To the Editor:
I read with interest the article by Jouve et al.1 comparing epidural analgesia with continuous wound infusion of local anaesthetic after fast-track colorectal surgery, and I would like to commend the authors on their thorough methodology.
An important aspect of this trial is the management of patients within an enhanced recovery program, and the authors cite consensus recommendations, which guided to their management decisions.2 There are two areas that I feel the authors did not strictly adhere to the enhanced recovery recommendations. First, the consensus group recommends that the use of mechanical bowel preparation should be avoided except in the case of low rectal resections where diverting stomas are planned. However, patients receiving stomas were excluded and all patients undergoing left-sided or rectal resections received bowel preparation at the night before surgery. Second, all of the patients recruited to this study received large (19–20 cm) periumbilical midline incisions. Although it is true that the recommendations do not dictate the preference of transverse over midline incisions, they do recognize the findings of a Cochrane review reporting that short transverse incisions were associated with lower postoperative analgesic requirement and reduced pulmonary complications. My concern is that by including only the patients receiving midline incisions, they have selected a group that are more likely to benefit from epidural analgesia but do not represent the surgical population seen in other centers using enhanced recovery protocols.
I also note the authors’ recognition of the potential bias resulting from early conclusion of the trial after interim analysis. This is of particular interest because a similar study recently completed in our institution recruited 60 patients, but did not reveal a significant difference in length of stay or dynamic pain scores between either epidural analgesia or continuous wound infusion.