To the Editor:—

We would like to comment on the study by Norris et al.  1This study did not show any benefit from the combination of epidural anesthesia and analgesia with general anesthesia and systemic opioid analgesia. We are concerned, however, that the negative findings (broadly stated as thoracic epidural anesthesia–analgesia “offers no major advantages or disadvantages”) may be caused by shortcomings in the study design. Specifically, we question the choice of length of stay as the primary outcome variable on which analyses are based. Length of stay is not very sensitive, and is affected by numerous factors, including surgical practices and established care paths, which may obscure the benefits of epidural analgesia (as measured by more sensitive parameters).

In fact, a growing body of evidence 2shows that the use of epidural anesthesia and analgesia in the perioperative period is beneficial. Using a rigorous recovery protocol in the context of “multimodal surgical recovery programs,”3recent studies have demonstrated clear benefits from epidural anesthesia and analgesia (e.g. , reduced hypercoagulability, accelerated return of bowel function, decreased pulmonary complications, and earlier mobilization).

Furthermore, studies demonstrating benefit from regional techniques used in multimodal recovery programs tend to minimize perioperative opioid use. 4Thus, analgesia is achieved while avoiding opioid-related adverse effects, such as decreased gastrointestinal motility 5that can delay recovery. Norris et al . chose to administer opioids (fentanyl) to all patients and may have obscured or offset the potential benefit of epidural analgesia—at least in terms of length of stay.

In sum, the conclusions of Norris et al.  may be overstated. The lack of a rigorous recovery protocol, use of opioids in all patients, and selection of an insensitive primary outcome measure (length of stay) may have contributed to the negative findings of this study. Therefore, we caution against the more general interpretation that epidural anesthesia– analgesia is not beneficial.

Norris EJ, Beattie C, Perler BA, Martinez EA, 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 alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery. A nesthesiology 2001; 95: 1054–67
Swarm RA, Karanikolas M, Kalauokalani D: Pain treatment in the perioperative period. Curr Probl Surg 2001; 38: 845–920
Kehlet H: Acute pain control and accelerated postoperative surgical recovery. Surg Clin North Am 1999; 79: 431–43
Bardram L, Funch-Jensen P, Kehlet H: Rapid rehabilitation in elderly patients after laparoscopic colonic resection. Br J Surg 2000; 87: 1540–5
Lee J, Shim JY, Choi JH, Kim ES, Kwon OK, Moon DE, Choi JH, Bishop MJ: Epidural naloxone reduces intestinal hypomotility but not analgesia of epidural morphine. Can J Anaesth 2001; 48: 54–8