Aryan Modasi, MD, David Pace, MD, MBA, Marshall Godwin, MD, MSc, Chris Smith, MD, Bryan Curtis, MD, MSc. Memorial University of Newfoundland
INTRODUCTION: Current enhanced recovery guidelines suggest that opioid sparing medications should be used for analgesia whenever possible following colorectal surgery. The present study aims to assess whether postoperative NSAID use is associated with an increased anastomotic leak rate following the creation of a colonic or rectal anastomosis, and if this association is generalizable to all NSAIDs as a whole.
METHODS: Systematic literature searches of the MEDLINE, EMBASE, and CINAHL databases were performed. Randomized control trials, cohort studies, and case-control studies were eligible for inclusion. Included trials were required to involve patients who received a primary colonic or rectal anastomosis and post-operative NSAID analgesia within 7 days of surgery, as well as a control group of patients undergoing a similar surgery who did not receive NSAIDs. Studies that included small-bowel anastomoses were not included. This decision to look exclusively at colonic and rectal anastomoses was made in conjunction with previous animal studies that demonstrated a location-dependant effect of NSAIDs on the gastrointestinal tract. Included studies underwent a risk of bias assessment using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool. Meta-analysis was then performed to assess for the overall risk of anastomotic leak with NSAID use, as well as sub-group analysis to compare selective vs non-selective NSAIDs and drug-specific NSAID safety profiles.
RESULTS: Seven studies (9,835 patients) were included in the final review. Use of an NSAID post-operatively was associated with an overall increased risk of anastomotic leakage (OR 1.58 [1.23, 2.03], P = 0.0003). Non-selective NSAIDs were associated with an increased risk (OR 1.79 [1.47, 2.18], P < 0.00001), but selective NSAIDs were not. The non-selective NSAID diclofenac was associated with an increased leak rate (OR 2.79 [1.96, 3.96], P < 0.00001), but ketorolac was not (OR 1.36 [0.89, 2.06], P = 0.16).
CONCLUSION: Great caution must be taken when prescribing NSAIDs following the creation of a colonic or rectal anastomosis. Overall, the evidence in this study indicates that NSAIDs are associated with an increased risk of anastomotic leakage following colorectal surgery. However, this effect was not found to be consistent across all NSAIDs, with medications within the same class demonstrated conflicting risk profiles. Where no conclusive recommendation currently exists regarding post-operative NSAID use, we advise great caution in prescribing NSAIDs to these patients until further research identifies which individual NSAIDs are safe for use and which are not.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 84875
Program Number: S127
Presentation Session: ERAS Session
Presentation Type: Podium