Ketorolac is not associated with adverse outcomes following pancreaticoduodenectomy
*Whitney S Brandt, *Sara Abou Azar, *Raymond A. Jean, *John W. Kunstman, Ronald R Salem
Yale New Haven Hospital, New Haven, CT
Objective: Perioperative narcotic use contributes to the ongoing opioid crisis. Outcome optimization, including reducing opiate usage, is an ongoing goal of pancreatic surgery. Ketorolac, a frequent component of opiate-minimizing recovery pathways, has not been universally adopted over concerns regarding adverse events, including anastomotic fidelity. Thus, we examined ketorolac’s effects on pancreatic fistula (PF) and related morbidity following pancreaticoduodenectomy (PD).
Design: Retrospective cohort
Setting: Academic center
Patients: 256 patients undergoing PD from 1/2013-9/2018
Intervention: Postoperative ketorolac versus no ketorolac
Outcome Measures: Development of clinically-relevant PF (CR-PF) as defined by international consensus was the primary outcome measure. Secondary outcomes included Fistula Risk Score (FRS)-adjusted PF incidence and cumulative operative morbidity.
Results: Of 256 patients, CR-PF occurred in 10.5% (n=27). 202 patients received ketorolac prior to postoperative day 6 (78.9%) with a mean dose of 45.6±27.4 mg/day. CR-PF occurred in 11.4% (n=23) of those receiving ketorolac versus 7.4% (n=4) that did not (p=0.47). Among those receiving >150 mg of ketorolac during postoperative day 0-5 (n=130, 50.8%), CR-PF occurred in 10.8% compared to 10.3% that did not (p=0.73). Increased FRS correlated with CR-PF risk (p=0.006); median FRS was 4 (range, 0-8). Overall CR-PF incidence was unaffected by ketorolac across all FRS categories (p=NS, all). Regression analysis with known PF risks (duct size, gland texture/pathology, BMI, blood loss) demonstrated ketorolac was not an independent CR-PF risk (OR 2.07 [0.57-7.52], p=0.27). 16% of patients had operative drains. Major (Clavien≥3) morbidity and 90-day mortality did not differ between groups (p=NS, all).
Conclusion: Ketorolac administration is not associated with increased risk of CR-PF or major morbidity following PD. These data suggest ketorolac can be safely employed in strategies to minimize opioid usage.
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