NSAID use and Colorectal Anastomotic Leaks. Caution and Further Investigation

Abstract

Non-steroidal anti-inflammatory drugs (NSAIDS) are an integral component of the postoperative analgesic regimen, particularlyinenhancedrecoveryprotocolsfor electivecolorectal resections. They are administered to reduce opioid requirements and mitigate the side effects of narcotics on the gastrointestinal tract. Recently however, there have been reports in the literature that have raised the possibility of an association between the use of NSAIDS and an increased risk of colorectal anastomotic leaks (AL). 1 –4 . The therapeutic effects of NSAIDS are due to their inhibition of the enzyme cyclooxygenase (COX) that occurs as two main isoforms, COX-1 and COX-2. This inhibition results in the decreased synthesis of prostanoids which are important mediators of inflammation and pain. NSAIDS are categorized based on the extent of inhibition of these isoforms as being either COX-2 selective or non-selective. However, the potency and selectivity of the different commercially available NSAIDS differ, as even non-selective inhibitors can preferentially inhibit COX-1. The exact mechanism by which NSAIDS result in an increased risk of AL remains unclear, but it is believed that the inhibition of COX interferes with the normal inflammatory processes necessary for wound repair including healing of intestinal anastomosis. 5 . Ketorolac is a commonly used NSAID that primarily inhibits COX-1, although it is classified as a non-selective inhibitor. In this issue of the Journal of Gastrointestinal Surgery, two reports have been published that have investigated the relationship between the postoperative use of ketorolac and the risk of AL. While both studies have asked the same research question, they have come up with conflicting findings.