A commentary on ‘Comparison of pharmacologic therapies alone versus operative techniques in combination with pharmacologic therapies for postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial’
Authors: Dongyao Xu, Youbao Huang, Wei Wang
Journal: International Journal of Surgery (2023)

Dear Editor, Recently, we read the article by Kim et al.1 with immense interest. The authors conducted a meaningful assessment of the quality of evidence concerning operative analgesic techniques for patients undergoing laparoscopic cholecystectomy (LC) with postoperative pain. The topic is particularly intriguing as it explores how these techniques can effectively reduce postoperative pain resulting from LC. Their findings revealed that not only pain at rest (P<0.001) but also pain on cough (P=0.001) scores were higher in the pharmacologic analgesia (P) group compared with those in the operative analgesic treatments with pharmacologic analgesia (OP) group. Additionally, the authors observed that the sleep quality scores at 24 h postoperatively were lower in the P group compared with the OP group (67±15 vs. 56±18; P=0.017). This randomized controlled trial provided significant evidence of the treatment techniques for patients undergoing LC. Although the study is inspiring and thought-provoking, we have the following comments: First, the inclusion criteria of this study did not clearly specify whether the enrolled patients had gallstones or other gallbladder diseases. It is essential to note that numerous patients undergo LC because of gallstones and a significant proportion of them have chronic cholecystitis. Patients with chronic cholecystitis suffer considerably more pain than those diagnosed with other gallbladder diseases, such as gallbladder polyps2. In addition, removing the gallbladder in patients with a large-sized stone is more challenging compared with those with smaller stones or other gallbladder diseases. In order to remove the large-sized stone, surgeons must enlarge the incision or repeatedly clamp it, which may cause increased postoperative pain3. In our opinion, this information is crucial for the readers' knowledge, as the inflammation and physical size of the gallbladder can influence the postoperative pain score comparison between the P and OP groups. Second, it is important to consider that different anesthesiologists may have diverse procedural habits in anesthesia interventions, such as tracheal intubation. As observed from the author's research, one of the assessments was pain scores on cough. Tracheal intubation can lead to upper airway complications and laryngeal injury, including sore throat, coughing, pain, dysphagia, and hoarseness4. However, we found no incidence rate of coughing following surgery. An increase in the frequency and intensity of coughing leads to a proportional escalation in the perception of pain and patient discomfort. Thus, considering whether the involvement of a single consistent anesthesiologist in performing the procedure could reduce the bias associated with general anesthesia endotracheal intubation procedures is important. Third, pain is a subjective sensation, and each patient exhibits a unique response to pain2. The postoperative pain assessment revealed that the pain scores at rest and on coughing in the OP group were lower than those of the P group, not only at the 0-hour time point but also through the entire research period. However, by conducting comprehensive preoperative evaluations of individual pain tolerance and perception thresholds, researchers can reveal the nuanced differences in their pain experience. Thus, different pain tolerance thresholds in different individuals may have contributed to the pain scores in the research. Fourth, although the placement of laparoscopic ports is relatively standardized, owing to the nature of LC, the exact location of the ports is determined based on individual factors, such as height, weight, and local skin conditions5. However, the authors did not provide information on patient characteristics, such as height, weight, or body mass index. The port placement may influence postoperative pain perception in patients, and the absence of information on patient characteristics may have impacted the results of this study. Despite these aforementioned points that require consideration, we are genuinely grateful for the authors' work in writing this article. This randomized controlled trial has been valuable in revealing the application of surgical analgesia interventions in LC, which has proven to be highly beneficial and useful for our understanding and potential future practices. Ethical approval Not applicable. Consent Not applicable. Sources of funding This study did not receive any funding. Author contribution D.X., Y.H., and W.W.: designed and wrote this letter. Conflicts of interest disclosure The authors declare that they have no conflicts of interest. Research registration unique identifying number (UIN) Not applicable. Guarantor Wei Wang. Data availability statement Not applicable. Provenance and peer review Not applicable.