Non-steroidal anti-inflammatory drugs in colorectal surgery: A risk factor for anastomotic complications?

Abstract

In a recent article, Gorissen et al report on 795 patients with primary colorectal anastomosis operated on during the period 2008-2010 for different colorectal conditions at two centres. The leakage rate was significantly higher among patients who were administered non-steroidal anti-inflammatory drugs (NSAIDs) in the perioperative course. A dose-response relationship could also be traced, where longer NSAID use yielded a higher risk of anastomotic breakdown. However, as this study is observational in design, confounding by indication may be present and there is also a risk of residual confounding from unmeasured covariates. Moreover, the question whether different affinity for the cyclooxygenase enzyme is important in different NSAIDs seems to be largely unanswered. The results, conclusions and clinical relevance of the aforementioned study, including the possible effects of different types of NSAIDs, are discussed. While acknowledging that this study represents the best attempt so far in establishing the causal relationship between perioperative NSAID use and anastomotic leakage, the need for further research in this important area is underlined.

Non-Steroidal Anti-Inflammatory Drug Use and Risk of Anastomotic Leakage after Anterior Resection: A Protocol-Based Study

“…However, the authors categorised diclofenac as a nonselective NSAID, and it was also the most common substance in this category. This may have confounded and diluted the association between the different NSAIDs and the leakage risk, as their COX-2 selective substances included celecoxib and meloxicam, both sharing similar affinity to the COX enzymes as diclofenac [15,16,24] . However, any NSAID use was still a risk factor for leakage, which is in contrast to the current study.…”

Total Flavonoids from Radix Glycyrrhiza Exert Anti‐Inflammatory and Antitumorigenic Effects by Inactivating iNOS Signaling Pathways

“…Chronic inflammation is recognized as one of cancer hallmarks [ 37 , 38 ]. The relationship between inflammation and cancer is supported by the observation that prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with reduced risk to developing various types of cancers [ 39 ]. With the setting of murine macrophage RAW264.7 cells experimental system, we showed that TFRG from RG effectively blocked LPS/IFN- γ -induced NO production and iNOS expression without cytotoxicity ( Table 1 ; Figures 1 and 2 ).…”

Effect of Perioperative Dexamethasone and Different NSAIDs on Anastomotic Leak Risk: A Propensity Score Analysis

“…As summarized in a review by Rushfeldt et al [4], three early clinical studies suggested that the cyclo-oxygenase-2 (COX-2)-selective NSAIDs diclofenac and celecoxib were associated with a 5-fold increase in the rate of anastomotic leaks when administered for postoperative analgesia [5][6][7]. These studies led to a growing interest in the possible adverse effects of NSAIDs on fresh intestinal anastomoses [8][9][10][11][12][13][14][15], and the question arose whether this was a class effect associated with the anti-inflammatory effect of NSAIDs in general, or whether the adverse effect was attributed to specific NSAIDs or subgroups of NSAIDs with a different COX selectivity [4,16,17]. As a consequence, if the anti-inflammatory effect per se was the reason for the anastomotic leaks, then the use of perioperative anti-inflammatory steroids should also be studied in a context with NSAID use.…”