To the Editor:—

We read with much interest the article of Li et al.  1These authors designed a study to test the hypothesis that the use of local anesthesia combined with propofol sedation for ambulatory anorectal surgery was superior to both general and spinal anesthesia with respect to recovery times, postoperative side effects, patient satisfaction, and total costs to the healthcare institution. Local anesthesia was performed according to the technique of Nivatvongs 2,3and associated with propofol infusion titrated to maintain a stable level of grade 3 sedation in the Observer’s Assessment of Alertness-Sedation score. They found that the use of local anesthesia with sedation is the most cost-effective technique for anorectal surgery in the ambulatory setting.

The authors did not include caudal anesthesia in their comparative study. Caudal anesthesia can also be used for sacroperineal surgery in adults. In a recent study, 4we found that caudal anesthesia is a reliable and safe anesthetic technique for hemorrhoidectomy in adults, despite the 10% rate of technical failure because of an absent hiatus due to wide anatomic variation in this region. 5When low volume (14 ml) of a mixture containing 2% lidocaine with 0.5% bupivacaine and 5 μg/ml epinephrine was used, adequate surgical anesthesia was obtained. All patients were satisfied with the anesthetic care. Time to oral intake was immediate. When the mixture of lidocaine with bupivacaine and epinephrine was used alone, no postoperative side effects occurred. First analgesic requirement after surgery, time to spontaneous standing, and first spontaneous voiding were 276 ± 131, 141 ± 26, and 406 ± 36 min, respectively. Using the same critique as Li et al. , 1we estimated that the marginal costs of drugs and resources in our study was similar. Because propofol was not used, the cost may be lower.

Li S, Coloma M, White PF, Watcha MF, Chiu JW, Li H, Hubert PJ Jr: Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. A nesthesiology 2000; 93: 1225–30
Nivatvongs S: An improved technique of local anesthesia for anorectal surgery. Dis Colon Rectum 1982; 25: 259–60
Nivatvongs S: Technique of local anesthesia for anorectal surgery. Dis Colon Rectum 1997; 40: 1128
Van Elstraete AC, Pastureau F, Lebrun T, Mehdaoui H: Caudal clonidine for postoperative analgesia in adults. Br J Anaesth 2000; 84: 401–2
Crighton IM, Barry BP, Hobbs GJ: A study of the anatomy of the caudal space using magnetic resonance imaging. Br J Anaesth 1997; 78: 391–5
Eisenach JC, De Koch M, Klimscha W:α2-Adrenergic agonists for regional anesthesia. A nesthesiology 1996; 85: 655–74