Bowel Surgery and Multimodal Analgesia: Same Game, New Team?

In Response: Epie and Penning1 state that a recent editorial by Shafer2 suggested that, until further research in the field of multimodal analgesia becomes available, the “future of COX-2 inhibitors in multimodal analgesic protocols is hanging by a proverbial thread.” They further opine that current evidence suggests that for minimally invasive (laparoscopic) bowel surgery, nonsteroidal antiinflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors should not be used in the perioperative period and recommended other nonopioid analgesic adjuvants, such as IV lidocaine, as part of multimodal analgesic protocols. This recommendation was based on recently published retrospective chart review studies by Klein et al.3 and Holte et al.,4 which reported that COX-2 inhibitors may delay bowel healing and increase the incidence of anastomotic leaks. Questions regarding the perioperative use of the COX-2 inhibitors had surfaced previously because of concerns about their potential for producing major cardiovascular complications.5 A recent editorial in this journal6 noted that the postoperative administration of COX-2 inhibitors has consistently demonstrated beneficial effects in decreasing pain, reducing opioid-related side effects, and improving the quality of patient recovery in the early and intermediate postoperative period when these drugs were administered as part of a multimodal analgesic regimen after orthopedic, laparoscopic, and plastic surgery.7–9 However, after the retraction of several articles by Reuben et al.,2,6 there is no longer unequivocal evidence supporting the “preemptive effect” of NSAIDs and COX-2 inhibitors. Furthermore, the clinical effects of NSAIDs and the COX-2 inhibitors on bone fusion and wound healing remain unclear and further investigative work is clearly needed.3–6 We agree that IV lidocaine merits attention, based on documented opioid-sparing effects after laparoscopic surgery.10,11 Esmolol is another novel alternative to opioid analgesics for maintaining intraoperative hemodynamic stability and improving postoperative pain management in patients undergoing minimally invasive (laparoscopic) surgery.12,13 Esmolol had been reported to improve postoperative pain control and the quality of recovery after laparoscopic surgery when administered as part of a multimodal analgesic regimen. It would be interesting to compare the effects of a continuous infusion of this rapid and short-acting β-blocking drug with those of a lidocaine infusion when they are administered during general anesthesia. Alternatively, these drugs may demonstrate synergy if given concurrently. Given the large disparity between our increased understanding of the basic pathophysiology of acute pain, and our limited ability to translate that understanding into improvements in clinical practice, practitioners are best advised to adopt procedure-specific, evidenced-based pain management protocols. The PROSPECT website (www.postoppain.org) is an excellent resource for evidence-based, procedure-specific pain management protocols. In addition, clinical investigators need to undertake the “heavy lifting” required to perform prospective, blinded, randomized, clinical trials evaluating the use of different combinations of opioid and nonopioid analgesics as part of multimodal analgesic treatment regimens in the perioperative period.14 Paul F. White, PhD, MD Department of Anesthesiology & Pain Management University of Texas Southwestern Medical Center Dallas, Texas [email protected] Steven L.