Perioperative Nonsteroidal Anti-inflammatory Drugs (NSAID) Administration and Acute Kidney Injury (AKI) in Major Gastrointestinal Surgery: A Prospective, Multicenter, Propensity Matched Cohort Study

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients

Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.

Association between perioperative flurbiprofen administration and acute kidney injury (AKI) in spine surgery: a retrospective cohort study

BACKGROUND

The association between nonsteroidal anti-inflammatory drugs (NSAIDs) and postoperative acute kidney injury (AKI) remains controversial, with limited studies specifically examining flurbiprofen. Therefore, this research aimed to investigate the association between intraoperative flurbiprofen administration and postoperative AKI.

METHODS

We retrospectively identified a cohort of patients at the Third Xiangya Hospital of Central South University. A total of 3882 adult patients undergoing spinal surgery between January 1, 2012, and July 31, 2018, were included and classified into two groups: those receiving flurbiprofen (50 or 100 mg once, 5 min after anesthesia start) and those not receiving flurbiprofen. The primary endpoint was the incidence of AKI.

RESULT

The flurbiprofen group (4.4%) had a lower incidence of AKI compared to the non-flurbiprofen group (6.5%, P < 0.001). After adjusting for potential confounding variables, the multivariable regression analysis showed that the flurbiprofen group had a 49% reduced risk of postoperative AKI (OR 0.51; 95% CI 0.31 to 0.82) compared to the non-flurbiprofen group. Subgroup analysis indicated that flurbiprofen injection was associated with a reduced incidence of postoperative AKI in patients without diabetes (OR 0.61; 95% CI 0.19 to 0.74), surgical times of 2-5 h (OR 0.54; 95% CI 0.23 to 0.75), and preoperative anemia (OR 0.57; 95% CI 0.21 to 0.74).

CONCLUSION

The study concluded that perioperative flurbiprofen treatment was associated with a lower risk of postoperative AKI in adult patients undergoing spinal surgery.

Candidate Kidney Protective Strategies for Patients Undergoing Major Abdominal Surgery: A Secondary Analysis of the RELIEF Trial Cohort

BACKGROUND

Acute kidney injury (AKI) is common after major abdominal surgery. Selection of candidate kidney protective strategies for testing in large trials should be based on robust preliminary evidence.

METHODS

A secondary analysis of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial was conducted in adult patients undergoing major abdominal surgery and randomly assigned to a restrictive or liberal perioperative fluid regimen. The primary outcome was maximum AKI stage before hospital discharge. Two multivariable ordinal regression models were developed to test the primary hypothesis that modifiable risk factors associated with increased maximum stage of postoperative AKI could be identified. Each model used a separate approach to variable selection to assess the sensitivity of the findings to modeling approach. For model 1, variable selection was informed by investigator opinion; for model 2, the Least Absolute Shrinkage and Selection Operator (LASSO) technique was used to develop a data-driven model from available variables.

RESULTS

Of 2,444 patients analyzed, stage 1, 2, and 3 AKI occurred in 223 (9.1%), 59 (2.4%), and 36 (1.5%) patients, respectively. In multivariable modeling by model 1, administration of a nonsteroidal anti-inflammatory drug or cyclooxygenase-2 inhibitor, intraoperatively only (odds ratio, 1.77 [99% CI, 1.11 to 2.82]), and preoperative day-of-surgery administration of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker compared to no regular use (odds ratio, 1.84 [99% CI, 1.15 to 2.94]) were associated with increased odds for greater maximum stage AKI. These results were unchanged in model 2, with the additional finding of an inverse association between nadir hemoglobin concentration on postoperative day 1 and greater maximum stage AKI.

CONCLUSIONS

Avoiding intraoperative nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors is a potential strategy to mitigate the risk for postoperative AKI. The findings strengthen the rationale for a clinical trial comprehensively testing the risk-benefit ratio of these drugs in the perioperative period.

EDITOR’S PERSPECTIVE

Association between perioperative non-steroidal anti-inflammatory drug use and cardiovascular complications after non-cardiac surgery in older adult patients

BACKGROUND

We investigated in older adult non-cardiac surgical patients whether receipt of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) is associated with increased incidence of postoperative cardiovascular complications.

METHODS

We retrospectively extracted the information for patients with age ≥  65 years who had inpatient non-cardiac surgery with a duration of ≥  1 h from the American College of Surgeons-National Surgical Quality Improvement Program registry data acquired at the University of Washington Medical Center. We compared patients who received NSAIDs perioperatively to those who did not receive NSAIDs, on the two composite outcomes: (1) the incidence of postoperative cardiovascular complications within 30 days of the surgery, and (2) the incidence of combined postoperative gastrointestinal and renal complications, and length of postoperative hospital stay. We used separate multivariable logistic regression models to analyze the two composite outcomes and a Poisson regression model for the length of hospital stay.

RESULTS

The receipt of perioperative NSAIDs was not associated with postoperative cardiovascular complications (estimated odds ratio (OR), 1.78; 95% confidence interval (CI), 0.97 to 3.25; P =  0.06), combined renal and gastrointestinal complications (estimated OR, 1.30; 95% CI, 0.53 to 3.20; P =  0.57), and length of postoperative hospital stay in days (incidence rate ratio, 1.06; 95% CI, 0.93 to 1.21; P =  0.39).

CONCLUSIONS

In older adult non-cardiac surgical patients, receipt of perioperative NSAIDs was not associated with increased incidences of postoperative cardiovascular complications, and renal and gastrointestinal complications within 30 days after surgery, or length of postoperative hospital stay.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Frailty: the perioperative and anesthesia challenges of an emerging pandemic

Frailty is a complex and multisystem biological process characterized by reductions in physiological reserve. It is an increasingly common phenomena in the surgical population, and significantly impacts postoperative recovery. In this review, we will discuss the pathophysiology of frailty, as well as preoperative, intraoperative, and postoperative considerations for frailty care. We will also discuss the different models of postoperative care, including enhanced recovery pathways, as well as elective critical care admission. With discoveries of new effective interventions, and advances in healthcare information technology, optimized pathways could be developed to provide the best care possible that meets the challenges of perioperative frailty.

Literature review: are NSAIDs harmful and is acetaminophen well tolerated?

PURPOSE OF REVIEW

On the basis of previous literature, NSAID use is typically avoided in patients at risk for kidney disease, while acetaminophen has generally been considered well tolerated. However, the extent of NSAID effect on the kidneys is not clear, especially in chronic kidney disease (CKD), and the concerns about the safety of acetaminophen have been rising. In this review, we will discuss the latest evidence of the effects of NSAIDs and acetaminophen in the context of nephrology and hypertension.

RECENT FINDINGS

The risk of acute kidney injury (AKI) by NSAIDs is higher with longer courses and in the presence of several factors such as older age, diabetes mellitus, lower eGFR, diuretic use and cardiovascular disease. The timing of NSAID use in relation to the onset of AKI may affect its progression. Regular NSAID use could be associated with an increased incidence of CKD, but the relation between NSAID use and CKD progression is less clear. Regular acetaminophen use was associated with increased SBP, while its use could have a renoprotective effect in certain situations.

SUMMARY

In patients at risk of kidney disease, NSAIDs may be used cautiously after discussing possible adverse effects. Regular acetaminophen use should be reassessed in patients with uncontrolled hypertension.

Impact of postoperative NSAIDs administration on anastomotic leak after esophago-gastric surgery: systematic review and meta-analysis

Anastomotic leak (AL) is a feared complication of esophago-gastric surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat postoperative pain. Previous analyses conveyed heterogeneous data for colorectal surgery with a tendency toward high risk for AL after NSAIDs administration. In the setting of upper gastrointestinal (GI) surgery data are even more puzzled. The purpose of the present study was to assess whether an association exists between postoperative NSAIDs administration and AL after esophago-gastric surgery. PubMed, MEDLINE, Scopus, and Web of Science were searched up to November 2022. The included studies evaluated outcomes for NSAIDs vs. no NSAIDs administration after esophago-gastric surgery. The primary outcome was anastomotic leak (AL). Risk ratio (RR) and 95% confidence intervals (95% CI) were used to assess pooled effect size and relative inference. Six studies (43,784 patients) were included. The patient age ranged from 31 to 84 years, 82.4% were males and preoperative BMI ranged from 15 to 31 kg/m². Esophagectomy was performed in 95% of patients. NSAIDs were administered in 18,075 (41.3%) patients. The cumulative incidence of AL was similar for NSAIDs vs. no NSAIDs (13.6% vs. 13.4%). The risk for postoperative AL was similar for NSAIDs vs. no NSAIDs administration (RR 1.49; 95% CI 0.81-2.75; p = 0.19). The cumulative incidence of postoperative gastrointestinal bleeding (0.36% vs. 0.39%), acute kidney injury (0.62% vs. 0.71%), and in-hospital mortality (2.39% vs. 2.66%) were comparable. NSAIDs administration for postoperative analgesia seems not associated with an increased risk for AL after esophago-gastric surgery.

Early postoperative non-steroidal anti-inflammatory drugs and anastomotic leakage after oesophagectomy

BACKGROUND

Previous studies have suggested that postoperative non-steroidal anti-inflammatory drug (NSAID) use may increase the risk of anastomotic leakage after colorectal surgery. However, the association between NSAIDs and anastomotic leakage after oesophagectomy is unclear. The aim of this retrospective study was to assess the effect of early postoperative NSAID use on anastomotic leakage after oesophagectomy.

METHODS

The Data of patients who underwent oesophagectomy for cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the association between NSAID use in the early postoperative period (defined as the day of and the day after surgery) and short-term outcomes, adjusting for potential confounders. The primary outcome was anastomotic leakage. The secondary outcomes were acute kidney injury, gastrointestinal bleeding, and mortality.

RESULTS

Among 39 418 eligible patients, early postoperative NSAIDs were used by 16 211 individuals (41 per cent). Anastomotic leakage occurred in 5729 patients (15 per cent). In stabilized IPTW analyses, NSAIDs were not associated with anastomotic leakage (odds ratio 1.04, 95 per cent c.i. 0.97 to 1.10). The proportions of acute kidney injury and gastrointestinal bleeding, as well as 30-day mortality and in-hospital mortality, did not differ according to NSAID use. Propensity score matching and instrumental variable analyses demonstrated similar results.

CONCLUSION

Early postoperative NSAID use was not associated with anastomotic leakage or other complications in patients who underwent oesophagectomy.

Annexin A2 plays a key role in protecting against cisplatin-induced AKI through β-catenin/TFEB pathway

Acute kidney injury (AKI) is in high prevalence in the world. However, the therapeutic strategies for AKI are still in mystery. Studies have shown to improve autophagy and lysosomal function could inhibit AKI. But their modulators need to be explored in detail. Annexin A2 (ANXA2) is a phospholipid-binding protein involving in organelle membrane integrity function, suggesting its important role in autophagy and lysosome homeostasis. It implicates ANXA2 potentially protects against AKI. However, this has not been elucidated. Herein, we found that ANXA2 is increased in renal tubules in cisplatin-induced AKI mice. Ectopic expression of ANXA2 improved lysosomal functions and enhanced autophagic flux, further protecting against renal tubular cell apoptosis and kidney injury. Conversely, knockdown of ANXA2 inhibited lysosomal function and autophagy, which aggravated the progression of AKI. Transcriptome sequencing revealed β-catenin signaling is highly responsible for this process. In vitro, we found ANXA2 induced β-catenin activation, further triggering T-cell factor-4 (TCF4)-induced transcription factor EB (TFEB). Furthermore, TFEB promoted lysosome biogenesis to enhance autophagic flux, resulting in the alleviation of AKI. Our new findings underline ANXA2 is a new therapeutic potential for AKI through modulating autophagy and lysosomal function. The underlying mechanism is associated with its inductive effects on β-catenin/TFEB pathway.

Postoperative nonsteroidal anti-inflammatory drugs in relation to recurrence, survival and anastomotic leakage after surgery for colorectal cancer

AIM

The aim of this work was to investigate whether nonsteroidal anti-inflammatory drugs (NSAIDs) could be beneficial or harmful when used perioperatively for colorectal cancer patients, as inflammation may affect occult disease and anastomotic healing.

METHOD

This is a protocol-based retrospective cohort study on colorectal cancer patients operated on between 2007 and 2012 at 21 hospitals in Sweden. NSAID exposure was retrieved from postoperative analgesia protocols, while outcomes and patient data were retrieved from the Swedish Colorectal Cancer Registry. Older or severely comorbid patients, as well as those with disseminated or nonradically operated tumours were excluded. Multivariable regression with adjustment for confounders was performed, estimating hazard ratios (HRs) for long-term outcomes and odds ratios (ORs) for short-term outcomes, including 95% confidence intervals (CIs).

RESULTS

Some 6945 patients remained after exclusion, of whom 3996 were treated at hospitals where a NSAID protocol was in place. No association was seen between NSAIDs and recurrence-free survival (HR 0.97, 95% CI 0.87-1.09). However, a reduction in cancer recurrence was detected (HR 0.83, 95% CI 0.72-0.95), which remained significant when stratifying into locoregional (HR 0.68, 95% CI 0.48-0.97) and distant recurrences (HR 0.85, 95% CI 0.74-0.98). Anastomotic leakage was less frequent (HR 0.69%, 95% CI 0.51-0.94) in the NSAID-exposed, mainly due to a risk reduction in colo-rectal and ileo-rectal anastomoses (HR 0.47, 95% CI 0.33-0.68).

CONCLUSION

There was no association between NSAID exposure and recurrence-free survival, but an association with reduced cancer recurrence and the rate of anastomotic leakage was detected, which may depend on tumour site and anastomotic location.

Postoperative Pain, Analgesic Choices, and Ileus: A Snapshot from a Teaching Hospital in a Developing Country

Background  Pain relief can be achieved by diversity of methods with analgesics being the basic form of treatment. Analgesic safety and clinical effectiveness are the core factors in determining the analgesic of choice. One adverse effect of concern with opioids is the postoperative ileus (POI).

Objective  In this study, we looked at the severity of postoperative pain, the type of analgesics used to control the pain, and the incidence of POI at Baghdad Teaching Hospital. We hypothesized that we would find an association between the type of analgesia used and POI.

Methods  This observational study was conducted among 100 patients who were residents at the general surgery wards of Baghdad Teaching Hospital. A structured questionnaire was employed focusing on types of analgesics, degree of pain control, and the presence of ileus.

Results  Sixty-nine percent of patients received a combination of opioids and nonopioids. Moderate-to-severe pain was the most commonly reported category on pain scales. More than half of the patients (57%) were found to have POI during their hospital stay and there was a statistically significant association between the type of analgesia and POI development ( p =0.001).

Conclusions  A mix of analgesics (opioids and nonopioids) was the most common regimen at our center. The majority of the surgical inpatients reported having moderate-to-severe pain on both pain scales used in this study. Ileus incidence following abdominal surgeries (61%) was significantly higher than the reported incidence worldwide (10–30%). Postoperative ileus has multifactorial causes, one of which is the use of opioids for pain control. Considering the high incidence of ileus in our center and the association we found between the use of opioids and ileus, further studies should look at the doses of opioids used and whether alternative analgesic methods might result in less ileus.

Kidney damage from nonsteroidal anti-inflammatory drugs-Myth or truth? Review of selected literature

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely available drugs with anti-inflammatory and analgesic properties. Their mechanism of action is associated with the enzymes of the arachidonic acid cycle (cyclooxygenases: COX-1 and COX-2). The cyclooxygenase pathway results in the formation of prostanoids (prostaglandins [PGs], prostacyclins, and thromboxanes). It affects various structures of the human body, including the kidneys. Medical literature associates the usage of NSAIDs with acute kidney injury (AKI), tubulointerstitial nephritis (TIN), as well as nephrotic syndrome and chronic kidney disease (CKD). AKI associated with the chronic consumption of NSAIDs is mainly attributed to pharmacological polytherapy and the presence of cardiovascular or hepatic comorbidities. The pathomechanism of AKI and CKD is associated with inhibition of the biosynthesis of prostanoids involved in the maintenance of renal blood flow, especially PGE2 and PGI2. It is suggested that both COX isoforms play opposing roles in renal function, with natriuresis increased by COX-1 inhibition followed by a drop in a blood pressure, whereas COX-2 inhibition increases blood pressure and promotes sodium retention. TIN after NSAID use is potentially associated with glomerular basement membrane damage, reduction in pore size, and podocyte density. Therefore, nephrotic proteinuria and impairment of renal function may occur. The following article analyzes the association of NSAIDs with kidney disease based on available medical literature.