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Letters to the Editor: Letters & Announcements

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

White, Paul F. PhD, MD; Shafer, Steven L. MD

Author Information
doi: 10.1213/ANE.0b013e3181b57c8a

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 ( 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

Steven L. Shafer, MD

Department of Anesthesiology

Columbia University

New York City, New York


1. Eipe N, Penning J. Bowel surgery and multimodal analgesia: same game, new team? Anesth Analg 2009;109:1703
2. Shafer SL. Tattered threads. Anesth Analg 2009;108:1361–3
3. Klein M, Andersen LP, Harvald T, Rosenberg J, Goqenur I. Increased risk of anastomotic leakage with diclofenac treatment after laparoscopic colorectal surgery. Dig Surg 2009;26:27–30
4. 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
5. White PF. Changing role of COX-2 inhibitors in the perioperative period: is paracoxib really the answer? Anesth Analg 2005;100:1306–8 [Editorial]
6. White PF, Kehlet H, Liu SS. Perioperative analgesia: what do we still know? Anesth Analg 2009;108:1364–7
7. Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement: a randomized controlled trial. JAMA 2003;290:2411–8
8. White PF, Sacan O, Tufanogullari B, Engl M, Nuangchamnong N, Ogunnaike B. Effect of short-term postoperative celecoxib administration on patient outcome after outpatient laparoscopic surgery. Can J Anaesth 2007;54:342–8
9. Sun T, Sacan O, White PF, Coleman J, Rohrich RJ, Kenkel JM. Perioperative versus postoperative celecoxib on patient outcomes after major plastic surgery procedures. Anesth Analg 2008;106:950–8
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;106:11–8
11. McKay A, Gottschalk A, Ploppa A, Durieux ME, Groves DS. Systemic lidocaine decreased the perioperative opioid analgesic requirements but failed to reduce discharge time after ambulatory surgery. Anesth Analg (in press)
12. White PF, Wang B, Tang J, Wender RH, Naruse R, Sloninsky A. Effect of intraoperative use of esmolol and nicardipine on recovery after ambulatory surgery. Anesth Analg 2003;97:1633–8
13. Collard V, Mistraletti G, Taqi A, Asenjo JF, Feldman LS, Fried GM, Carli F. Intraoperative esmolol infusion in the absence of opioids spares postoperative fentanyl in patients undergoing ambulatory laparoscopic cholecystectomy. Anesth Analg 2007;105:1255–62
14. White PF, Kehlet H. Postoperative pain management and patient outcome: time to return to work! Anesth Analg 2007;104:487–9
© 2009 International Anesthesia Research Society