Postoperative administration of non-steroidal anti-inflammatory drugs in colorectal cancer surgery does not increase anastomotic leak rate; A systematic review and meta-analysis

Abstract

Background: Evidence on the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on anastomotic leak (AL) rate after colorectal surgery is conflicting. Effects of NSAIDs might depend on the underlying disease. This meta-analysis aimed to review the effect of NSAIDs on AL rate in a homogeneous colorectal cancer patient population. Methods: A systematic literature search using MEDLINE and EMBASE database was performed for studies with AL as primary outcome comparing NSAID use in the early postoperative phase with no NSAID administration in colorectal cancer patients undergoing surgical resection. Results: Nine studies including 10,868 patients met the inclusion criteria. The majority, 7689 patients (70.7%) underwent low anterior resection and 3050 patients (28.1%) underwent colonic resection. The pooled incidence of AL was 8.6% (95%CI 7.0e10.0). Overall AL rate after colorectal cancer surgery was not increased in patients using NSAIDs for postoperative analgesia compared to non-users (p ¼ 0.34, RR 1.23; 95%CI 0.81e1.86). This effect remained non-significant after stratification for low anterior resections (p ¼ 0.07). Stratification for colonic resections could not be performed because AL results for this subgroup were not reported separately. Neither non-selective NSAID use nor COX-2 selective NSAID use caused an increased AL rate (p ¼ 0.19, p ¼ 0.26). The results were robust throughout sensitivity analyses. Conclusion: Use of NSAIDs in cohorts with patients undergoing surgical resection for colorectal cancer does not increase overall AL rate. Since results were robust throughout several subgroup and sensitivity analyses, prescription of NSAIDs after colorectal cancer surgery seems safe.

Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low–Middle‐Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation

“…NSAIDs are equally useful in postoperative analgesia. However, the concern of an increased risk of an anastomotic leak remains, but recent literature and meta-analysis remain inconclusive [ 85 , 86 ].…”

Ketorolac Administration After Colorectal Surgery Increases Anastomotic Leak Rate: A Meta-Analysis and Systematic Review

“…A previous meta-analysis has examined the effect of NSAIDs on the healing of anastomoses after colorectal surgery ( 26 , 27 ). Modasi et al discovered that post-colorectal surgery NSAID administration increases anastomotic leak rate, while Arron et al discovered that post-colorectal cancer surgery NSAID administration does not increase anastomotic leak rate ( 26 , 28 ). There is still controversy over whether post-colorectal surgery NSAID administration will increase the anastomotic leak rate, and more clinical studies are needed to verify it.…”

“…There is still controversy over whether post-colorectal surgery NSAID administration will increase the anastomotic leak rate, and more clinical studies are needed to verify it. Arron et al also found that neither non-selective NSAID use nor COX-2 selective NSAID use caused an increased anastomotic leak rate ( 28 ). Besides, Huang et al and Modasi et al discovered that ketorolac was not associated with an increase in leak rate; however, their meta-analyses only included 2–3 studies on ketorolac ( 26 , 27 ).…”

Attitudes towards Enhanced Recovery after Surgery (ERAS) interventions in colorectal surgery: nationwide survey of Australia and New Zealand colorectal surgeons

“…Several guidelines have identified non-steroidal anti-inflammatory drugs (NSAIDs) as the key opioid-sparing component of multimodal analgesia [3,4] and there is evidence that their use reduces the time to flatus and stool [55]. However, their use remains controversial due to a possible association with anastomotic leakage [56][57][58][59]. Non-selective NSAIDs are likely to be higher risk than selective NSAIDs [58].…”