To the Editor:
Recent editorials1,2 discussing retraction of many papers related to use of cyclooxygenase-2 (COX-2) inhibitors suggest that, until the results of further research becomes available, the future of COX-2 inhibitors in Multi-Modal Analgesic Protocols (MMAP) may be uncertain. Although our confidence in MMAP may also have been somewhat shaken, we would like to add information from two recent publications elsewhere3,4 that may further impact MMAP for bowel surgery.
For open bowel resection and anastomosis once an epidural catheter is removed, MMAP have effectively included nonsteroidal antiinflammatory drugs (NSAIDs) and COX-2 inhibitors for their documented opioid-sparing effects.3 These drugs are useful to achieve the goals of early mobilization and feeding.5 Although antiinflammatory drugs may affect wound healing, the use of steroids in patients with inflammatory bowel disease has been associated with increased risk of anastomotic leaks.6 These implications of delayed bowel healing have also been suggested with NSAIDs such as diclofenac.7 Now, a retrospective study suggests that a COX-2 inhibitor may increase the incidence of anastomotic leaks in a clinically relevant manner.3
We find ourselves in a conundrum with MMAP for patients undergoing colon resections, when these are performed laparoscopically. For these procedures with multiple small incisions, epidural techniques are often not indicated.8 The onus on MMAP to help achieve the goals of fast-track surgery, we believe, is greater in these situations than elsewhere. We know from experience that reliance on opioids alone for postoperative analgesia delays the recovery of bowel function. It is rather unfortunate that in a type of surgery where opioid sparing is so important, COX-2 inhibitors have been implicated in a major adverse effect.3 Although these findings should be interpreted with caution (the paper itself mentions that several other centers have used intensive perioperative COX-2 therapy after colonic surgery without anastomotic leaks), there is clearly now an urgent need for a well-controlled, randomized, prospective, double-blind study to examine the effects of COX-2 inhibitors on bowel anastomosis, especially when performed laparoscopically. Until such time should we have to reconsider using epidurals8 in patients undergoing laparoscopic bowel resections to avoid COX-2 inhibitors and decrease opioid requirements?
Intravenous lidocaine is one of the nonopioid analgesic adjuvants that may be a suitable replacement for the NSAIDs/COX-2 inhibitors.10 A recent meta-analysis confirms this beneficial effect of lidocaine in decreasing opioid requirements and facilitating early rehabilitation after bowel surgery.4 Our own unpublished experience with IV lidocaine in laparoscopic bowel surgery has been similar and very encouraging.
In summary, until further evidence becomes available for patients undergoing major laparoscopic bowel surgery, it seems that COX-2 inhibitors will “sit out” while other players such as lidocaine move into key positions on the MMAP “team.”
Naveen Eipe, MBBS, MD
John Penning, MD, FRCP(C)
Department of Anesthesiology
The Ottawa Hospital
Civic Hospital Campus
Ottawa, Ontario, Canada
1. Shafer SL. Tattered threads. Anesth Analg 2009;108:1361–3
2. White P, Kehlet H, Liu SS. Perioperative analgesia: what do we still know? Anesth Analg 2009;108:1364–7
3. Holte K, Andersen J, Jakobsen DH, Kehlet H. Cyclo-oxygenase 2 inhibitors and the risk of anastomotic leakage after fast-track colonic surgery. Br J Surg 2009;96:650–4
4. Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg 2008;95:1331–8
5. White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F; Fast-Track Surgery Study Group. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 2007;104:1380–96
6. Alves A, Panis Y, Bouhnik Y, Pocard M, Vicaut E, Valleur P. Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn’s disease: a multivariate analysis in 161 consecutive patients. Dis Colon Rectum 2007;50:331–6
7. Klein M, Andersen LP, Harvald T, Rosenberg J, Gogenur I. Increased risk of anastomotic leakage with diclofenac treatment after laparoscopic colorectal surgery. Dig Surg 2009;26:27–30
8. Delaney CP. Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery. Dis Colon Rectum 2008;51:181–5
9. Zingg U, Miskovic D, Hamel CT, Erni L, Oertli D, Metzger U. Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection: benefit with epidural analgesia. Surg Endosc 2009;23:276–82
10. Kaba A, Laurent SR, Detroz BJ, Sessler DI, Durieux ME, Lamy ML, Joris JL. Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology 2007;106:11–18