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Ketorolac Use and Anastomotic Leak in Elective Colorectal Surgery

A Detailed Analysis

Hawkins, Alexander T., M.D., M.P.H.1; McEvoy, Matthew D., M.D.2; Wanderer, Jonathan P., M.D., M.Phil.2,3; Ford, Molly M., M.D.1; Hopkins, M. Benjamin, M.D.1; Muldoon, Roberta L., M.D.1; Martin, Barbara J., R.N., B.S.N., M.B.A.1; King, Adam B., M.D.2; Geiger, Timothy M., M.D.1

doi: 10.1097/DCR.0000000000001244
Original Contributions: Socioeconomic
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BACKGROUND: Recent population-level analyses have linked ketorolac use to adverse outcomes. However, its use is also associated with decreased opioids and faster return of bowel function.

OBJECTIVE: This study aims to assess the association between ketorolac and anastomotic leak. We hypothesize that receiving at least 1 dose of ketorolac will not be associated with anastomotic leak in elective colorectal surgery.

DESIGN: This is a retrospective, observational cohort study of a prospectively collected data base. Anastomotic leak rates and other patient outcomes were adjusted for patient-level factors and then compared via a multivariable logistic regression. A secondary analysis assessed a dose-response association with anastomotic leak.

SETTING: This study was conducted at a tertiary care colorectal surgery service.

PATIENTS: Consecutive patients undergoing elective colorectal surgery with a nondiverted anastomosis were identified from 2012 to 2016.

INTERVENTION: Exposure was defined as any administration of ketorolac during the perioperative time period.

MAIN OUTCOME MEASURES: The primary outcome measured was anastomotic leak.

RESULTS: A total of 877 patients met inclusion criteria. Of these, 479 (54.6%) were women, and the median age was 55 years. Overall, 566 (64.5%) patients were exposed to ketorolac. In the cohort, 27 (3.1%) patients experienced an anastomotic leak. In an unadjusted analysis, there was no association between ketorolac exposure and anastomotic leak (ketorolac: 3.1% vs no ketorolac: 3.3%; p = 0.84). This persisted in a multivariable model (OR, 0.98; 95% CI, 0.38–2.57; p = 0.98). Neither AKI (OR, 3.24; 95% CI, 0.51–20.6; p = 0.21), return to the operating room (OR, 1.07; 95% CI, 0.40–2.85; p = 0.88), nor readmission (OR, 1.03; 95% CI, 0.59–1.80; p = 0.93) was associated with ketorolac use. In a secondary analysis of patients receiving ketorolac, there was no association between total ketorolac dosing and anastomotic leak (OR, 0.99; 95% CI, 0.99–1.00; p = 0.20).

LIMITATIONS: This study was a retrospective review, and there was a low incidence of anastomotic leak.

CONCLUSION: Ketorolac exposure was associated with neither anastomotic leak nor other important postoperative outcomes. See Video Abstract at

1 Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee

2 Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee

3 Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee

Funding/Support: Departmental.

Financial Disclosures: The American College of Surgeons National Surgical Quality Improvement Program is one of the sources of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Nashville, TN, May 19 to 23, 2018.

Correspondence: Alexander T. Hawkins, M.D., M.P.H., Section of Colon & Rectal Surgery, Vanderbilt University, 1161 21st Ave, South Rm D5248 MCN, Nashville, TN 37232. E-mail:

© 2018 The American Society of Colon and Rectal Surgeons