We thank Dr. Harper for his comments and interest on our recent study published in Anesthesiology.1
We fully agree with the author that complete compliance with the enhanced recovery after surgery recommendations would have involved absence of mechanical bowel preparation (MBP) in left-sided colonic surgery. Nevertheless, the largest systematic review on the role of MBP in colonic surgery (including approximately 5,000 patients) failed to demonstrate harmful effects of MBP in terms of anastomotic leakage.2 In addition, two large-scale randomized controlled trials3,4 suggested more deep intraabdominal abscesses in the absence of MBP and a significant benefit in patients who had MBP. It has also been shown that preoperative MBP is useful when intraoperative colonoscopy is required to precisely locate small tumors. Finally, although MBP has adverse physiologic effects attributed to dehydration, omission of preoperative fasting and use of individualized goal-directed fluid administration may easily and effectively compensate for this.
We respectfully disagree with the author when stated that midline incision may not represent current daily for colorectal surgery. To the best of knowledge, current recommendations do not advocate use of transverse or oblique incisions for open colorectal surgery. Since the publication of the Cochrane review, the Postsurgical Pain Outcome of Vertical and Transverse Abdominal Incision randomized controlled trial5 has shown no relevant difference in pain scores and postoperative morbidity between incision types after major abdominal procedures, whereas more wound infections were seen after transverse incisions. Although problematic, these concerns are not the most important ones. Indeed, as a possible clinical benefit of wound catheters placement in oblique and/or transverse incisions has never been explored during colorectal surgery, any comparison between continuous wound analgesia, as an interventional treatment group in this setting, and epidural analgesia would have been only speculative.
Until more thorough studies addressing the question have been carried out, our opinion is that there is no sufficient evidence to shift from epidural analgesia to continuous wound infiltration of local anesthetics in elective open colorectal surgery. We are convinced that the soon-to-be-published Dr. Harper’s study will help provide answers to the many remaining questions regarding the optimal analgesic regimen in open colorectal surgery.