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Department of Anesthesiology, Stanford University, Stanford, California
To the Editor:
There are several reasons why an individual might be asked to write an editorial. First, the editorial might be calling attention to an especially noteworthy paper describing an important advance in patient care. Second, the editorial might be calling attention to a paper that while innovative is at the same time somewhat flawed—but not sufficiently so as to preclude publication. In both cases the editorialist should be somewhat remote from the authors so that kudos or criticism (or both) can be given without an appearance of a conflict of interest (COI). Thus, I find it odd that the author of a recent editorial (1) in the Journal is also an author of the same paper that was the subject of the editorial (2).
My comments are in no way intended to be critical of either the paper or the editorial. To the contrary, the paper describes an interesting and extensive experience treating patients undergoing inguinal herniorrhaphy under local anesthesia without the presence of anesthesia personnel and without routine monitoring while the editorial makes a reasonable case for such a practice becoming even more routine. The problem however, is that most readers would, I suspect, be somewhat suspect of the comments in the editorial because one of the editorialists (Kehlet) is also an author of the paper and cites the paper numerous times in support of the technique. Thus, the requirement that the editorialist be free of an appearance of COI is not satisfied.
References
Department of Surgical Gastroenterology 435, Hvidovre University Hospital, DK-2650, Hvidovre, Denmark Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
In Response:
We would agree with Dr. Saidman that there are many different reasons for writing editorials in medical journals, and it is important that the author(s) of an editorial have no conflict of interest when it is written about a specific article in the Journal.
However, the Editorial in question (1) focused on a broader issue than the specific article (2) referred to in Dr. Saidman’s "Letter to the Editor." Our unsolicited Editorial was intended to serve as the basis for debate and reconsideration of long-standing clinical practices. The Editorial was an attempt to bring to the attention of practitioners an apparent paradox between scientific data and clinical practice. Despite clinical data suggesting that local infiltration anesthesia with IV sedation is a superior anesthetic technique for inguinal hernia surgery (3,4), general and spinal anesthesia remain the most commonly used techniques for this operation (1). Similar findings have also been reported for anorectal (5), arthroscopy (6,7), and vein stripping (8) procedures. We also wanted to emphasize that future improvement in this field of clinical research will require multidisciplinary collaborations between anesthesiologists and surgeons.
Therefore, our Editorial was not intended to be a critical discussion of the article describing an "unmonitored" local anesthetic technique for inguinal hernia repair (2). With all due respect to Dr. Saidman, we attempted to avoid any appearance of a conflict of interest in our reference to this article. Hopefully, this Editorial will serve its intended purpose of educating both surgeons and anesthesiologists regarding potential changes in clinical practice that may lead to improved patient outcomes.
References
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