NESPS - Intraoperative Ketorolac is associated with risk of reoperation after mastectomy: Update after four years of practice change

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Intraoperative Ketorolac is associated with risk of reoperation after mastectomy: Update after four years of practice change
Ayana K. Cole-Price^*¹, Patrick McCormick², Hanae Tokita², Andrew Vickers³, Audree B. Tadros⁴, Sigrid Carlsson³, Mellissa Assel⁵, Jonas Nelson¹
¹Plastic & Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; ²Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; ³Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY; ⁴Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; ⁵Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY

Background: Ketorolac is an effective analgesic frequently used in Enhanced Recovery After Surgery (ERAS) protocols. However, a prior study at our institution linked intraoperative ketorolac to increased bleeding-related reoperations following mastectomy, prompting its removal from our ERAS protocol. This study evaluates the impact of that change on bleeding-related reoperation and postoperative opioid use. Methods: We conducted a retrospective review of mastectomy cases performed at our ambulatory surgery cancer center from January 2016 to June 2024. Patients were stratified by ketorolac use before and after its removal on May 1, 2020. The primary outcome was reoperation for bleeding on postoperative day 0 or 1. Multivariable logistic regression adjusted for age, BMI, bilateral procedure, anticoagulant or antiplatelet use, and reconstruction type (none, subpectoral, pre-pectoral). Secondary analysis evaluated the need for high-dose postoperative opioids. Results: Among 9,085 patients, reoperation rates declined from 3.2% (n=141) before to 2.0% (n=94) after ketorolac removal. On multivariable analysis, the risk of reoperation significantly decreased among patients undergoing unilateral mastectomy (OR 0.33, 95% CI 0.20-0.51, p<0.001), though results in bilateral cases did not reach statistical significance (OR 0.71, 95% CI 0.47-1.06, p=0.10). Despite removal of ketorolac, postoperative opioid use decreased by 30% in both unilateral (OR 0.76, 95% CI 0.63-0.92, p=0.005) and bilateral cases (OR 0.69, 95% CI 0.60-0.81, p<0.001). Conclusion: Removal of ketorolac from our ERAS protocol significantly reduced bleeding-related reoperations without increasing postoperative opioid use, supporting its exclusion in mastectomy care pathways.

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