Postoperative NSAIDs may impair anastomotic healing

Last Updated: 2015-01-27

By Will Boggs MD

NEW YORK (Reuters Health) - Postoperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with an increased risk of anastomotic failure, especially after nonelective colorectal surgery, researchers report.

With the advent of intravenous formulations, NSAIDs are increasingly used postoperatively, but some studies have suggested they might impair healing of gastrointestinal anastomoses and increase the risk of leaks.

Dr. Timo W. Hakkarainen from the University of Washington in Seattle and colleagues used data from Washington State's Surgical Care and Outcomes Assessment Program (SCOAP) to evaluate the association between postoperative NSAIDs and anastomotic complications in 13,082 patients after colorectal or bariatric surgery.

About a quarter of the patients (25.4% having colorectal surgery and 20.4% having bariatric procedures) received NSAIDs, they reported January 21 online in JAMA Surgery.

The overall rate of anastomotic complications did not differ between the NSAID and non-NSAID groups (4.3% vs 4.2%; P=0.16).

After controlling for covariates, however, NSAIDs were associated with a 24% increased risk for anastomotic leak, with the increase largely isolated to patients undergoing nonelective colorectal procedures.

The investigators found no such effect among patients undergoing elective colorectal or bariatric procedures. But after nonelective colorectal surgery, the 90-day rate of anastomotic leak was 12.3% among those receiving NSAIDs, compared with 8.3% among those not receiving NSAIDs (p=0.03).

Post hoc analysis revealed no significant association between NSAID administration and the risk for 90-day mortality.

"(W)e believe that the results of the present study are sufficient to suggest caution in the use of NSAIDs in the postoperative treatment of patients undergoing nonelective colorectal surgery and highlight the importance of further evaluation of this association, including investigation into rates of anastomotic complications inclusive of those radiographically identified, regardless of reintervention," the authors conclude.

Dr. Anand Govindarajan, from Mount Sinai Hospital in Toronto, Ontario, Canada, recently reported an association between NSAIDs and the risk of anastomotic leaks after colorectal surgery. He told Reuters Health by email, "I think the findings of this study and others should give surgeons some pause when using NSAIDs postoperatively after colorectal surgery. I personally don't think this applies only to nonelective surgery, as other studies have shown that the same risk is present in elective colorectal surgery as well." (His study is at http://bit.ly/1yLa8yS.)

"There is no clear evidence that suggests that we should avoid NSAIDs preoperatively as well," he said.

"NSAIDs are a very effective postoperative painkiller, and one still needs to weigh its benefits against its risks," Dr. Govindarajan said. "Also, there is still a lot unanswered on this issue including whether the risk of anastomotic leak is related to the type of NSAID, or the dose or duration, and whether it is limited to colorectal surgery only."

Dr. Marc Rhainds, from CHU de Quebec, Quebec City, Canada, coauthor of another recent study on this topic (http://bit.ly/18p4IzY), told Reuters Health by email, "Our paper published in fall 2014 gives the essential information about what we know actually about the association between NSAID use and anastomotic leak in terms of causal relationship. Really, I think there is a call to not systematically use NSAIDs in colorectal surgery (e.g. ERAS protocol). Meanwhile, clinicians should weigh the risks and benefits based on the comorbid conditions of the patients."

Dr. Hakkarainen did not respond to a request for comments.

This research was supported by the Washington State Life Science Discovery Fund and the National Institutes of Health.

SOURCE: http://bit.ly/1JActjL

JAMA Surg 2015.