In Response

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We thank Dr Muggleton for his interest in our work.1 Although it may seem curious to end up with high-quality evidence while including randomized trials with suboptimal quality, we would like to reassure your readers that the quality of evidence was assessed on the criteria recommended by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group.2 The GRADE scale is officially endorsed by the Cochrane Collaboration. For time-to-first-flatus after the surgery, we downgraded the level of evidence by 2 for risk of bias (quality of included trials). We did not downgrade the level on the basis of inconsistency (reasonable explanation was found for heterogeneity) or indirectness (direct comparisons only) or imprecision (optimal information size achieved) or publication bias (applying a correction would not modify the conclusion). We upgraded the level by 1 level for a large effect size (standardized mean difference > 0.8).3 We found no evidence of confounding factors to justify upgrading. We upgraded the level by 1 for a dose response (increasing the concentration of the local anesthetic increased the effect size; Figure 3 in the article).1,3
We agree that the type of surgery should be taken into account in the decision to use an epidural for postoperative analgesia. “…the decision to use epidural analgesia after an abdominal surgery versus other modalities has to be considered on a case by case basis taking into account age, associated comorbidities, relative contraindications, and type of surgery.”1
We also agree that older patients may benefit more from epidural analgesia than younger ones. A meta-regression of pain scores on movement at 48 hours versus age of the participants included in the trials showed that older participants benefit more from an epidural containing a local anesthetic (P = .002; Figure).
We agree that further research or reviews could be useful. “The optimal concentration of local anesthetic required to hasten the return of gastrointestinal transit without impeding ambulation and the optimal duration of administration may need to be determined in futures studies or reviews.”4
We do not think that our review demonstrated a lack of benefit of epidural analgesia for abdominal surgeries. “In conclusion, an epidural with a local anesthetic will accelerate the return of gastrointestinal transit by approximately 17 hours. The effect is proportional to the local anesthetic concentration. This effect will translate in shorter hospital length of stay for open surgeries only. An epidural with a local anesthetic also improves pain scores (open or laparoscopic surgeries).
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