To the Editor:—

We read with great interest the report by Norris et al.  1“Double-masked randomized trial comparing alternative combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery.” Since the landmark reports of Yeager et al.  2and Tuman et al. , 3it appeared that either intraoperative anesthesia or postoperative analgesia may indeed affect postoperative outcome in certain high-risk patients undergoing major operations. However, more recent studies have suffered methodologic deficiencies in trying to confirm or refute these findings. It is therefore quite gratifying to see a large, randomized, blinded clinical trial to determine what effect, if any, intraoperative anesthesia and postoperative analgesia has on outcome and length of stay in these high-risk patients.

However, we do not believe the findings of Norris et al.  support the conclusion that intraoperative anesthesia or postoperative analgesia “offers no major advantage or disadvantage.”1Multiple studies consistently demonstrate that postoperative epidural analgesia provides superior pain relief compared with systemic opioids. 4–10However, Norris et al.  states “there were no differences in VAS pain scores over time among the four treatment groups for VAS-least pain, VAS-now pain, or VAS-cough pain.”1The mechanism by which previous papers demonstrated improved outcome is unclear. 2,3The working hypothesis is that epidural analgesia blunts the stress response either through improved analgesia or sympatholysis. This stress reduction then attenuates the postoperative hypercoagulable state, thereby improving outcome. If, as in Norris et al. , postoperative pain scores are the same in all groups, how would one ever expect to see a difference in outcome? If the patients had received more aggressive dosing regimens and thus produced the expected better pain control in the epidural groups, one might then expect an outcome difference.

Norris EJ, Beattie C, Perler BA, Martinez EA, Grass JA, Meinert CL, Anderson GF, Grass JA, Sakima NT, Gorman R, Achuff SC, Martin BK, Minken SL, Williams GM, Traystman RJ: Double-masked randomized trial comparing alternative combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery. A nesthesiology 2001; 95: 1054–67
Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T: Epidural anesthesia and analgesia in high-risk surgical patients. A nesthesiology 1987; 66: 729–36
Tuman KJ, McCarthy RJ, March RJ, DeLaria GA, Patel RV, Ivankovich AD: Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 1991; 73: 696–704
Park WY, Thompson JS, Lee KK: Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg 2001; 234: 560–9
Correll DJ, Viscusi ER, Grunwald Z, Moore JH Jr: Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction. Reg Anesth Pain Med 2001; 26: 444–9
Flisberg P, Tornebrandt K, Walther B, Lunberg J: Pain relief after esophogectomy: Thoracic epidural analgesia is better than parenteral opioids. J Cardiothorac Vasc Anesth 2001; 15: 282–7
Boylan JF, Katz J, Kavanagh BP, Klinck JR, Cheng DCH, DeMajo WC, Walker PM, Johnston KW, Sandler, AN: Epidural bupivicaine-morphine analgesia versus patient-controlled analgesia following abdominal aortic surgery. A nesthesiology 1998; 89: 585–93
Bois S, Couture P, Boudreault D, Lacombe P, Fugere F, Giraerd D, Nadeau N: Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesth Anal 1997; 85: 1233–9
Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TSJ, Feinglass NG, Metzger PP, Fulmer JT, Smith SL: Effects of perioperative analgesia technique on rate of recovery after colon surgery. A nesthesiology 1995; 83: 757–65
Jayr, C, Thomas H, Rey A, Farhat F, Lasser P, Bourgain J-L: Postoperative pulmonary complications: epidural analgesia using bupivicaine and opioids versus parenteral opioids. A nesthesiology 1993; 78: 666–76