A Reply to Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review

To the Editor The Cochrane review of epidural local anesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting, and pain after abdominal surgery1 raises a number of issues. Despite epidural anesthesia being practiced on a regular basis, only the evidence regarding flatus was judged to be of high quality and 30 of the included studies were judged to be of very low quality. Second, abdominal surgery shows a wide variation of complexity and in the extent of the surgical insult. For example, an esophagectomy carries significantly different risks to a cholecystectomy. The benefits, or lack thereof, are also likely to significantly differ. This is equally true for the patients involved; a healthy 50-year-old patient may gain less benefit than the 80-year-old multimorbid patient. We, therefore, believe that this review should not be used as a reason to abandon epidural anesthesia but as a motivation to improve the quality, coordination, and organization of the studies of epidural anesthesia to determine with much more confidence whether there are, or are not, clinically significant benefits to be gained for specific patient groups undergoing specific procedures. With the increasing interest in the role of regional anesthesia in the prognosis of patients with cancer,2 the need for controlled, well-performed prospective studies is of significant importance. Finally, given the lack of overwhelming benefit of epidural anesthesia demonstrated in this review, it would interest us as to the authors’ opinion of epidural anesthesia initiated postoperatively as a rescue therapy for patients experiencing postoperative complications such as bowel paralysis or pain proving difficult to control with standard parenteral opiates. Ellis Muggleton, MBChBTülin Muggleton, MDDepartment of Anaesthesia & Intensive Care MedicineRotkreuzklinikum MünchenMunich, Germany[email protected]; [email protected]