Beverley P Chan, MD, Adena S Scheer, MD, Amber Menezes, MD, Husein Moloo, MD, Eric C Poulin, MD, Robin P Boushey, MD, Joseph Mamazza, MD. Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
INTRODUCTION: The objective of this study was to determine whether perioperative non-steroidal anti-inflammatory drug (NSAID) use increased the risk for anastomotic leaks in elective colorectal surgery patients.
METHODS AND PROCEDURES: A case-control study evaluated colorectal surgery patients at a tertiary care center from July 2006-June 2009. Cases were defined as patients with an anastomotic leak within 30-days postoperatively. Exclusion criteria were patients with diverting stomas, pelvic exenterations, emergency resections, or less than 18 years of age. Controls were defined as patients without an anastomotic leak and were matched to cases 3:1 by age, gender, surgical indication, and resection type. NSAID exposure was defined as any NSAID use in the perioperative period. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to determine the risk of anastomotic leak with NSAID exposure. Subgroup analysis was done by NSAID type and NSAID dose.
RESULTS: 48 cases and 132 controls were identified. It was not possible to match four cases. Cases were 65% male and had a mean age of 66 (SD16) years. 63% had open surgery, 31% had rectal surgery, and 79% were for malignancy. The cases had a median length of stay of 22.5 days (IQR: 13.5, 33.5) with 10% in-hospital mortality. Controls had a median length of stay of 6 days (IQR: 4, 8) and had 0% in-hospital mortality. NSAIDs used at the institution included celecoxib, ketorolac, naproxen, aspirin, ibuprofen, and diclofenac. There was no significant increased risk of anastomotic leak with NSAID use in the perioperative period, OR 1.00 (95% CI: 0.44, 2.26). However, there was a dose response trend with increasing NSAID dose. Compared to no NSAID use, low dose NSAID use had an OR of 0.71 (95% CI: 0.25, 2.02), medium dose had an OR of 1.00 (95% CI: 0.41, 2.44), and high dose had an OR of 1.71 (95% CI: 0.56, 5.28). In a subgroup analysis, celecoxib use, a selective cyclooxgenase 2 (COX2) inhibitor, had an adjusted OR of 1.37 (95% CI: 0.64, 2.97) and ketorolac use had an adjusted OR of 1.66 (95% CI: 0.76, 3.61).
CONCLUSIONS: This study failed to identify a significant relationship between perioperative NSAID exposure and anastomotic leaks in elective colorectal surgery. There was however a non-significant dose response curve identified raising the possibility of an association given adequate power. Further, larger studies are required to clarify the relationship between NSAID use and anastomotic leaks in elective colorectal surgery.
Program Number: P143