Response to comments 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 thank the readers for their interest in our systematic review and meta-analysis on the external oblique intercostal plane block (EOIB) after laparoscopic sleeve gastrectomy and for their thoughtful comments.[1]

We agree that placebo/no-block comparators and active regional techniques are not clinically equivalent.[1] Our objective, however, was pragmatic: to evaluate the overall analgesic effectiveness and safety of EOIB within a small, evolving evidence base.[2] Methodological guidance permits pooling across different comparator types when the intervention, population, and setting are comparable, provided that heterogeneity is explored.[3,4] Accordingly, we presented subgroup analyses separating EOIB versus placebo/no block and EOIB versus active techniques [port-site infiltration, modified thoracoabdominal nerve block via perichondrial approach (M-TAPA)], restricted claims of superiority to placebo/no-block comparisons, and described EOIB as broadly comparable—not superior—to other interfascial blocks.[2]

Pooling pain scores at 6, 12, and 24 hours into a single “total” estimate does introduce a potential unit-of-analysis issue.[1,3] This approach was used only to summarise early postoperative pain where reporting was inconsistent, alongside separate time-specific estimates with their own heterogeneity, and we explicitly acknowledged this limitation and appropriately downgraded Grading of Recommendations Assessment, Development and Evaluation certainty.[2,3]

Substantial heterogeneity for some continuous outcomes likely reflects genuine clinical and methodological diversity across the four trials; with so few studies, more complex analyses would have been underpowered, so we used random-effects models and interpreted such findings cautiously.[2,3,4] Funnel plots and Eggers tests were reported for transparency only; we clearly stated that publication bias cannot be reliably excluded and did not upgrade certainty on this basis.[2,3]

Despite these limitations, all trials favored EOIB for at least some key outcomes, and pooled data showed reduced early pain, fewer patients requiring rescue analgesia, and an opioid-sparing effect over 24 hours.[2] We therefore believe our cautious conclusion—that EOIB is a promising, technically simple component of multimodal analgesia for laparoscopic sleeve gastrectomy, superior to placebo/no block, and broadly comparable to other interfascial techniques—remains justified pending larger multicentre trials.[2]

Study data availability

Not applicable.

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

The AI tools or language models (LLMs) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.

Authors contributions

DA, PS: Manuscript preparation, editing. AR, DKC: editing.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.