for early postoperative pain therapy (Hasenberg 2009), providing superior pain relief compared to parenteral opioids (Block 2001).

The open question of analgesic adjuncts to epidural analgesia. However, it is debated whether non-opioid analgesics should be given as adjuncts when epidural analgesia is already present. Some studies have found reduced pain using NSAID as adjunct (Scott 1994), leading to a positive recommendation in the German guidelines for postoperative pain therapy (S3-Leitlinie). However, other studies (Mogensen 1992) have not found an effect of non-opioids in addition to epidural analgesia. Further studies are also needed to assess whether nonopioid adjuncts can facilitate the change from epidural to systemic analgesia (typically on the 2nd or 3rd postoperative day) and reduce opioid consumption during the days after catheter removal.

Fast-track surgery is a multi-model process, and every step in this process needs to be fine-tuned to yield best results (Langelotz 2005). Until now studies have compared only groups with either epidural or systemic analgesia, but for optimal recovery a sequential approach with a combination of both is probably a better choice. A typical multimodal analgesia regimen after removal of an epidural at our institution consists of acetaminophen and ibuprofen. Opioids are avoided if possible, but are added if needed. An improved non-opioid analgesia regimen is a sought-after goal in this fast-track-phase. The study is controlled in terms of the type of surgery (laparoscopic colon and rectal surgery) and all factors of the multimodal analgesia treatment.