Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review

The effect of the duration of preoperative smoking cessation timing on outcomes after elective open abdominal aortic aneurysm repair and lower extremity bypass

OBJECTIVE

Smoking has been associated with poor postoperative outcomes across various surgical procedures. However, the effect of quitting smoking preoperatively for elective operations is unclear. Our goal was to assess the temporal effect of smoking cessation before elective lower extremity bypass (LEB) and open abdominal aortic aneurysm (AAA) repair on perioperative outcomes.

METHODS

The Vascular Quality Initiative was reviewed for all patients with a documented smoking history and who underwent an elective LEB or open AAA repair from 2010 to 2017. Patients were then categorized into three groups: long-term smoking cessation (LTSC; defined as quitting smoking ≥8 weeks before surgery), short-term smoking cessation (STSC; defined as quitting smoking < 8 weeks before surgery), and current smokers (CS). Patient and procedure details were recorded. Univariate and multivariate analysis for crude and propensity-matched data were used to compare outcomes among groups.

RESULTS

We identified 15,950 patients with a documented smoking history who underwent an elective LEB (43.3% LTSC, 2.2% STSC, 54.5% CS) and 5215 patients who underwent an elective open AAA repair (42.9% LTSC, 2.4% STSC, 54.7% CS). LTSC patients compared with STSC and CS, respectively, were more often obese, diabetic, on aspirin, on a statin, had coronary artery disease, and had congestive heart failure, but were less likely to have chronic obstructive pulmonary disease (all P < .05). Perioperative outcomes demonstrated significant differences comparing LTSC with STSC and CS for myocardial infarction (3.4% vs 1.4% vs 1.4%), dysrhythmia (4.2% vs 2.5% vs 2.7%), 30-day mortality (1.6% vs .3% vs .9%), in-hospital mortality (1.1% vs 0% vs 0.5%; all P < .001) and congestive heart failure (1.8% vs .8% vs 1.5%; P = .003). There was no difference in outcomes after analysis of propensity-matched data for LTSC or STSC on any postoperative outcomes for LEB. For open AAA repair, LTSC compared with CS patients, respectively, were older, more often male, obese, on a statin, diabetic, and less frequently had chronic obstructive pulmonary disease (P < .05 for all). Perioperative outcomes demonstrated differences in pulmonary complications when comparing LTSC with STSC and CS (9.5% vs 8.0% vs 12.5%; P = .002). Multivariate analysis demonstrated that LTSC patients compared with CS were less likely to experience pulmonary complications (odds ratio, 0.65; 95% confidence interval, 0.53-0.79; P < .001). Propensity-matched multivariate analysis confirmed that LTSC remained significantly less likely to encounter pulmonary complications (odds ratio, 0.49; 95% confidence interval, 0.33-0.74; P = .001).

CONCLUSIONS

In our propensity-matched, risk-adjusted cohort, LTSC and STSC were not associated with perioperative outcomes after elective LEB. LTSC was associated with a significantly decreased odds of pulmonary complications after elective open AAA repair. STSC was not associated with perioperative outcomes after elective open AAA repair. If time permits, a longer period of smoking cessation should be attempted before elective open AAA repair.

Surgical repair of a large ventral hernia under spinal anaesthesia: A case report

BACKROUND

Secondary ventral hernias are incisional hernias developed in former postoperative scars. Up to 30% of all patients undergoing laparotomy develop an incisional hernia. Open ventral hernia repair is often performed under general anaesthesia but can also be performed under regional anaesthesia.

CASE REPORT

We report the case of an elderly man, who underwent open surgery of a large incisional hernia in spinal block. Regional anaesthesia was chosen due to the patient's additional diseases and disorders.

CONCLUSION

Open surgery of large ventral hernia in spinal anaesthesia can be performed because the spinal anaesthesia provides adequate conditions for ventral hernia repair. The patient has to be in good physical condition in order for the surgery to be successful. During the surgery the patient has to be watched over vigilantly by the anaesthesiologist.

Smoking As a Risk Factor for Postcraniotomy 30-Day Mortality

BACKGROUND

There is limited information on the impact of smoking on postcraniotomy mortality. In this study we used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to examine this issue.

METHODS

We identified 16,280 postcraniotomy patients in the ACS-NSQIP database. Indications for surgery were categorized by vascular, trauma, epilepsy, malignant tumor, and benign tumor. Univariate and multivariable logistic regression analyses were used to identify risk factors associated with mortality.

RESULTS

In the ACS-NSQIP dataset, postcraniotomy mortality within 30 days of surgery was 5.03%. An area under the curve analysis indicated 30 pack-years as the optimal discriminating threshold for risk stratification in terms of 30-day postcraniotomy mortality. Using this threshold, multivariate analyses revealed 3 variables that were closely associated with 30-day post-craniotomy mortality: male gender (P = 0.002), indication for operation (P < 0.001), and a smoking history of ≥30 pack-years (P < 0.001). In subsequent stratified analyses, smoking-associated mortality risk was observed only in males (odds ratio of 2.33 comparing males with ≥30 and <30 pack-years of smoking history; 97.5% confidence interval 1.36-4.03). When the analysis was further stratified by surgical indications, the mortality association with smoking was found only in male patients who underwent craniotomy as treatment for neurovascular diseases (odds ratio 3.88, 97.5% confidence interval 1.39-11.65). Such an association was not seen in patients who underwent craniotomy for traumatic brain injury, malignant tumors, benign tumors, or epilepsy.

CONCLUSIONS

This study identified ≥30 pack-years as a risk factor for male patients undergoing craniotomy as treatment for neurovascular diseases.

Preoperative Interventions for Alcohol and Other Recreational Substance Use: A Systematic Review and Meta-Analysis

Background: Preoperative alcohol and other recreational substance use (ORSU) may catalyze perioperative complications. Accordingly, interventions aiming to reduce preoperative substance use are warranted. Methods: Studies investigating interventions to reduce alcohol and/or ORSU in elective surgery patients were identified from: Cochrane Library; MEDLINE; PSYCINFO; EMBASE; and CINAHL. In both narrative summaries of results and random effects meta-analyses, effects of interventions on perioperative alcohol/ORSU, complications, mortality and length of stay were assessed. Primary Results: Nine studies (n = 903) were included. Seven used behavioral interventions only, two provided disulfiram in addition. Pooled analyses found small effects on alcohol use (d: 0.34; 0.05-0.64), though two trials using disulfiram (0.71; 0.36-1.07) were superior to two using behavioral interventions (0.45; -0.49-1.39). No significant pooled effects were found for perioperative complications, length of hospital stay or mortality in studies solely targeting alcohol/ORSU. Too few interventions targeting ORSU (n = 1) were located to form conclusions regarding their efficacy. Studies were generally at high risk-of-bias and heterogeneous. Conclusions: Preoperative interventions were beneficial in reducing substance use in some instances, but more high-quality studies targeting alcohol/ORSU specifically are needed. The literature to date does not suggest that such interventions can reduce postoperative morbidity, length of hospital stay or mortality. Limitations in the literature are outlined and recommendations for future studies are suggested.

Cost-Effectiveness of Preoperative Smoking Cessation Interventions in Total Joint Arthroplasty

BACKGROUND

Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear.

METHODS

Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis.

RESULTS

In our model, the average 90-day cost was $32 less for patients enrolled in a mandatory smoking cessation intervention ($23,457) compared with patients who were not ($23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than $95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than $219, or the success rate of the intervention was greater than 56%.

CONCLUSION

Smoking cessation interventions prior to TJA can increase the value of care and are an important public health initiative. Routine referral to smoking cessation interventions should be considered for smokers indicated for TJA.

LEVEL OF EVIDENCE

Level II, economic and decision analyses.

Evaluation of a Pilot Perioperative Smoking Cessation Program: A Pre-Post Study

BACKGROUND

Surgical clinic and perioperative settings are critical touchpoints for treating smoking, yet health care systems have not typically prioritized smoking cessation among surgical patients. We evaluated the implementation of a pilot smoking cessation intervention integrated into standard perioperative care.

MATERIALS AND METHODS

English-speaking adult smokers undergoing elective surgery in Kaiser Permanente San Francisco before (2015) and after (2016-2017) the implementation of a smoking cessation intervention were included. Provider outcomes included counseling referrals, cessation medication orders (between surgery scheduling and surgery), and preoperative carbon monoxide testing. Patient outcomes included counseling and medication use, smoking status at surgery and 30 d after discharge, and surgical complications. Multivariable logistic regression analyses examined pre-to-post intervention changes in outcomes using electronic health record data and 30-d postdischarge telephone surveys.

RESULTS

The sample included 276 patients (70% male; 59% non-Hispanic white; mean age = 50 y). There were significant pre-to-post increases in tobacco cessation counseling referrals (3% to 28%, adjusted odds ratio [AOR] = 11.12, 95% confidence interval [CI] = 3.78-32.71) and preoperative carbon monoxide testing (38% to 50%, AOR = 1.83, 95% CI = 1.10-3.06). At ∼30 d after discharge, patients in the postintervention period were more likely to report smoking abstinence in the previous 7 d (24% pre, 44% post; AOR = 2.39, 95% CI = 1.11-5.13) and since hospital discharge (18% pre, 39% post; AOR = 3.20, 95% CI = 1.42-7.23). Cessation medication orders and patient use of counseling and medications increased, whereas surgical complications decreased, but pre-to-post differences were not significant.

CONCLUSIONS

A perioperative smoking cessation program integrated into standard care demonstrated positive smoking-related outcomes; however, larger studies are needed to evaluate the effectiveness of these programs.

Longitudinal study to assess impact of smoking at diagnosis and quitting on 1-year survival for people with non-small cell lung cancer

OBJECTIVES

To update the prevalence of smoking in people as they were diagnosed with non-small cell lung cancer (NSCLC) and to see whether smoking status at baseline and quitting are independently associated with 1-year survival.

DESIGN

A real-world cohort study following patients from diagnosis for up to 1 year or until death.

SETTING

UK multi-centre study (28 sites) based in secondary and primary care.

PARTICIPANTS

1124 patients with newly diagnosed NSCLC between 2010-2016.

MAIN OUTCOME MEASURES

Smoking status was validated at diagnosis and at every routine and emergency hospital visit. Cancer treatments were offered according to local multi-disciplinary team decisions following UK guidelines and smoking cessation treatments offered according to local practice /availability. Survival analysis and Cox Proportional Hazards Modelling examined the associations of a) smoking at baseline and b) quitting smoking, on survival at 1 year.

RESULTS

77% of never smokers, 60% of ex-smokers and 57% of current smokers, were alive at 1 year (p = 0.01). After adjusting for age, stage, EGOG, surgery and gender, ex smokers (adjusted HR 1.96, 95% CI 1.16-2.31) and current smokers (aHR 2.04, 1.19-3.48) were both more likely to die within one year. 23% of smokers with NSCLC quit within 3 months of diagnosis. At 1 year, 69% of those who quit were alive versus 53% of those who continued to smoke (p < 0.01). After adjusting the risk of dying was lower (aHR 0.75), in those who quit smoking, although this was not statistically significant (p = 0.23).

CONCLUSIONS

This is the largest prospective study that validates smoking in NSCLC; it shows a third of people are smoking at the time of diagnosis. Smokers have lower 12-month survival than never and ex -smokers. Quitting smoking was associated with 25% reduction in mortality which may be clinically important although not statistically significant, after adjusting for other factors.

Preoperative cigarette smoking and short-term morbidity and mortality after cardiac surgery: a meta-analysis

Currently, the choice of whether or not to electively operate on current smokers is varied among cardiothoracic surgeons. This meta-analysis aims to determine whether preoperative current versus ex-smoking status is related to short-term postoperative morbidity and mortality in cardiac surgical patients. Systematic literature searches of the PubMed, MEDLINE and Cochrane databases were carried out to identify all studies in cardiac surgery that investigated the relationship between smoking status and postoperative outcomes. Extracted data were analysed by random effects models. Primary outcomes included 30-day or in-hospital all-cause mortality and pulmonary morbidity. Overall, 13 relevant studies were identified, with 34 230 patients in current or ex-smoking subgroups. There was no difference in mortality (p=0.93). Current smokers had significantly higher risk of overall pulmonary complications (OR 1.44; 95% CI 1.27 to 1.64; p<0.001) and postoperative pneumonia (OR 1.62; 95%  CI 1.27 to 2.06; p<0.001) as well as lower risk of postoperative renal complications (OR 0.82; 95%  CI 0.70 to 0.96; p=0.01) compared with ex-smokers. There was a trend towards an increased risk of postoperative MI (OR 1.29; 95%  CI 0.95 to 1.75; p=0.10). No difference in postoperative neurological complications (p=0.15), postoperative sternal surgical site infections (p=0.20) or postoperative length of intensive care unit stay (p=0.86) was seen. Cardiac surgical patients who are current smokers at the time of operation do not have an increased 30-day mortality risk compared with ex-smokers, although they are at significantly increased risk of postoperative pulmonary complications.

[Relationship between cigarette smoking and the carbon monoxide concentration in the exhaled breath with perioperative respiratory complications]

BACKGROUND

The purpose of the current study was to determine the effects of preoperative cigarette smoking and the carbon monoxide level in the exhaled breath on perioperative respiratory complications in patients undergoing elective laparoscopic cholecystectomies.

METHODS

One hundred and fifty two patients (smokers, Group S and non-smokers, Group NS), who underwent laparoscopic cholecystectomies under general anesthesia, were studied. Patients completed the Fagerstrom Test for Nicotine Dependence. The preoperative carbon monoxide level in the exhaled breath levels were determined using the piCO+Smokerlyzer 12h before surgery. Respiratory complications were recorded during induction of anesthesia, intraoperatively, during extubation, and in the recovery room.

RESULTS

Statistically significant increases were noted in group S with respect to the incidence of hypoxia during induction of anesthesia, intraoperative bronchospasm, bronchodilator treatment intraoperatively, and bronchospasm during extubation. The carbon monoxide level in the exhaled breath and the Fagerstrom Test for Nicotine Dependence, and number of cigarettes smoked 12h preoperatively were designated as covariates in the regression model. Logistic regression analysis of anesthetic induction showed that a 1 unit increase in the carbon monoxide level in the exhaled breath level was associated with a 1.16 fold increase in the risk of hypoxia (OR=1.16; 95% CI 1.01-1.34; p=0.038). Logistic regression analysis of the intraoperative course showed that a 1 unit increase in the number of cigarettes smoked 12h preoperatively was associated with a 1.16 fold increase in the risk of bronchospasm (OR=1.16; 95% CI 1.04-1.30; p=0.007). While in the recovery room, a 1 unit increase in the Fagerstrom Test for Nicotine Dependence score resulted in a 1.73 fold increase in the risk of bronchospasm (OR=1.73; 95% CI 1.04-2.88; p=0.036).

CONCLUSIONS

Cigarette smoking was shown to increase the incidence of intraoperative respiratory complications while under general anesthesia. Moreover, the estimated preoperative carbon monoxide level in the exhaled breath level may serve as an indicator of the potential risk of perioperative respiratory complications.

Surgery is unlikely to be enough for a patient to stop smoking 24 h prior to hospital admission

Introduction

The need for surgery can be a decisive factor for long-term smoking cessation. On the other hand, situations that precipitate stress could precipitate smoking relapse. The authors decided to study the impact of a surgery on the patient's effort to cease smoking for, at least, 24 h before hospital admission and possible relapse on the last 24 h before hospital admission for ex-smokers.

Methods

Smoker, ex-smokers and non-smokers adults, either from pre-anesthetic clinic or recently hospital admitted for scheduled elective surgeries that were, at most, 6 h inside the hospital buildings were included in the study. The patients answered a questionnaire at the ward or at the entrance of the operating room (Admitted group) or at the beginning of the first pre-anesthetic consultation (Clinic group) and performed CO measurements.

Results

241 patients were included, being 52 ex-smokers and 109 never smokers and 80 non-smokers. Smokers had higher levels of expired carbon monoxide than non-smokers and ex-smokers (9.97 ± 6.50 vs. 2.26 ± 1.65 vs. 2.98 ± 2.69; p = 0.02). Among the smokers, the Clinic group had CO levels not statistically different of those on the Admitted group (10.93 ± 7.5 vs. 8.65 ± 4.56; p = 0.21). The ex-smokers presented with no significant differences for the carbon monoxide levels between the Clinic and Admitted groups (2.9 ± 2.3 vs. 2.82 ± 2.15; p = 0.45).

Conclusion

A medical condition, such as a surgery, without proper assistance is unlikely to be enough for a patient to stop smoking for, at least, 24 h prior to admission. The proximity of a surgery was not associated with smoking relapse 24 h before the procedure.

[Surgery is unlikely to be enough for a patient to stop smoking 24h prior to hospital admission]

INTRODUCTION

The need for surgery can be a decisive factor for long-term smoking cessation. On the other hand, situations that precipitate stress could precipitate smoking relapse. The authors decided to study the impact of a surgery on the patient's effort to cease smoking for, at least, 24h before hospital admission and possible relapse on the last 24h before hospital admission for ex-smokers.

METHODS

Smoker, ex-smokers and non-smokers adults, either from pre-anesthetic clinic or recently hospital admitted for scheduled elective surgeries that were, at most, 6h inside the hospital buildings were included in the study. The patients answered a questionnaire at the ward or at the entrance of the operating room (Admitted group) or at the beginning of the first pre-anesthetic consultation (Clinic group) and performed CO measurements.

RESULTS

241 patients were included, being 52 ex-smokers and 109 never smokers and 80 non-smokers. Smokers had higher levels of expired carbon monoxide than non-smokers and ex-smokers (9.97±6.50 vs. 2.26±1.65 vs. 2.98±2.69; p=0.02). Among the smokers, the Clinic group had CO levels not statistically different of those on the Admitted group (10.93±7.5 vs. 8.65±4.56; p=0.21). The ex-smokers presented with no significant differences for the carbon monoxide levels between the Clinic and Admitted groups (2.9±2.3 vs. 2.82±2.15; p=0.45).

CONCLUSION

A medical condition, such as a surgery, without proper assistance is unlikely to be enough for a patient to stop smoking for, at least, 24h prior to admission. The proximity of a surgery was not associated with smoking relapse 24h before the procedure.

The importance of incorporating smoking cessation into lung cancer screening

Lung cancer is the leading cause of cancer-related death in the United States (U.S.) and is the second most common non-skin cancer among men and women, accounting for about 30% of cancer-related deaths. There is clear and accumulating evidence that continued tobacco use has multiple adverse effects on cancer treatment outcomes, including greater probability of recurrence, second primary malignancies, reduced survival, greater symptom burden, and poorer quality of life (QOL). Recent findings suggest an avenue to significantly mitigate the impact of smoking on lung cancer mortality rates through the use of low-dose computed tomography (LDCT) lung cancer screening. Based on the reviewed evidence (type B), the U.S. Preventive Services Task Force (USPSTF) guidelines of 2015 recommend screening combined with smoking cessation interventions for high-risk heavy smokers and recent quitters. These practice changes offer opportunities to develop novel smoking cessation strategies tailored to highly specific settings that aim to amplify the survivorship gains expected from screening alone. However, there is a paucity of research and data that speaks to the feasibility and efficacy of providing smoking cessation treatment specifically within the context of the LDCT lung cancer screening environment. While some studies have attempted to characterize the parameters within which smoking cessation interventions should be implemented in this context, further research is needed to explore relevant factors such as the format, components, and timing of interventions, as well as the influence of risk perceptions and results of the screening itself on motivation and ability to quit smoking.

Effectiveness of pulmonary rehabilitation and correlations in between functional parameters, extent of thoracic surgery and severity of post-operative complications: randomized clinical trial

Background

Pulmonary rehabilitation can be effective in perioperative condition. Our aim was to examine whether the changes of functional markers are significant and search connections between these values and the severity of postoperative complications.

Methods

A total of 238 chronic obstructive pulmonary disease (COPD) patients underwent perioperative pulmonary rehabilitation with thoracic surgery. Health status and the following parameters were examined: lung function (FEV₁, FVC), chest kinematics [chest wall expansion (CWE)], 6-minute walking test (6MWT), breath holding time (BHT), grip strength (GS) and exercise capacity. Patients were separated into three groups: 72 patients had preoperative rehabilitation only (PRE group), 80 had only postoperative rehabilitation (POS group), and 86 patients underwent pre- and postoperative rehabilitation as well (PPO group). Postoperative complications were classed as "severe" and "not severe". We evaluated the changes in functional parameters. Significance was recognized at P<0.05. Connections in between variables and severity of complications were analyzed.

Results

Pulmonary rehabilitation resulted significant changes of all examined parameters in all three groups. The direction of changes were favourable, so all of the changes can be considered to be improvement [PRE: CWE: 4.2±2.3 vs. 5.8±2.2 cm; FEV₁: 63.2±15.6 vs. 70.1±16.6%pred; 6-minute walking distance (6MWD): 392.9±93.5 vs. 443.2±86.6 m; FVC: 83.1±15.9 vs. 90.9±15.6%pred; POS: CWE: 2.9±1.4 vs. 5.0±2.0 cm; FEV₁: 56.4±15.6 vs. 64.6±16.0%pred; 6MWD: 354.7±90.7 vs. 437.0±96.0 m; FVC: 66.2±18.7 vs. 76.1±17.7%pred; PPO: preoperatively: CWE: 4.0±2.1 vs. 5.6±2.6 cm; FEV₁: 58.2±15.1 vs. 67.0±14.6%pred; 6MWD: 378.3±90.5 vs. 441.3±86.4 m; FVC: 82.4±16.7 vs. 93.3±16.7%pred; postoperatively: CWE: 2.7±1.5 vs. 4.4±2.2 cm; FEV₁: 47.4±13.0 vs. 53.4±14.7%pred; 6MWD: 341.4±115.9 vs. 403.3±98.4 m; FVC: 63.6±16.9 vs. 72.6±18.6%pred; P<0.05]. BHT, GS, dyspnoea and health status were also improved significantly. By discriminant analysis 5 of the variables proved to have discriminative value: kilometers travelled via cycle ergometer at the onset of the preoperative rehabilitation, gender, FEV₁ after preoperative rehabilitation, extent of the operation and 6MWD before preoperative rehabilitation. These 5 parameters can predict severe complications correctly in 72.5% of all cases.

Conclusions

Pulmonary rehabilitation can reduce the functional depletion caused by the thoracic surgical operation. Identification of more predictive factors of severe complications can help making preoperative risk stratification more precisely.

The association between smoking cessation outpatient visits and total medical costs: a retrospective, observational analysis of Japanese employee-based public health insurance data

AIMS

The short-term effects of smoking cessation (SC) on overall healthcare costs are unclear. This study aimed to compare the short-term medical costs between patients with SC outpatient visits (SCOVs) and those without SCOVs, consisting of SCOV itself and overall medical costs.

MATERIALS AND METHODS

This study is a retrospective, observational study using a Japanese employee-based health insurance claims database (January 1, 2005-December 31, 2013). It analyzed individuals who were registered as smokers based on their medical checkup details. It compared the per-patient-per-year (PPPY) medical costs for male smokers who made ≥1 claim for SCOVs with those who made no claims. We also assessed whether the number of SCOVs by male and female smokers impacted medical costs. The Index Year was the year after the first SCOV claim and that after the first registration as a smoker (non-SCOV group). Medical costs were calculated using regression analysis and adjusted for baseline costs.

RESULTS

In Index Year -1, PPPY medical costs for male smokers were ∼USD 323.01 (JPY 36,500, as of November 2017) higher in the SCOV (n = 5,608) vs the non-SCOV (n = 81,721) group; however, by Year 6 the costs were similar. From Year 4-6, PPPY medical costs for SCOVs were lower than those in the adjusted non-SCOV group. For 2,576 male and female smokers in the SCOV group, the average rates of increasing medical costs before and after the SCOV for 1, 2, 3, 4, and 5 SCOVs made were 58%, 44%, 50%, 41%, and 34%, respectively.

LIMITATIONS

The database includes limited data on individuals >65 years. Only SCOVs based on claims data and not on other outcomes were assessed.

CONCLUSIONS

Medical costs declined in the short-term following the first SCOV. Attendance at a greater number of SCOVs was associated with a lower increase ratio of medical costs.

Rationing elective surgery for smokers and obese patients: responsibility or prognosis?

Background

In the United Kingdom (UK), a number of National Health Service (NHS) Clinical Commissioning Groups (CCG) have proposed controversial measures to restrict elective surgery for patients who either smoke or are obese. Whilst the nature of these measures varies between NHS authorities, typically, patients above a certain Body Mass Index (BMI) and smokers are required to lose weight and quit smoking prior to being considered eligible for elective surgery. Patients will be supported and monitored throughout this mandatory period to ensure their clinical needs are appropriately met.

Controversy regarding such measures has primarily centred on the perceived unfairness of targeting certain health states and lifestyle choices to save public money. Concerns have also been raised in response to rhetoric from certain NHS authorities, which may be taken to imply that such measures punitively hold people responsible for behaviours affecting their health states, or simply for being in a particular health state.

Main Body

In this paper, we examine the various elective surgery rationing measures presented by NHS authorities. We argue that, where obesity and smoking have significant implications for elective surgical outcomes, bearing on effectiveness, the rationing of this surgery can be justified on prognostic grounds. It is permissible to aim to maximise the benefit provided by limited resources, especially for interventions that are not urgently required. However, we identify gaps in the empirical evidence needed to conclusively demonstrate these prognostic grounds, particularly for obese patients. Furthermore, we argue that appeals to personal responsibility, both in the prospective and retrospective sense, are insufficient in justifying this particular policy.

Conclusion

Given the strength of an alternative justification grounded in clinical effectiveness, rhetoric from NHS authorities should avoid explicit statements, which suggest that personal responsibility is the key justificatory basis of proposed rationing measures.

Postoperative mortality and morbidity following non-cardiac surgery in a healthy patient population

PURPOSE

Perioperative mortality ranges from 0.4% to as high as nearly 12%. Currently, there are no large-scale studies looking specifically at the healthy surgical population alone. The primary objective of this study was to report 30-day mortality and morbidity in healthy patients and define any risk factors.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset, all patients assigned an American Society of Anesthesiologists physical status (ASA PS) classification score of 1 or 2 were included. Further patients were excluded if they had a comorbidity or underwent a procedure not likely to classify them as ASA PS 1 or 2. Multivariable logistic regression was performed to identify predictors of the outcomes, in which odds ratios (OR) and 95% confidence intervals (95% CI) were reported.

RESULTS

There were 687,552 healthy patients included in the final analysis. Following surgery, 0.7, 7.0, and 0.7 per 1000 persons experienced 30-day mortality, sepsis, and stroke or myocardial infarction, respectively. Healthy patients greater than 80 years of age had the highest odds for mortality (OR 17.7, 95% CI 12.4-25.1, p < 0.001). Case duration was associated with increased mortality, especially in cases greater than or equal to 6 h (OR 3.0, 95% CI 2.0-4.5, p < 0.001).

CONCLUSIONS

Thirty-day mortality and morbidity is, as expected, lower in the healthy surgical population. Age may be an indication to further risk stratify patients that are ASA PS 1 or 2 to better reflect perioperative risk.

Impact of alcohol & smoking on the surgical management of gastrointestinal patients

Alcohol and smoking are repeatedly described as modifiable risk factors in clinical studies across all surgical specialities. These lifestyle choices impart a sub-optimal physiology via multiple processes and play an important role in the surgical management of the gastrointestinal patient. Cessation is imperative to optimise the patient's fitness for surgery with surgery itself being a prime opportunity for sustained cessation. A consistent, planned and integrated management involving surgical, anaesthetic, medical, and primary care facets will aid in successful cessation and perioperative care. This review highlights the pathological processes which contribute to perioperative complications and details the current practices to detect, predict and appropriately manage the perioperative gastrointestinal patient who smokes and consumes alcohol.

Effect of patient-reported smoking status on short-term bariatric surgery outcomes

INTRODUCTION

Preoperative patient screening is a major contributor to the remarkable safety of bariatric surgery. Smoking status is a modifiable patient risk factor, and smoking cessation is associated with improved outcomes in surgical patients. However, the length of smoking cessation necessary to optimize bariatric surgery patient outcomes is not yet defined. We sought to explore the relationship between patient-reported smoking status and short-term bariatric surgery outcomes.

METHODS

Using prospectively collected data from the MBSC registry, we evaluated the effects of patient-reported length of tobacco abstinence on 30-day surgical outcomes. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) patients (n = 49,772) were divided into three categories based on smoking status: never smoker, former smoker, and recent smoker. We compared risk-adjusted complication rates using multivariable logistic regression models and compared excess body weight loss using a one-way ANOVA test.

RESULTS

The risk-adjusted rate of severe complications among RYGB patients in the recent smoker group was significantly increased relative to patients who had never smoked (OR 1.34; 95% CI, 1.01-1.77), but not among SG patients (OR 1.18; 95% CI 0.87-1.62). In the same populations, differences in overall complication rate were not significant for either RYGB (OR, 1.11; 95% CI 0.94-1.31) or LSG (OR 1.04; 95% CI 0.86-1.25).

CONCLUSIONS

Recent smokers suffer detrimental effects of smoking on serious postoperative complications following RYGB surgery, but may not suffer an elevated risk of complications attributable to smoking for sleeve gastrectomy. An evaluation of the effect on long-term outcomes is necessary to further define the risks of smoking on bariatric surgery outcomes.

Effectiveness of perioperative pulmonary rehabilitation in thoracic surgery

BACKGROUND

Functional condition is crucial for operability of patients with lung cancer and/or chronic respiratory diseases. The aim of the study was to measure changes of functional and quality of life parameters in terms of the effectiveness of perioperative pulmonary rehabilitation (PR).

METHODS

A total of 208 COPD patients (age: 63±9 years, man/woman: 114/94, FEV1: 62±14%pred) participated in a perioperative PR program. The indication was primary lung cancer in 72% of the patients. The 68 patients participated in preoperative (PRE) rehabilitation, 72 in a pre- and postoperative rehabilitation (PPO) and 68 patients only in postoperative rehabilitation (POS). PR program included respiratory training techniques, individualized training and smoking cessation. Lung function tests, 6 minutes walking distance (6MWD) were measured before and after the rehabilitation. Quality of life tests [COPD Assessment Test (CAT) and Modified Medical Research Council Dyspnoea Scale (mMRC)] were evaluated as well.

RESULTS

There was a significant improvement in FEV1 (PRE: 64±16 vs. 67±16%pred; PPO: 60±13 vs. 66±13%pred before the operation, 48±13 vs. 52±13%pred after the operation; POS: 56±16 vs. 61±14%pred, P<0.05) and 6MWD (PRE: 403±87 vs. 452±86 m; PPO: 388±86 vs. 439±83 m before, 337±111 vs. 397±105 m after the operation; POS: 362±89 vs. 434±94 m, P<0 0001). Significant improvement was detected in FVC, grip strength, mMRC and CAT questionnaires as an effectiveness of PR, also. Average intensive care duration was 3.8±5.2 days with vs. 3.1±3.6 without preoperative PR.

CONCLUSIONS

Improvements in exercise capacity and quality of life were seen following PR both before and after thoracic surgery.

Smoking Increases the Rate of Reoperation for Infection within 90 Days After Primary Total Joint Arthroplasty

BACKGROUND

The relationship between smoking and complications after total joint arthroplasty is unclear. Prior studies have been limited by relatively small sample sizes or investigation of select cohorts. The purpose of this study was to investigate the association between smoking and readmission and/or reoperation within 90 days of total joint arthroplasty in a large, non-select cohort of patients.

METHODS

Using our institutional database, we retrospectively identified patients who underwent primary total joint arthroplasty between 2000 and 2014. Patients were stratified into 1 of 3 groups: current smokers, former smokers, and nonsmokers. The association between smoking status and subsequent readmission and/or reoperation within 90 days was investigated using multivariate regression analysis.

RESULTS

We retrospectively identified 15,264 patients (6,749 male and 8,515 female) who underwent 17,394 total joint arthroplasties during the study period. Of these patients, 1,371 (9.0%) were current smokers, 5,195 (34.0%) were former smokers, and 8,698 (57.0%) were nonsmokers. Former smokers reported a median of 22.2 years (range, 0.2 to 60 years) of abstinence prior to the surgical procedure. Current smokers were significantly younger (p < 0.001) at a mean age (and standard deviation) of 57.7 ± 10.3 years than nonsmokers at 63.2 ± 11.8 years. Current smokers were significantly more likely than nonsmokers to undergo reoperation for infection (odds ratio [OR], 1.82 [95% confidence interval (CI), 1.03 to 3.23]; p = 0.04), and former smokers were at no increased risk (OR, 1.11 [95% CI, 0.73 to 1.69]; p = 0.61). Packs per decade were independently associated with an increased risk of 90-day nonoperative readmission regardless of smoking status (OR, 1.12 [95% CI, 1.03 to 1.20]). Lastly, neither smoking status nor packs per decade were associated with aseptic or total reoperations.

CONCLUSIONS

This study, after controlling for confounding factors, demonstrated not only that current smokers have a significantly increased risk of reoperation for infection within 90 days of a surgical procedure compared with nonsmokers, but also that the amount that one has smoked, regardless of current smoking status, significantly contributed to increased risk of nonoperative readmission.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Can a urine dipstick test be used to assess smoking status in patients undergoing planned orthopaedic surgery? a prospective cohort study

AIMS

Smoking is associated with post-operative complications but smokers often under-report the amount they smoke. Our objective was to determine whether a urine dipstick test could be used as a substitute for quantitative cotinine assays to determine smoking status in patients.

PATIENTS AND METHODS

Between September 2013 and July 2014 we conducted a prospective cohort study in which 127 consecutive patients undergoing a planned foot and ankle arthrodesis or osteotomy were included. Patients self-reported their smoking status and were classified as: 'never smoked' (61 patients), 'ex-smoker' (46 patients), or 'current smoker' (20 patients). Urine samples were analysed with cotinine assays and cotinine dipstick tests.

RESULTS

There was a high degree of concordance between dipstick and assay results (Kappa coefficient = 0.842, p < 0.001). Compared with the quantitative assay, the dipstick had a sensitivity of 88.9% and a specificity of 97.3%. Patients claiming to have stopped smoking just before surgery had the highest rate of disagreement between reported smoking status and urine testing.

CONCLUSION

Urine cotinine dipstick testing is cheap, fast, reliable, and easy to use. It may be used in place of a quantitative assay as a screening tool for detecting patients who may be smoking. A positive test may be used as a trigger for further assessment and counselling. Cite this article: Bone Joint J 2016;98-B:1418-24.

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

The Impact of Current Smoking and Smoking Cessation on Short-Term Morbidity Risk After Lumbar Spine Surgery

STUDY DESIGN

A retrospective review of prospectively collected data.

OBJECTIVE

The aim of this study was to determine the impact of current smoking or prior smoking cessation on 30-day morbidity risk following lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Prior studies have reported conflicting data regarding the impact of smoking on morbidity risk, and few studies have investigated smoking cessation.

METHODS

A large, multicenter, prospectively collected clinical registry was queried for all adult patients undergoing lumbar spine surgery in 2012 and 2013, and 35,477 cases were identified. Morbidity data are collected by on-site clinical personnel for 30 days postoperatively. Patients were divided into categories of "never-smoker," for patients with no reported cigarette use (n = 27,246), "former smoker," for patients who quit smoking more than 12 months before surgery (n = 562), and "current smoker," for patients still using cigarettes (n = 7669). A univariate analysis was conducted to identify un-adjusted differences in morbidity risk, and a multivariate analysis was conducted in an attempt to control for confounders.

RESULTS

In the multivariate analysis, current smokers had a significantly higher risk of both superficial surgical site infection and overall wound complications, than never-smokers (P < 0.05 for each). Current smokers also had a significantly higher risk of total 30-day morbidity (P = 0.04). There was a trend toward former smokers also having an increased risk, but this did not reach significance in any category. Patients with a pack-year smoking history of 1 to 20 pack-years and more than 40 pack-years both had a significantly higher risk of superficial surgical site infections (P < 0.05 for each).

CONCLUSION

Current smoking is associated with a small but significant increase in systemic morbidity and wound complications following elective lumbar spine procedures. Increasing pack year history was also associated with wound complication risk, suggesting a dose-related effect. The data provide preliminary support for future studies on smoking cessation.

LEVEL OF EVIDENCE

3.

Feasibility of Electronic Nicotine Delivery Systems in Surgical Patients

INTRODUCTION

Cigarette smoking is a known risk factor for postoperative complications. Quitting or cutting down on cigarettes around the time of surgery may reduce these risks. This study aimed to determine the feasibility of using electronic nicotine delivery systems (ENDS) to help patients achieve this goal, regardless of their intent to attempt long-term abstinence.

METHODS

An open-label observational study was performed of cigarette smoking adults scheduled for elective surgery at Mayo Clinic Rochester and seen in the pre-operative evaluation clinic between December 2014 and June 2015. Subjects were given a supply of ENDS to use prior to and 2 weeks after surgery. They were encouraged to use them whenever they craved a cigarette. Daily use of ENDS was recorded, and patients were asked about smoking behavior and ENDS use at baseline, 14 days and 30 days.

RESULTS

Of the 105 patients approached, 80 (76%) agreed to participate; five of these were later excluded. Among the 75, 67 (87%) tried ENDS during the study period. At 30-day follow-up, 34 (51%) who had used ENDS planned to continue using them. Average cigarette consumption decreased from 15.6 per person/d to 7.6 over the study period (P < .001). At 30 days, 11/67 (17%) reported abstinence from cigarettes.

CONCLUSION

ENDS use is feasible in adult smokers scheduled for elective surgery and is associated with a reduction in perioperative cigarette consumption. These results support further exploration of ENDS as a means to help surgical patients reduce or eliminate their cigarette consumption around the time of surgery.

IMPLICATIONS

Smoking in the perioperative period increases patients' risk for surgical complications and healing difficulties, but new strategies are needed to help patients quit or cut down during this stressful time. These pilot data suggest that ENDS use is feasible and well-accepted in surgical patients, and worthy of exploration as a harm reduction strategy in these patients.

The Effect of Smoking on Short-Term Complications Following Total Hip and Knee Arthroplasty

BACKGROUND

Total joint arthroplasty is the most frequently performed orthopaedic procedure in the United States. The purpose of the present study was to identify differences in thirty-day morbidity and mortality following primary total hip and total knee arthroplasty according to smoking status and pack-year history of smoking.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who had undergone primary total hip or total knee arthroplasty between 2006 and 2012. Patients were stratified by smoking status and pack-year history of smoking. Thirty-day rates of mortality, wound complications, and total complications were compared with use of univariate and multivariate analyses.

RESULTS

We identified 78,191 patients who had undergone primary total hip or total knee arthroplasty. Of these, 81.8% (63,971) were nonsmokers, 7.9% (6158) were former smokers, and 10.3% (8062) were current smokers. Current smokers had a higher rate of wound complications (1.8%) compared with former smokers and nonsmokers (1.3% and 1.1%, respectively; p < 0.001). Former smokers had a higher rate of total complications (6.9%) compared with current smokers and nonsmokers (5.9% and 5.4%, respectively; p < 0.001). Multivariate analysis identified current smokers as being at increased risk of wound complications (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.21 to 1.78), particularly deep wound infection, while both current smokers (OR, 1.18; 95% CI, 1.06 to 1.31) and former smokers (OR, 1.20; 95% CI, 1.08 to 1.34) were at increased total complication risk. Increasing pack-year history of smoking resulted in increasing total complication risk.

CONCLUSIONS

On the basis of our findings, current smokers have an increased risk of wound complications and both current and former smokers have an increased total complication risk following total hip or total knee arthroplasty.

Preoperative smoking cessation counseling activities of anesthesiologists: a cross-sectional study

BACKGROUND

Smokers undergoing surgery are at a higher risk of complications than non-smokers. Preoperative evaluation by an anesthesiologist could provide an excellent opportunity to promote smoking cessation. Previous surveys of anesthesiologists have found that self-reported smoking cessation counseling rates have room for improvement, but no study has surveyed patients to obtain more accurate estimates.

METHODS

A single-center study was conducted from January 2010 to June 2010 in a tertiary teaching hospital. A telephone survey was conducted, which included all adult cigarette smokers who visited the preoperative anesthesia clinic. The survey recorded anesthesiologist-delivered interventions to help patients quit smoking before surgery. At the end of the study period, the self-reported smoking cessation counseling of the anesthesiologist was evaluated by questionnaire.

RESULTS

One thousand one hundred and sixty-five patients were evaluated, of which 217 were current smokers with a median pack-year of 15 (interquartile range 5.25-30.00) and 34% were scheduled to undergo major surgery. With regard to preoperative interventions, most anesthesiologists (85%) asked about smoking status, although only 31% advised patients about the health risks of smoking and 23% advised patients to quit before surgery. Provision of assistance to help patients quit was provided in 3% of cases. By contrast, 75% of anesthesiologists stated that they frequently or almost always advised patients about the health risks of smoking.

CONCLUSIONS

This study shows significant discrepancies between direct patient surveys of preoperative smoking cessation counseling activities by anesthesiologists and the self-reported perceptions of the anesthesiologists. Future studies are urgently needed to evaluate the provision of educational materials and other interventions to improve smoking cessation counseling rates among anesthesiologists and to narrow these discrepancies.

Fast-track surgery: Toward comprehensive peri-operative care

Fast-track surgery is a multimodal approach to patient care using a combination of several evidence-based peri-operative interventions to expedite recovery after surgery. It is an extension of the critical pathway that integrates modalities in surgery, anesthesia, and nutrition, enforces early mobilization and feeding, and emphasizes reduction of the surgical stress response. It entails a great partnership between a surgeon and an anesthesiologist with several other specialists to form a multi-disciplinary team, which may then engage in patient care. The practice of fast-track surgery has yielded excellent results and there has been a significant reduction in hospital stay without a rise in complications or re-admissions. The effective implementation begins with the formulation of a protocol, carrying out each intervention and gathering outcome data. The care of a patient is divided into three phases: Before, during, and after surgery. Each stage needs active participation of few or all the members of the multi-disciplinary team. Other than surgical technique, anesthetic drugs, and techniques form the cornerstone in the ability of the surgeon to carry out a fast-track surgery safely. It is also the role of this team to keep abreast with the latest development in fast-track methodology and make appropriate changes to policy. In the Indian healthcare system, there is a huge benefit that may be achieved by the successful implementation of a fast-track surgery program at an institutional level. The lack of awareness regarding this concept, fear and apprehension regarding its implementation are the main barriers that need to be overcome.

The effects of smoking on perioperative outcomes and pseudarthrosis following anterior cervical corpectomy: Clinical article

OBJECT

Smoking is one of the leading causes of preventable morbidity and death in the U.S. and has been associated with perioperative complications. In this study, the authors examined the effects of smoking on perioperative outcomes and pseudarthrosis rates following anterior cervical corpectomy.

METHODS

All adult patients from 2006 to 2011 who underwent anterior cervical corpectomy were identified. Patients were categorized into 3 groups: patients who never smoked (nonsmokers), patients who quit for at least 1 year (quitters), and patients who continue to smoke (current smokers). Demographic, medical, and surgical covariates were collected. Multivariate analysis was used to define the relationship between smoking and blood loss, 30-day complications, length of hospital stay, and pseudarthrosis.

RESULTS

A total of 160 patients were included in the study. Of the 160 patients, 49.4% were nonsmokers, 25.6% were quitters, and 25.0% were current smokers. The overall 30-day complication rate was 20.0%, and pseudarthrosis occurred in 7.6% of patients. Mean blood loss was 368.3 ml and mean length of stay was 6.5 days. Current smoking status was significantly associated with higher complication rates (p < 0.001) and longer lengths of stay (p < 0.001); current smoking status remained an independent risk factor for both outcomes after multivariate logistic regression analysis. The complications that were experienced in current smokers were mostly infections (76.5%), and this proportion was significantly greater than in nonsmokers and quitters (p = 0.013). Current smoking status was also an independent risk factor for pseudarthrosis at 1-year follow-up (p = 0.012).

CONCLUSIONS

Smoking is independently associated with higher perioperative complications (especially infectious complications), longer lengths of stay, and higher rates of pseudarthrosis in patients undergoing anterior cervical corpectomy.

Strategies to prevent surgical site infections in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,”1 published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.2

Smoking status and health care costs in the perioperative period: a population-based study

IMPORTANCE

Cigarette smoking adds an estimated $100 billion in annual incremental direct health care costs nationwide. Cigarette smoking increases complication risk in surgical patients, but the potential effects of smoking status on perioperative health care costs are unclear.

OBJECTIVE

To test the hypothesis that current and former smoking at the time of admission for inpatient surgery, compared with never smoking, are independently associated with higher incremental health care costs for the surgical episode and the first year after hospital discharge.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, propensity-matched cohort study, with cohort membership based on smoking status (current smokers, former smokers, and never smokers) was performed at Mayo Clinic in Rochester (a tertiary care center) and included patients at least 18 years old who lived in Olmsted County, Minnesota, for at least 1 year before and after the index surgery.

EXPOSURE

Undergoing an inpatient surgical procedure at Mayo Clinic hospitals between April 1, 2008, and December 31, 2009.

MAIN OUTCOMES AND MEASURES

Total costs during the index surgical episode and 1 year after hospital discharge, with the latter standardized as costs per month. Costs were measured using the Olmsted County Healthcare Expenditure and Utilization Database, a claims-based database including information on medical resource use, associated charges, and estimated economic costs for patients receiving care at the 2 medical groups (Mayo Clinic and Olmsted Medical Center) that provide most medical services within Olmsted County, Minnesota.

RESULTS

Propensity matching resulted in 678 matched pairs in the current vs never smoker grouping and 945 pairs in the former vs never smoker grouping. Compared with never smokers, adjusted costs for the index hospitalization did not differ significantly for current or former smokers. However, the adjusted costs in the year after hospitalization were significantly higher for current and former smokers based on regression analysis (predicted monthly difference of $400 [95% CI, $131-$669] and $273 [95% CI, $56-$490] for current and former smokers, respectively).

CONCLUSIONS AND RELEVANCE

Compared with never smokers, health care costs during the first year after hospital discharge for an inpatient surgical procedure are higher in both former and current smokers, although the cost of the index hospitalization is not affected by smoking status.