LAUSR

We are happy to learn that our anesthesia colleagues have taken an interest in our research and thank them for their valuable critique. We acknowledge the limitations of a database study and recognize that our study is unable to answer very granular inquiries, for instance, questions about individualized patient opioid use. However, our study objective was to use the National Surgical Quality Improvement Program (NSQIP) database to look at 30day complications in a large population of patients who received epidural analgesia at hysterectomy. Our study included 2035 patients in the epidural cohort; other studies in this area have included at most ~300 patients. Propensity score matching is routinely used in observational studies and is well established as a reliable method to reduce bias in large cohorts. In our study, all covariates outlined in Table 1 were used in the propensity model and are detailed in our article. We acknowledge in our article that we are unable to know the details of the epidural placement (eg, timing, duration, indications) but we did include covariates in our propensity model that may reduce the bias of the epidural being placed in only challenging cases. Proxy variables were used to account for surgical complexity (performance of lymphadenectomy), advanced stage (preoperative ascites), and conditions affecting anemia (preoperative platelet and hematocrit). Our objective was to examine 30day complications in a large cohort with the power that would allow us to view differences in relatively lowprevalence complications. The epidural has further received attention in other trials that employ it in an Enhanced Recovery After Surgery (ERAS) protocol, finding it to reduce pain and opioid use without major complications. These findings should also be used in the ongoing debate about the epidural. We hope that our study helps us to better identify and address some of the challenges of the epidural. We believe that until we have a randomized controlled trial that is powered to answer this question, scrutinizing available data with acceptable statistical methods is an important way to contribute to the ongoing discussion.