Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery (Br J Surg 2011; 98: 1068–1078)

Sir We read with interest this trial investigating the impact of epidural compared with spinal or patient-controlled analgesia on clinical outcomes for patients undergoing laparoscopic colorectal cancer. The results provide further evidence to support a move away from epidural use in laparoscopic procedures, particularly in the context of an enhanced recovery programme (ERP). The multimodal package of techniques used to reduce the physiological stress response to surgery within an ERP, combined with the benefits of laparoscopic surgery, appear to negate the potential benefits in terms of analgesic efficacy provided by an epidural, and highlight the potential disadvantages in terms of sympathetic blockade and impairment of mobility. The study concludes that spinal anaesthesia would seem to be the analgesic mode of choice but recognizes further assessment is necessary, particularly in comparison with transversus abdominis plane (TAP) block. Our institution now has significant experience in use of TAP block for laparoscopic colorectal procedures, initially using a ‘blind’ technique and subsequently under ultrasound guidance. Consistent with other institutions, we have found that TAP block can effectively reduce postoperative pain and is ideal for a safe ERP1,2. The choice of postoperative analgesic control will be influenced by multiple factors related to the patient, the surgery required, and surgeon and anaesthetic preference. To achieve the high standards of clinical outcomes reported in this study a multidisciplinary approach must be taken to ensure that all aspects of the ERP are optimized. We believe that TAP block has a role in laparoscopic colorectal ERP and agree that further studies are necessary.