Comment on: “Impact of external oblique intercostal plane block on postoperative pain and opioid consumption after laparoscopic sleeve gastrectomy: A systematic review and meta-analysis”

Dear Editor,

We read with interest the study by Arora et al.[1] on the external oblique intercostal plane block for post-operative analgesia after laparoscopic sleeve gastrectomy. While clinically relevant, several methodological issues warrant consideration.

First, the meta-analysis pooled external oblique intercostal block (EOIB) comparisons against both placebo and active regional anaesthesia techniques, including the modified thoracoabdominal nerve block via perichondrial approach (M-TAPA). Although sub-group analyses suggested comparable analgesia between EOIB and other regional techniques and superiority over placebo, the primary pooled estimates combined clinically non-equivalent comparators within single forest plots. This approach introduces substantial clinical heterogeneity and may obscure important differences in relative efficacy.[2]

Second, pain scores at 6, 12, and 24 hours were pooled into a single estimate despite representing repeated measurements from the same patients. Treating these observations as independent constitutes a unit-of-analysis error, inflates the effective sample size, and may overstate precision, as also reflected by participant numbers reported in the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) summary.

Third, we agree that heterogeneity is unavoidable in this evolving evidence base. However, the magnitude of inconsistency reported across several key outcomes (I² often exceeding 80–90%) limits confidence in the pooled estimates. Additional exploration through pre-specified sensitivity analyses or meta-regression, where feasible, would have strengthened interpretation.

Finally, although the authors correctly acknowledge the limitations of publication bias assessment with fewer than ten studies, the presentation of funnel plots and Egger’s tests may imply unwarranted robustness. The Cochrane Handbook for Systematic Reviews of Interventions advises caution in this context, favouring qualitative discussion over formal testing.[3]

Study data availability

No new data were generated or analyzed in this study.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

An AI-based language model (ChatGPT 5.2, OpenAI) was used exclusively for language polishing. No AI tools were used for data analysis, study design, or decision-making. All content was reviewed and approved by the authors.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.