There is an interesting paper from JAMA Surgery this month (on-line version only as of yet) that studies the use of NSAID's (non steroidal anti-inflammatory drugs) in the post operative period and their impact on anastomotic leak rates. NSAID's are medicines like Alleve and Motrin. As a surgeon, I prescribe Motrin to most of my post op hernia and laparoscopy patients for non-narcotic pain control. I am also a big fan of the intravenously administered NSAID, Toradol. Toradol is an extremely useful adjunct in the management of post operative pain in the inpatient setting. I order it often. (Also, NFL football players seem to like it, not always to their benefit.)
The risk with Toradol and other NSAID's in the post op period was usually related to kidney injury and potential bleeding complications. But NSAID's work by attenuating the body's natural inflammatory response to stress. And sometimes that inflammatory response is beneficial. As a surgeon I need that inflammatory response to occur, especially if I am sewing one end of bowel to another. Those inflammatory mediators bring the kinds of cells and proteins necessary for a strong anastomosis.
The JAMA paper is a large retrospective cohort study over over 13,000 patients who had undergone colorectal or bariatric surgery at over 40 hospitals in Washington state. The question the investigators asked was: how was the leak rate affected when NSAID's were started within 24 hours of surgery? The findings:
The risk with Toradol and other NSAID's in the post op period was usually related to kidney injury and potential bleeding complications. But NSAID's work by attenuating the body's natural inflammatory response to stress. And sometimes that inflammatory response is beneficial. As a surgeon I need that inflammatory response to occur, especially if I am sewing one end of bowel to another. Those inflammatory mediators bring the kinds of cells and proteins necessary for a strong anastomosis.
The JAMA paper is a large retrospective cohort study over over 13,000 patients who had undergone colorectal or bariatric surgery at over 40 hospitals in Washington state. The question the investigators asked was: how was the leak rate affected when NSAID's were started within 24 hours of surgery? The findings:
The overall 90-day rate of anastomotic leaks was 4.3% for all patients (151 patients [4.8%] in the NSAID group and 417 patients [4.2%] in the non-NSAID group; P = .16). After risk adjustment, NSAIDs were associated with a 24% increased risk for anastomotic leak (odds ratio, 1.24 [95% CI, 1.01-1.56]; P = .04). This association was isolated to nonelective colorectal surgery, for which the leak rate was 12.3% in the NSAID group and 8.3% in the non-NSAID group
That's a significant finding! The good news is that the statistical differences were only seen in patients undergoing non-elective colon surgery. These are typically semi-urgent cases in a patient population already compromised by factors of infection or malignancy. NSAID's, given their mechanism of action, could very well function as a tipping point that compromises anastomotic healing in such cases. Further study is certainly warranted, but I'm inclined to change my practice. The next perforated diverticulitis case I get that can be treated with a single stage sigmoid colectomy will probably just get a PCA post op.
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