A prospective study of tobacco smoking as a predictor of complications in general surgery

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

Objectives

Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients.

Methods

Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion.

Results

A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation.

Conclusion

Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol.

Level of Evidence

2a.

Impact of tobacco usage on readmission and complication rates following shoulder replacement surgery: A study of 164,527 patients

Background

Tobacco carcinogens have adverse effects on bone health and are associated with inferior outcomes following orthopedic procedures. The purpose of this study was to assess the impact tobacco use has on readmission and complication rates following shoulder arthroplasty.

Methods

The 2016-2018 National Readmissions Database was queried to identify patients who underwent anatomical, reverse, and hemi-shoulder arthroplasty. ICD-10 codes Z72.0 ×  (tobacco use disorder) and F17.2 ×  (nicotine dependence) were used to define "tobacco-users." Demographic, 30-/90-day readmission, surgical complication, and medical complication data were collected. Inferential statistics were used to analyze complications for both the cohort as a whole and for each procedure separately (i.e. anatomical, reverse, and hemiarthroplasty).

Results

164,527 patients were identified (92% nontobacco users). Tobacco users necessitated replacement seven years sooner than nonusers (p < 0.01) and were more likely to be male (52% vs. 43%; p < 0.01). Univariate analysis showed that tobacco users had higher rates of readmission, revisions, shoulder complications, and medical complications overall. In the multivariate analysis for the entire cohort, readmission, revision, and complication rates did not differ based on tobacco usage; however, smokers who underwent reverse shoulder arthroplasty in particular were found to have higher 90-day readmission, dislocation, and prosthetic complication rates compared to nonsmokers.

Conclusion

Comparatively, tobacco users required surgical correction earlier in life and had higher rates of readmission, revision, and complications in the short term following their shoulder replacement. However, when controlling for tobacco usage as an independent predictor of adverse outcomes, these aforementioned findings were lost for the cohort as a whole. Overall, these findings indicate that shoulder replacement in general is a viable treatment option regardless of patient tobacco usage at short-term follow-up, but this conclusion may vary depending on the replacement type used.

The association between smoking status and post-operative complications in pelvic organ prolapse corrective surgeries

INTRODUCTION AND HYPOTHESIS

Tobacco is a known risk factor for pelvic organ prolapse (POP) as well as postoperative complications in general surgery procedures. Very little is known regarding the impact of tobacco use on postoperative outcomes in POP-correcting procedures, however. We hypothesize that tobacco use will be associated with an increased risk of postoperative complications in these procedures.

METHODS

This study utilized the National Surgical Quality Improvement Program (NSQIP) database for the years 2012-2020. Patients who underwent POP-correcting procedures were identified using current procedural terminology (CPT) codes. Baseline characteristics between the patient populations were compared using chi-square and one-way ANOVA tests as indicated. Binary logistic regression was used to evaluate the incidence of postoperative complications based on smoking status while controlling for demographic and clinical factors.

RESULTS

This study included 43,406 total patients, 39,614 non-smokers and 3792 smokers. Postoperative complications including deep wound infections (P < 0.001), intraperitoneal infections (P = 0.003), wound dehiscence (P = 0.014), urinary tract infections (P = 0.029), and hospital readmissions (P < 0.001) were significantly higher in patients who smoke than those who do not. Further evaluation of patients who did not undergo mesh placement intraoperatively and those who solely underwent vaginal procedures showed similar trends.

CONCLUSIONS

This study demonstrates a higher incidence of postoperative complications after POP-correcting procedures in patients with who smoke. Wound complications, urinary tract infections, and hospital readmission confer a considerable amount of risk to patient outcomes in addition to significant healthcare cost. Consideration should be given to smoking status in preoperative evaluation and counseling before these procedures.

The Effect of Smoking Status on Perioperative Morbidity and Mortality after Open and Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVES

This study quantifies the extent to which active tobacco smoking is deleterious towards outcomes following open and endovascular AAA repair.

METHODS

Open and endovascular abdominal aortic aneurysm (AAA) repairs between January 2003 and June 2020 in the Vascular Quality Initiative (VQI) were queried. Rupture, symptomatic status, and lack of 90 day follow up were exclusions. Patients were then placed into one of six groups : open AAA with active smoking (n=3788); open AAA with prior smoking (n=4614); open AAA never smokers (817); endovascular AAA active smokers (n=14173); endovascular AAA former smokers (n=25,831); and, endovascular AAA never smokers (n=6064). Comparison of baseline characteristics, co-morbidities, and adverse outcomes across each of the 6 cohorts was performed with open AAA in active smokers serving as the reference. Sub-analysis investigating open AAA repair in active smokers relative to open AAA in patients confirmed in VQI to have quit smoking between 30 and 90 days before surgery was performed. Smoking cessation for a minimum of 30 days before surgery was required to fall into the former smoker category.

RESULTS

In comparing open AAA in active smokers to open AAA in former and never smokers, the active smokers experienced significantly higher rates of pneumonia (P<.001). Combined additive morbidity and mortality was highest (54%) in active smokers (P<.001 relative to all cohorts other than open AAA former smokers P=.21). Smoking status did not impact morbidity or mortality incidence across individuals undergoing EVAR. Binary logistic regression for all AAA patients (open and endovascular combined) revealed those with any history of smoking to be more likely to experience 90 day mortality (adjusted OR 2.5 (2.2-2.9), P<.001) relative to never-smokers. Active smokers were similarly more likely to experience 90 day mortality than prior/never smokers combined (OR 1.23 (1.07-1.38), P<.001). Mortality within 90 days was significantly more likely (P<.001) with aging, female gender, larger aneurysms, preoperative history of congestive heart failure, chronic obstructive pulmonary disease, chronic renal insufficiency, peripheral artery disease, body mass index under 20 and over 35 mg/kg². Diabetes and coronary artery disease were also associated with 90 day mortality (P= .045 and .049 respectively). Quitting smoking between 30 and 90 days before open repair reduced combined additive morbidity and mortality relative to active smokers (OR 1.34, P =.038).

CONCLUSIONS

Smoking cessation 30 days before open AAA repair reduces perioperative morbidity and mortality. Smoking status does not impact morbidity and mortality in patients undergoing endovascular AAA repair. When combining all patients (open and endovascular), higher rates of 90 day mortality are associated with any history of smoking, aging, female gender and advanced pre-existing co-morbidities on multivariable analysis.

The Effect of Smoking on the Fusion Rate of Spinal Fusion Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To conduct a systematic review and meta-analysis comparing the fusion rate after spinal fusion surgery between smokers and nonsmokers.

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science electronic databases through March 10, 2021 for cohort and case-control studies assessing the effect of smoking on the fusion rate of spinal fusion surgery. Two researchers independently screened the literature and extracted data according to the inclusion and exclusion criteria. Statistical analysis was performed using RevMan, version 5.4.

RESULTS

A total of 26 studies, including 4 case-control studies and 22 cohort studies, with 4409 patients, were included in the present meta-analysis. Follow-up was at least 6 months. Overall, the pooled results demonstrated that the fusion rate of smokers after spinal fusion was significantly lower than that of nonsmokers. The odds ratio (OR) was 0.55 (95% confidence interval [CI] 0.45-0.67, P < 0.0001). Subgroup analyses by fusion level showed the adverse effect of smoking on the fusion rate at single level (OR 0.61, 95% CI 0.41-0.91, P = 0.02) was more significant than that of multiple levels (OR 0.55, 95% CI 0.38-0.80, P = 0.0010). Subgroup analysis according to the type of bone graft revealed an apparent association between smoking and fusion rate in the autograft subgroup (OR 0.47, 95% CI 0.33-0.66, P < 0.0001) but not in the allograft subgroup (OR 0.69, 95% CI 0.47-1.01, P = 0.06).

CONCLUSIONS

The fusion rate of smokers is significantly lower than that of nonsmokers in spinal fusion surgery. Smokers should be encouraged to quit smoking to improve the outcome of spinal fusion surgery.

Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine

Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use-associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify "at-risk" individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use.

Pre-operative patient optimization to prevent postoperative pulmonary complications-Insights and roles for the respiratory therapist: A narrative review

Background

The preoperative period has gained recognition as a crucial time to identify and manage preoperative medical conditions for preventing perioperative complications. Consequently, preoperative clinics have now become an essential component of perioperative care at many large hospitals. As the prevalence of preoperative clinics continues to grow, and the field of perioperative medicine progresses, respiratory therapists (RTs) will inevitably find a growing role to participate in preoperative patient optimization to mitigate pulmonary complications.

Methods

Keyword searches on perioperative pulmonary complications were conducted on the Medline database via PubMed and identified over 2000 candidate articles for review. Articles were included if they were English only and resulted with one or more of the following search terms; pulmonary complications, postoperative complications, postoperative pulmonary complications (PPCs), prehabilitation, incentive spirometry, smoking cessation, noninvasive ventilation. Preference was given for meta-analyses, randomized controlled trials, and systematic reviews. Publications within the past two decades were given additional preference toward final inclusion. The authors discussed eligible articles in group meetings over the span of multiple years to assess relevance and quality of data for narrowing eligible articles to the final selection of publications for the review.

Findings

The following narrative review examines preoperative optimization strategies to prevent PPCs and highlight areas where RTs may play a key role. After examining challenges in defining PPCs, the review examines key risk models available to predict PPCs and their implications for subsequent discussion on preventive measures that RTs may assist with in a multidisciplinary team.

Conclusion

RTs can reduce the health care burden of PPCs by assisting fellow perioperative clinicians in providing respiratory care for patients with premorbid conditions. While much of our review focused on pre-existing pulmonary pathologies and both the pharmacological and nonpharmacological optimization of these pathologies, there are other factors contributing to PPCs deserving future exploration.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

Comorbid tobacco and other substance use and symptoms of anxiety and depression among hospitalised orthopaedic trauma patients

BACKGROUND

No study has examined the prevalence of tobacco, other substance use, and symptoms of anxiety and depression, and rates of comorbidities among the orthopaedic trauma population, despite the impact they have on recovery from surgery. This study aims to 1) describe the rates of symptoms and substance use; 2) compare rates of symptoms and substance use among smokers versus non-smokers; and 3) examine the relationship between symptoms and substance use with smoking status.

METHODS

A cross-sectional survey of orthopaedic trauma patients was conducted in two Australian public hospitals. Demographic characteristics, smoking status, alcohol consumption, recent cannabis use, and symptoms of anxiety and/or depression were examined. Differences between current and non-smokers were compared using Pearson Chi² tests. Multivariate logistic regression explored variables related to tobacco smoking.

RESULTS

Eight hundred nineteen patients participated. Over one-fifth (21.8%) identified as a current smoker, half (51.8%) reported consuming alcohol at hazardous levels in the last 12 months, and about 10% stated that they had used cannabis in the last 30 days (9.7%), or experienced symptoms of either anxiety (12.4%), or depression (12.9%) in the last two weeks. Over one-fifth of current tobacco smokers (21.8%) reported drinking heavily in the last 12 months and using cannabis recently. Males, with a lower educational attainment, who were unmarried, had used cannabis recently, and report drinking heavily were more likely to be current smokers.

CONCLUSIONS

Health behaviour interventions addressing comorbidities are warranted among the orthopaedic trauma population given the high rate of comorbidity and impact these may have on recovery.

Smoking and Risk of Surgical Site Infection after Spinal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

The effect of smoking on the risk of surgical site infection (SSI) after spinal surgery remains controversial. Therefore, we conducted a meta-analysis to determine whether there is an association between smoking and the risk of SSI and to calculate the relative risk of infections attributable to smoking.

METHODS

We performed a literature search of cohort and case-control studies in the MEDLINE, Embase, and ISI Web of Science databases. Sensitivity and subgroup analyses were performed to test the robustness of overall estimates of risk and to investigate potential sources of heterogeneity. We further calculated the population-attributable fraction (PAF) to evaluate the proportion of SSIs associated with smoking.

RESULTS

In total, 26 independent observational studies involving 67,405 patients who underwent spinal surgery were analyzed. Smokers had a significantly higher risk of SSI than did nonsmokers (odds ratio [OR] 1.26; 95% confidence interval [CI] 1.05-1.51). Subgroup analysis according to the study design revealed an apparent association between smoking and SSI in the cohort subgroup (OR 1.40; 95% CI 1.17-1.66), but not in the case-control subgroup (OR 0.99; 95% CI 0.64-1.53). After evaluation of the PAF, the proportion of SSIs associated with smoking increased to 10.37%.

CONCLUSIONS

This meta-analysis demonstrated that smoking increases the risk of SSI after spinal surgery. False-negative associations in other studies may have resulted from defects in the study design. However, because of the heterogeneity among the studies in the present meta-analysis, the results should be interpreted with caution.

Increased Myeloid Cell Production and Lung Bacterial Clearance in Mice Exposed to Cigarette Smoke

Pneumonia is a leading cause of hospitalization in patients with chronic obstructive pulmonary disease (COPD). Although most patients with COPD are smokers, the effects of cigarette smoke exposure on clearance of lung bacterial pathogens and on immune and inflammatory responses are incompletely defined. Here, clearance of Streptococcus pneumoniae and Pseudomonas aeruginosa and associated immune responses were examined in mice exposed to cigarette smoke or after smoking cessation. Mice exposed to cigarette smoke for 6 weeks or 4 months demonstrated decreased lung bacterial burden compared with air-exposed mice when infected 16 to 24 hours after exposure. When infection was performed after smoke cessation, bacterial clearance kinetics of mice previously exposed to smoke reversed to levels comparable to those of control mice, suggesting that the observed defects were not dependent on adaptive immunological memory to bacterial determinants found in smoke. Comparing cytokine levels and myeloid cell production before infection in mice exposed to cigarette smoke with mice never exposed or after smoke cessation revealed that reduced bacterial burden was most strongly associated with higher levels of IL-1β and granulocyte-macrophage colony-stimulating factor in the lungs and with increased neutrophil reserve and monocyte turnover in the bone marrow. Using Serpinb1a-deficient mice with reduced neutrophil numbers and treatment with granulocyte colony-stimulating factor showed that increased neutrophil numbers contribute only in part to the effect of smoke on infection. Our findings indicate that cigarette smoke induces a temporary and reversible increase in clearance of lung pathogens, which correlates with local inflammation and increased myeloid cell output from the bone marrow.

Greater weight loss with the omega loop bypass compared to the Roux-en-Y gastric bypass: a comparative study

BACKGROUND

Despite similar initial results on weight loss and metabolic control, with a better feasibility than the Roux-en-Y gastric bypass (RYGBP), the omega loop bypass (OLB) remains controversial. The aim of this study was to compare the short-term outcomes of the laparoscopic OLB versus the RYGBP in terms of weight loss, metabolic control, and safety.

METHODS

Two groups of consecutive patients who underwent laparoscopic gastric bypass surgery were selected: 20 OLB patients and 61 RYGBP patients. Patients were matched for age, gender, and initial body mass index (BMI). Data concerning weight loss, metabolic outcomes, and complications were collected prospectively.

RESULTS

Mean duration of the surgical procedure was shorter in the OLB group (105 vs. 152 min in the RYGBP group; p < 0.001). Mean excess BMI loss percent (EBL%) at 6 months and at 1 year was greater in the OLB group (76.3 vs. 60.0%, p = 0.001, and 89.0 vs. 71.0%, p = 0.002, respectively). After adjustment for age, sex, initial BMI, and history of previous bariatric surgery, the OLB procedure was still associated with a significantly greater 1-year EBL%. Diabetes improvement at 6 months was similar between both groups. The early and late complication rates were not statistically different. There were three anastomotic ulcers in the OLB group, in smokers, over 60 years old, who were not taking proton pump inhibitor medication.

CONCLUSIONS

In this short-term study, we observed a greater weight loss with OLB and similar efficiency on metabolic control compared to RYGBP. Long-term evaluation is necessary to confirm these outcomes.

Smoking is Associated with Poorer Quality-Based Outcomes in Patients Hospitalized with Spinal Disease

STUDY DESIGN

Retrospective cross-sectional database analysis.

OBJECTIVE

The cost of spine surgery is growing exponentially, and cost-effectiveness is a critical consideration. Smoking has been shown to increase hospital costs in general surgery, but this impact has not been reported in patients with spinal disease. The objective of this work was to evaluate the effect of smoking on cost and complications in a large sample of patients admitted for treatment of spinal disease.

METHODS

In 2012, the authors identified all inpatient admissions to all University HealthSystem Consortium (UHC) hospitals from 2005 to 2011 for spinal disease based on the principal diagnosis ICD-9-CM codes from the prospectively collected UHC database. Patient outcomes - including length of stay; complication, readmission, intensive care unit admission rates; and total cost - were compared for non-obese smokers and non-smokers using a two-sample t-test.

RESULTS

There were 137,537 patients, including 136,511 (122,608 non-smokers and 13,903 smokers) in the 4 largest diagnostic groups. Smoking was associated with increased complications and worse outcomes in three of these four groups. All outcomes in the two largest groups - fracture and dorsopathy - were worse in the smoking patients.

CONCLUSION

Smoking patients admitted for spinal disease in the sample had worse outcomes, increased complications, and higher costs than their non-smoking counterparts. In the current health-care climate focused on cost-effectiveness, smoking represents a potentially modifiable area for cost reduction.

[Operative risk related to tobacco in gynecology]

If tobacco has been recognized for many years as a major risk factor for cardiovascular, lung diseases and cancer in the general population, women are insufficiently aware of the consequences and the specific gynecological operative risks related to this intoxication. Thus, a regular tobacco consumption increases the risk for many gynecological conditions may require surgical treatment with in addition a significant negative impact on the healing process and the risk of postoperative complications. The operative risk must be explained by surgeons in daily practice gynecological, pelvic surgery or breast screening. The issue of smoking cessation should precede surgery has been established by a consensus conference of experts on perioperative smoking held in 2005. The implementation of these recommendations during the preoperative period requires improvement of staff training and better practices to allow smoking cessation effective and sustainable. It is lawful in this context to delay scheduled surgery of 6 to 8 weeks to allow an optimal smoking cessation and to continue smoking cessation for the time necessary for healing to reduce the excess operative risk associated with smoking.

[Smoking prevention in preoperative patient factsheets]

INTRODUCTION

Information for patients undergoing elective surgery is often supported by factsheets. This information is required for ethical and legal reasons. Among the 11 million surgical procedures performed annually in France, three million concern smokers. Data of a 2005 French Expert's conference show that smoking doubles or triples the risk of postoperative complications and quitting smoking cancels this risk.

METHODS

By a query on www.google.fr, 100 factsheets were collected in 2009 (pilot study) and 500 in 2012. These factsheets were systematically analyzed on tobacco information. Issuers were contacted by mail, email and telephone to suggest improvements on these factsheets. A return to the websites where the 500 factsheets have been issued was performed 6 months later.

RESULTS

In 2009, only 24.0% of factsheets mentioned tobacco. In 2012, 29.4% of factsheets evoked tobacco. When tobacco is mentioned, information's were rarely complete. Cosmetic surgeons, maxillofacial surgeons and to a lesser extent orthopaedists are those who raise most often the tobacco issue. After contact with issuers, 41 factsheets were removed from the sites. Factsheets with tobacco information increased from 147/500 (29.4%) to 175/459 (38.1%) and the quality score of the information increased from 3.4 to 6.0. The message suggested by OFT was: "Smoking increases the risk of surgical complications of any surgery. Quitting smoking 6-8 weeks before surgery eliminates this additional risk. If you smoke, talk to your doctor, your surgeon and your anesthesiologist or call the French quitline TIS 3989 to help you to reduce the risk and put all the chances on your side". This sentence was included in 54 factsheets.

CONCLUSION

There is still work to do to improve information's on smoking risk in perioperative factsheets. The aim is to reduce postoperative complications, costs and avoid court sentences against practitioner who do not inform properly on the risks of smoking on surgical procedures.

Cigarette smoking and mechanisms of susceptibility to infections of the respiratory tract and other organ systems

The predisposition of cigarette smokers for development of oral and respiratory infections caused by microbial pathogens is well recognised, with those infected with the human immunodeficiency virus (HIV) at particularly high risk. Smoking cigarettes has a suppressive effect on the protective functions of airway epithelium, alveolar macrophages, dendritic cells, natural killer (NK) cells and adaptive immune mechanisms, in the setting of chronic systemic activation of neutrophils. Cigarette smoke also has a direct effect on microbial pathogens to promote the likelihood of infective disease, specifically promotion of microbial virulence and antibiotic resistance. In addition to interactions between smoking and HIV infection, a number of specific infections/clinical syndromes have been associated epidemiologically with cigarette smoking, including those of the upper and lower respiratory tract, gastrointestinal tract, central nervous and other organ systems. Smoking cessation benefits patients in many ways, including reduction of the risk of infectious disease.

A Dutch version of the modified reasons for smoking scale: factorial structure, reliability and validity

AIMS

The Modified Reasons for Smoking Scale (MRSS) is a widely accepted scale that measures psychological functions of smoking. The scale has been translated in Dutch and has been validated, in order to be used in clinical smoking cessation practice in the Dutch-speaking part of Belgium. This study examined the factorial structure, reliability and validity of the scale in a sample of smokers, who are characterized by a high level of dependence and an explicit motivation to stop smoking.

METHOD

The participants were 383 smokers, who volunteered at the stop-smoking clinic of a Belgian university hospital, and completed the translated scale. They were administered the translated MRSS, the Fagerstrom Test for Nicotine Dependence (FTND). Through a clinical interview, smoking behaviour and smoking history was assessed (daily smoking consumption, years smoking, number of quit attempts, weeks stopped, alcohol and coffee consumption, CO level). Exploratory factor analysis was performed. Internal consistency was studied in order to examine the reliability. The concurrent validity was assessed by means of manova, anova and correlation analysis.

RESULTS

Factor analysis identified four factors, named stimulation, pleasure of smoking, social smoking and automatism of smoking. Cronbach's alpha ranged from 0.65 (automatism) to 0.72 (stimulation). manova indicated the influence of the variables age, sex, daily consumption and the FTND (the latter two variables showed a dose-dependent association with each subscale). Regression analysis revealed a relationship with dependence indicators, namely: the daily consumption, the number and duration of previous quit attempts, FTND, CO level and daily coffee intake.

CONCLUSIONS

The Dutch translation of the MRSS identified four factors and revealed acceptable validity and reliability. The adapted version of the translated scale as a component of the psychological assessment procedure in a smoking cessation treatment in Dutch-speaking areas should be implemented.

Hospital costs associated with smoking in veterans undergoing general surgery

BACKGROUND

Approximately 30% of patients undergoing elective general surgery smoke cigarettes. The association between smoking status and hospital costs in general surgery patients is unknown. The objectives of this study were to compare total inpatient costs in current smokers, former smokers, and never smokers undergoing general surgical procedures in Veterans Affairs (VA) hospitals; and to determine whether the relationship between smoking and cost is mediated by postoperative complications.

STUDY DESIGN

Patients undergoing general surgery during the period of October 1, 2005 to September 30, 2006 were identified in the VA Surgical Quality Improvement Program (VASQIP) data set. Inpatient costs were extracted from the VA Decision Support System (DSS). Relative surgical costs (incurred during index hospitalization and within 30 days of operation) for current and former smokers relative to never smokers, and possible mediators of the association between smoking status and cost were estimated using generalized linear regression models. Models were adjusted for preoperative and operative variables, accounting for clustering of costs at the hospital level.

RESULTS

Of the 14,853 general surgical patients, 34% were current smokers, 39% were former smokers, and 27% were never smokers. After controlling for patient covariates, current smokers had significantly higher costs compared with never smokers: relative cost was 1.04 (95% Cl 1.00 to 1.07; p = 0.04); relative costs for former smokers did not differ significantly from those of never smokers: 1.02 (95% Cl 0.99 to 1.06; p = 0.14). The relationship between smoking and hospital costs for current smokers was partially mediated by postoperative respiratory complications.

CONCLUSIONS

These findings complement emerging evidence recommending effective smoking cessation programs in general surgical patients and provide an estimate of the potential savings that could be accrued during the preoperative period.

Impact of smoking on disease phenotype and postoperative outcomes for Crohn's disease patients undergoing surgery

AIM

Whether smoking affects disease distribution, phenotype, and perioperative outcomes for Crohn's disease (CD) patients undergoing surgery is not well characterized. The aim of this study is to evaluate the impact of smoking on disease phenotype and postoperative outcomes for CD patients undergoing surgery

METHODS

Prospectively collected data of CD patients undergoing colorectal resection were evaluated. CD patients who were current smokers (CS) were compared to nonsmokers (NS) and ex-smokers (ES) for disease phenotype, anatomic site involved, procedures performed, postoperative outcomes, and quality of life using the Cleveland Global Quality of Life instrument (CGQL).

RESULTS

Of 691 patients with a diagnosis of CD requiring surgery 314 were classified as CS, 330 as NS, and 47 as ES. CS and ES in comparison to NS were significantly older at diagnosis of Crohn's disease (mean, 29.3 vs. 29.2 vs. 26.3 years) (P = 0.001) and older at the time of primary surgery (mean, 42.9 vs. 48.4 vs. 39 years) (P = 0.001) with a greater frequency of diabetes. In all groups requiring surgery, there was a significant change in disease phenotype from the time of diagnosis to surgical intervention. The predominant phenotype at diagnosis was inflammatory which changed to stricturing and penetrating as the dominant phenotypes at time of surgery. All groups had a significant improvement in CGQL scores post-surgery with the greatest benefit observed in NS. Postoperative complications and 30-day readmission rates were similar between all groups.

CONCLUSIONS

The findings of this study show that in patients with CD, disease phenotype changes over time. This occurs independent of smoking. Smoking does not appear to predispose to complications for CD patients undergoing surgery. CS and ES have a persistently reduced quality of life in comparison to NS post-surgery.

[Risk factors for postoperative complications in major head and neck surgery]

BACKGROUND AND OBJECTIVE

Tumor extension is the factor that usually determines the choice of radiotherapy or surgery for head and neck cancers. The choice of surgery carries with it certain specific risks that must be assessed jointly by the maxillofacial surgeon and the anesthetist so that they can agree on the best course of action to choose. We aimed to identify risk factors for complications after major head and neck surgery.

PATIENTS AND METHODS

Retrospective descriptive analysis of data for patients who underwent oncologic head and neck surgery with graft reconstruction. The main candidate predictors gathered from records were age, sex, ASA physical status classification, time under anesthesia, and intra- and postoperative events. The main dependent variables were records of early and delayed complications, time until extubation, and related mortality.

RESULTS

We identified 61 interventions in 56 patients (mean duration of surgery, 9 hours). Early complications developed in 57.4% while they were in the critical care area. Age > or =60 years was associated with longer hospital stays. Short-term mortality was higher in current smokers (P= .01). Survival was significantly higher in patients classified ASA 1 or 2 in comparison with those classified as ASA 3 or 4, in whom long-term mortality was higher (P < .05).

CONCLUSIONS

The incidence of postoperative complications was associated with comorbidity and risk behaviors found in this type of patient. We feel that a multidisciplinary medical team should assess the surgical and postoperative care of these patients.

Surgical site infections in a tertiary health care center: prospective cohort study

PURPOSE

To investigate the incidence and risk factors associated with the development of surgical site infections (SSIs) using the National Nosocomial Infection Surveillance (NNIS).

METHODS

A prospective cohort study was conducted at a tertiary health care center. Infection control personnel collected general and health care related data about patients. The NNIS risk index was calculated on the basis of data relating to the operation: wound contamination class, duration of surgery, and the American Society of Anesthesiologists (ASA) score.

RESULTS

A total of 5109 surgical procedures were included in the study. The overall cumulative incidence rate was 6.3%. The incidence of SSIs was 2.3% (63.5% of operative procedures), 8.3% (29.7%), 34.6% (6.2%), and 43.3% (0.6%), in patients with 0, 1, 2, and 3 risk index, respectively. The length of hospital stay (OR: 1.0; 95% CI: 1.053-1.075), preoperative length of stay (odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.953-1.981), antibiotic prophylaxis (OR: 2.5; 95% CI: 1.421-4.628), drainage (OR: 1.7; 95% CI: 1.360-2.353), ASA score (OR: 1.5; 95% CI: 1.235-1.946), class of wound contamination (OR: 2.0; 95% CI: 1.745-2.003), and NNIS risk index (OR: 1.3; 95% CI: 1.063-1.7) were independently associated with an increased risk for SSIs. Staphylococcus aureus was the most frequently isolated microorganism, 64% of them being methicillin-resistant.

CONCLUSION

The aim of this study was to investigate the most important risk factors associated with the development of surgical site infections (SSIs). Therefore, greater attention has been given to adherence to recommendations for the prevention and control of SSIs as well as to antibiotic prophylaxis protocols.

Perioperative management of patients who have pulmonary disease

The identification of risk factors and optimization of respiratory status are crucial to the successful management of patients who have pulmonary disease and are undergoing a surgical procedure. This article explores the approach to pulmonary patients, from the preoperative assessment to the intraoperative and postoperative periods. The management of specific pulmonary disorders in the perioperative period is discussed.

[Risks related to tobacco use in general and intestinal surgery]

Peri-operative smoking history is an important risk factor, which is often under-appreciated by surgeons. In the first place, tobacco use predisposes patients to specific pathologies, which may require surgical intervention. Secondarily, smoking has been shown to increase surgical risks of mortality, morbidity and length of hospital stay. Of particular importance in general surgery is the increased risk of anastomotic leak with fistula formation, of deep infections, and of abdominal wall complications (infection and ventral hernia). If the patient can stop smoking prior to surgery, there is a concomitant decrease in post-operative complications. Surgeons should be familiar with the pharmacologic and behavioral interventions, which may help the patient with smoking cessation and should not hesitate to defer elective surgery for four to eight weeks so that the patient may have the full benefit of smoking cessation.

A prospective, randomized, blinded, single-site study to evaluate the clinical and radiographic differences between frozen and freeze-dried allograft when used as part of a circumferential anterior lumbar interbody fusion procedure

STUDY DESIGN

Prospective, randomized clinical trial from a single surgeon's patient population.

OBJECTIVE

The purpose of this study is to compare the outcomes and fusion rates of an anterior lumbar interbody fusion (ALIF) procedure when 2 different preservation methods of the femoral ring allograft (FRA) are used.

SUMMARY OF BACKGROUND DATA

FRA can be stored via freeze-drying (FD) or freezing (FZ). In a previous biomechanical PLIF model, FZ cancellous allograft failed at an average load 50% less than FD cancellous allograft. Despite this finding, there is no evidence to support which preservation method is more effective at achieving solid fusion in ALIF procedures.

METHODS

Fifty ALIF patients received either FZ or FD FRA. Patients were observed for a minimum of 24 months. Outcome measures included complications, fusion status, implant intactness, 1 to 10 pain scale scores, Oswestry Disability Index (ODI), and SF-36 scores.

RESULTS

Univariate comparisons for grafting material are as follows: Average ODI-FD: 46.05 +/- 16.7, FZ: 39.24 +/- 23.65, P = 0.296. Average Physical Component Summary from SF36-FD: 33.47 +/- 10.12, FZ: 39.76 +/- 11.50, P = 0.074. Average 1 to 10 back pain with medication-FD: 3.47 +/- 2.59, FZ: 2.95 +/- 2.48, P = 0.527. ODI scores improved more than 10 points in 62.5% of patients. SF-36 Physical Component Summary scores improved more than 10 points in 27.5% of patients. Back pain with medication scores improved 2 or more points in 60.5% of patients. Seven patients required revision for psuedarthrosis (FD: 6, FZ: 1, P = 0.026). Fusion was achieved in 40 levels (71.4%). The freeze-dried graft had a higher likelihood of pseudarthrosis (P = 0.026).

CONCLUSION

When the results are considered in terms of clinical outcomes, the 2 methods of graft preservation perform with few statistically significant differences. Radiographic analysis showed that the freeze-dried graft had a higher likelihood of pseudarthrosis.

Obesity, diabetes, and smoking are important determinants of resource utilization in liver resection: a multicenter analysis of 1029 patients

OBJECTIVE

To investigate independent contributions of obesity, diabetes, and smoking to resource utilization in patients following liver resection.

SUMMARY BACKGROUND DATA

Despite being highly resource-intensive, liver resections are performed with increasing frequency. This study evaluates how potentially modifiable factors affect measures of resource utilization after hepatectomy.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) public-use database was queried for patients undergoing liver resection. Resource variables were operative time (OT), intraoperative transfusion, length of stay (LOS), ventilator support at 48 hours, and reoperation. Bivariable and multivariable linear and logistic regressions were performed.

RESULTS

There were 1029 patients identified. Most resections involved less than a hemiliver (599 patients, 58.2%). Mean BMI was 28.0 +/- 6.0. Mean OT was 253 +/- 122 minutes (range, 27 to 794) but varied by procedure (P < 0.001). Mean LOS was 8.7 +/- 10.7 days (range, 0 to 202). Morbid obesity added 48 minutes to OT (P = 0.018), 1.1 units to transfusions (P = 0.049), 2.2 days to LOS (P < 0.001), and accounted for delayed ventilator weaning (odds ratio, 4.5; P = 0.022). Underweight patients had shorter OT, but stayed 3.3 days longer than normal weight patients (P < 0.001). Insulin-treated patients with diabetes had longer OT (P < 0.001), increased transfusions (P < 0.001), and delayed ventilator weaning (odds ratio, 6.7; P < 0.001), while orally-treated patients with diabetes showed opposite trends. Smokers stayed 1.9 days longer (P < 0.001), with increased risk of prolonged ventilation (odds ratio, 3.3; P = 0.002) and reoperation (odds ratio, 2.3; P = 0.015).

CONCLUSION

Obesity, diabetes, and smoking are each associated with important components of healthcare expenditure. Education and prevention programs are needed to limit their impact on overall resource utilization.

Current trends in the management of acute appendicitis

BACKGROUND

While laparoscopic appendectomy (LA) has become established in the diagnosis and treatment of acute appendicitis, its utilisation compared to open appendectomy (OA) is variable.

AIM

To compare the utilisation and outcome of laparoscopic (LA) versus OA in an Irish regional hospital setting.

METHOD

Retrospective review of OA and LA performed from 2003 to 2005.

RESULTS

Intention-to-treat analysis of 787 patients in this study revealed that 149 patients (19%) had LA and 638 patients (81%) had OA. Consultants were significantly more likely than trainees to undertake a LA (P < 0.0001). Twenty-two complications (2.8%) were recorded in the post-operative period. The overall negative appendectomy rate by histopathology was 17% with no significant difference between the rate in the LA group (19%) and the OA (17%) group.

CONCLUSION

Mean length of stay and complication rate were comparable between the LA and OA groups.

Marginal Lung Donors: A Diminishing Margin of Safety?

Lung donor shortages have resulted in the critical appraisal of cadaveric donor acceptability criteria and the gradual relaxation of once strict guidelines. Many centers have reported their results with these "extended criteria" donors and an increasing number of multicenter registry studies have also been published. The results have been contradictory and leave many questions unanswered. Important new data has however come to light since the last review of the subject by the International Society for Heart and Lung Transplantation Pulmonary Council. We review the current literature focusing on recent developments in the pursuit of an expanded lung donor pool with acceptable outcomes.

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

OBJECTIVES

To establish the effect of preoperative smoking cessation on the risk of postoperative complications, and to identify the effect of the timing of preoperative cessation.

DATA SOURCES

The Cochrane Library Database, PsycINFO, EMBASE, Medline, and CINAHL databases were searched, using the terms: "smoking", "smoking-cessation", "tobacco-use", "tobacco-abstinence", "cigarett$", "complication$", "postoperative-complication$", "preoperative", "perioperative" and "surg$". Further articles were obtained from reference lists. The search was limited to articles on adults, written in English and published up to November 2005.

STUDY SELECTION

Prospective cohort designs exploring the effects of preoperative smoking cessation on postoperative complications were included. Two reviewers independently scanned abstracts of relevant articles to determine eligibility. Lack of agreement was resolved through discussion and consensus. Twelve studies met the inclusion criteria.

DATA EXTRACTION

Methodological quality was assessed by both reviewers, exploring validation of smoking status, clear definition of the period of smoking cessation, control for confounding variables and length of follow-up.

DATA SYNTHESIS

Only four of the studies specified the exact period of smoking cessation, with six studies specifying the length of the follow-up period. Five studies revealed a lower risk or incidence of postoperative complications in past smokers than current smokers or reported that there was no significant difference between past smokers and non-smokers.

CONCLUSIONS

Longer periods of smoking cessation appear to be more effective in reducing the incidence/risk of postoperative complications; there was no increased risk in postoperative complications from short term cessation. An optimal period of preoperative smoking cessation could not be identified from the available evidence.

Indices of Surgical Site Infection Risk and Prediction of Other Adverse Outcomes During Hospitalization

Objective.

To assess which adverse postsurgical outcomes are best predicted by the Study on the Efficacy of Nosocomial Infection Control (SENIC) index and the National Nosocomial Infection Surveillance system (NNIS) index.

Design.

Prospective cohort study.

Setting.

The service of general surgery at a tertiary care hospital.

Patients.

A consecutive series of patients hospitalized for more than 1 day (n = 2,989).

Results.

The outcome best predicted by the SENIC and NNIS indices was assessed by estimating the area under the receiver operating characteristic (ROC) curve. The areas under the ROC curves for nosocomial infection and in-hospital death were higher for the NNIS index than they were for the SENIC index (P<.05). The NNIS index predicted in-hospital death better than it predicted surgical site infection (area under the ROC curve ± SE, 0.836 ± 0.022 vs 0.689 ± 0.017; P = .001).

Conclusions.

The NNIS index is superior to the SENIC index for all adverse postsurgical outcomes. Its ability to predict in-hospital mortality is clearly better than its ability to predict surgical site infection.

Indices of surgical site infection risk and prediction of other adverse outcomes during hospitalization

OBJECTIVE

To assess which adverse postsurgical outcomes are best predicted by the Study on the Efficacy of Nosocomial Infection Control (SENIC) index and the National Nosocomial Infection Surveillance system (NNIS) index.

DESIGN

Prospective cohort study.

SETTING

The service of general surgery at a tertiary care hospital.

PATIENTS

A consecutive series of patients hospitalized for more than 1 day (n=2,989).

RESULTS

The outcome best predicted by the SENIC and NNIS indices was assessed by estimating the area under the receiver operating characteristic (ROC) curve. The areas under the ROC curves for nosocomial infection and in-hospital death were higher for the NNIS index than they were for the SENIC index (P<.05). The NNIS index predicted in-hospital death better than it predicted surgical site infection (area under the ROC curve+/-SE, 0.836+/-0.022 vs 0.689+/-0.017; P=.001).

CONCLUSIONS

The NNIS index is superior to the SENIC index for all adverse postsurgical outcomes. Its ability to predict in-hospital mortality is clearly better than its ability to predict surgical site infection.

Frequência de infecção do sítio cirúrgico em gastrectomia

A presente investigação teve como objetivo identificar a freqüência de infecção do sítio cirúrgico (ISC), em paciente submetido a cirurgia eletiva de gastrectomia, potencialmente contaminada, na especialidade de Gastrocirurgia, no período compreendido de 1998 a 2002, em um hospital escola de Ribeirão Preto - SP. Realizou-se um estudo retrospectivo, por meio do levantamento de informações contidas nos prontuários médicos. Em 181 casos investigados, detectou-se a ocorrência de infecção do sítio cirúrgico em 17 pacientes (9,4%), sendo 23,5% classificadas como infecção incisional superficial; 52,9%, infecção incisional profunda e 23,5%, infecção de órgão/espaço; 41,2% dos casos de infecção desenvolveram-se no período de 6 a 10 dias após a cirurgia e foram isolados diferentes microrganismos nas culturas solicitadas. Evidenciou-se que a freqüência de ISC em cirurgia potencialmente contaminada está de acordo com o encontrado na literatura. Entretanto, em relação à topografia, a maioria dos casos detectados foi classificada como infecção incisional profunda e a literatura retrata que dois terços das infecções são confinados à incisão.

Mucociliary clearance is impaired in acutely ill patients

OBJECTIVE

This study aimed to investigate nasal mucociliary clearance in acutely ill patients who were clinically stable and had no airway manipulation.

DESIGN

Prospective clinical study.

SETTING

Medical ICU.

PATIENTS AND PARTICIPANTS

Sixteen medical patients admitted to the ICU and 16 healthy subjects were studied. Patients who were receiving airway manipulation, including tracheal suctioning, nasogastric or enteral tubes, noninvasive and invasive mechanical ventilation, were excluded.

INTERVENTIONS

Mucociliary clearance was evaluated by saccharine transit time (STT) measurements at ICU admission (admission) and 90 days after hospital discharge (recovery). Healthy subjects were also subjected to two measurements 90 days apart.

MEASUREMENTS AND RESULTS

The STT of patients was 26.4 +/- 11.3 min and 17.9 +/- 8.6 min at admission and recovery (p = 0.002) [mean +/- SD] but did not change along the 90-day interval in healthy subjects (17.2 +/- 10.2 min and 16.7 +/- 10.3 min), respectively. Smokers (patients and healthy subjects) presented prolonged STT when compared to nonsmokers (p = 0.026). STT at admission correlated positively with heart rate (r = 0.560; p = 0.024) and hospital stay (r = 0.634; p = 0.008).

CONCLUSION

Mucociliary clearance is impaired in stable acutely ill patients with no airway manipulation and correlates with simple markers of underlying disease severity. Mucociliary dysfunction may help to explain the increased susceptibility of hospital-acquired respiratory infection in critically ill patients.

[Nosocomial infections in the departments of orthopedics and traumatology]

AIM

To determine the incidence and the localization of nosocomial infections (NI) in the departments of orthopedics and traumatology.

METHODS

A prospective cohort study carried out between February 1 and July 31, 2002 included all of the surgical patients who were hospitalized longer than 48 hours, as well as 30 days after the discharge. The patients were examined and their diagnoses made according to the definition of NI, that was based on the clinical and/or laboratory findings.

RESULTS

Out of 277 hospitalized patients, 78 had a total of 91 NIs. Sixty-seven (85.8%) of the patients had 1 registered NI each, 9 (11.6%) of the patient had 2 NIs each, while only the 2 (2.6%) were with 3 NIs. The incidence of the patients with HAI was 28.2% (95% IP = 22.9-33.5), while the incidence of HAI was 32.8%. The patients who developed a NI were hospitalized almost twice as long as the patients who did not (t test = 6.0, DF = 275, p < 0.001). In regard to the duration of hospitalization, the incidence of NI was 12.3 per 1000 patient-hospital days. The patients operated on most frequently had the surgical-site infections (69.2%). Of 63 infections of the surgical site, 3 patients (4.8%) were diagnosed as having the NI at that localization following the discharge, and then the urinary tract infections, 25.3% (23/91), and sepsis, 5.5% (5/91).

CONCLUSION

Epidemiological surveillance was the first step towards the prevention and the eradication of NI. The results of this study could be of use in planning of the adequate measures for the prevention of NI in the departments of orthopedic surgery.

A donor history of smoking affects early but not late outcome in lung transplantation

BACKGROUND

Liberalization of tobacco exposure history as an exclusion to lung donation has recently occurred to increase donor organ availability. This study investigated the effect of donor smoking status and current and cumulative cigarette dose on early and late outcomes in lung transplantation.

METHODS

From 1995 to 2002, 173 heart-lung and bilateral single-lung transplant recipients were retrospectively reviewed. Seventy-seven (45%) of 173 donors were ever-smokers and 64 of those 77 were current smokers. These were divided into subgroups by current number of cigarettes smoked to investigate acute dose effects and by pack-year to investigate cumulative dose effects. Risks of smoking were assessed by univariate and multivariate hazard regression models.

RESULTS

Univariate analysis revealed that there were significant differences between current and cumulative dose subgroups in early postoperative variables, including Pao2/Fio2 ratio, ventilation time, and intensive care unit stay. Additionally, these variables were dose dependent. There was no significant difference in 3-year survival between never-smokers and ever-smokers (73% versus 64%, P = 0.27), and a rate of decline of survival was similar. There was a trend for the percentage of patients dying of bronchiolitis obliterans syndrome to be lower in the ever-smokers group compared with the never-smokers group (6% versus 11%, respectively). Multivariate analysis revealed current and cumulative smoking as a risk factor for early but not late outcomes.

CONCLUSIONS

Donor smoking history had a significant effect on early outcomes in lung transplantation in a current and cumulative dose-dependent fashion. However, no significant effect on late outcomes, including bronchiolitis obliterans syndrome, was seen.