Risk of Respiratory Complications and Wound Infection in Patients Undergoing Ambulatory Surgery: Smokers versus Nonsmokers

Background: Smoking is considered to be a risk factor for patients undergoing surgery and anesthesia, but it is unclear whether this is applicable to patients undergoing ambulatory surgery. The aim of this study was to determine the risk of respiratory complications and wound infection among smokers.

Methods: The authors studied a random selection of 489 adult patients undergoing ambulatory surgery. Smoking status was determined by self-report and confirmed with end-expired carbon monoxide analysis. The risk of respiratory complications (i.e., desaturation, cough, laryngospasm, bronchospasm, breath-holding, or apnea) and wound infection (i.e., wound redness or discharge +/- positive microbial culture, requiring antibiotic therapy) in smokers versus nonsmokers was ascertained. Odds ratios were estimated from multivariable logistic regression and adjusted for age, gender, body mass index, partner's smoking status, domiciliary smoking exposure, and extent and duration of surgery.

Results: Most smokers continued to smoke up until the day of surgery. Smokers had a higher rate of respiratory complications (32.8%vs. 25.9%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.84;P = 0.038) and wound infection (3.6%vs. 0.6%; odds ratio, 16.3; 95% confidence interval, 1.58-175;P = 0.019). Odds ratios comparing current plus ex-smokers with nonsmokers were of similar magnitude for most of these complications.     

Smoking increases the risk of postoperative wound complications: A propensity score-matched cohort study

Cigarette smoking is associated with surgical complications, including wound healing and surgical site infection. However, the association between smoking status and postoperative wound complications is not completely understood. Our objective was to investigate the effect of smoking on postoperative wound complications for major surgeries. Data were collected from the 2013 to 2018 participant use files of the American College of Surgeons National Surgical Quality Improvement Program database. A propensity score matching procedure was used to create the balanced smoker and nonsmoker groups. Multivariable logistic regression was used to calculate the odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative wound complications, pulmonary complications, and in-hospital mortality associated with smokers. A total of 1 156 002 patients (578 001 smokers and 578 001 nonsmokers) were included in the propensity score matching analysis. Smoking was associated with a significantly increased risk of postoperative wound disruption (OR 1.65, 95% CI 1.56-1.75), surgical site infection (OR 1.31, 95% CI 1.28-1.34), reintubation (OR 1.47, 95% CI 1.40-1.54), and in-hospital mortality (OR 1.13, 95% CI 1.07-1.19) compared with nonsmoking. The length of hospital stay was significantly increased in smokers compared with nonsmokers. Our analysis indicates that smoking is associated with an increased risk of surgical site infection, wound disruption, and postoperative pulmonary complications. The results may drive the clinicians to encourage patients to quit smoking before surgery.     

A study of the impact of long-term tobacco smoking on postoperative intensive care admission

Smoking is a risk factor for intra-operative pulmonary complications and a wide range of postoperative pulmonary, cardiovascular, infection and wound-related complications. These may all lead to unplanned postoperative intensive care admission. We tested the hypothesis that smokers have an increased incidence of postoperative intensive care admission and more postoperative complications than nonsmokers in a general and orthopaedic surgical population. The following information was assessed in 6026 surgical patients: age, sex and smoking status (pack-years), history of heart and lung disease, American Society of Anesthesiologists (ASA) physical classification, intensive care admission and postoperative complications. Two thousand five hundred and twenty-six (46%) were smokers but for 620 patients (10.3%) smoking status was not confirmed. Postoperative intensive care admission was required by 319 patients (5.3%). Patients with > 50 pack-years were admitted to the intensive care more frequently than were smokers with < or = 50 pack-years history and nonsmokers (p < 0.001). Ex-smokers with > 50 pack-years history had the same risk of postoperative admission to intensive care as smokers with > 50 pack-years history. Smokers admitted to intensive care with > 50 pack-years history had a higher incidence of chronic lung disease (p < 0.005) and heavy alcohol consumption (p < 0.001). These smokers also had a higher incidence of postoperative pulmonary complications (odds ratio = 3.91, p < 0.01). The mortality rate was 37% in smokers with > 50 pack-years history and 24% in nonsmokers (odds ratio = 2.02, p = 0.08). We conclude long-term tobacco smoking (> 50 pack-years) carries a higher risk of postoperative admission to intensive care, and there seems to be a dose relationship between the amount of tobacco consumed and the risk of postoperative intensive care admission.     

Determination of the Duration of Preoperative Smoking Cessation to Improve Wound Healing after Head and Neck Surgery

Background: Preoperative smoking cessation has been suggested to be effective in reducing various postoperative complications. However, the optimal duration of preoperative smoking cessation for reducing wound complications is unclear.

Methods: One hundred eighty-eight consecutive patients who underwent reconstructive head and neck surgery at the authors' institution were included in this retrospective study. Information on preoperative smoking habits was obtained from the patients' medical records. Smokers were defined as having smoked within 7 days before surgery. Late, intermediate, and early quitters were defined as patients whose duration of abstinence from smoking was 8-21, 22-42, and 43 days or longer before the operation, respectively. Patients who required postoperative debridement, resuture, or reconstruction of their flap before hospital discharge were defined as having had impaired wound healing.

Results: The incidences (95% confidence intervals) of impaired wound healing among the late, intermediate, and early quitters and nonsmokers were 67.6% (52-83%), 55.0% (33-77%), 59.1% (47-71%), and 47.5% (32-63%), respectively, and the incidence of impaired wound healing was significantly lower among the intermediate quitters, early quitters, and nonsmokers than among the smokers (85.7% [73-97%]). After controlling for sex, age, American Society of Anesthesiologists physical status, operation time, history of diabetes mellitus, chemotherapy, radiation therapy, and the type of flap, the odds ratios (95% confidence intervals) for development of impaired wound healing in the late, intermediate, early quitters, and nonsmokers were 0.31 (0.08-1.24), 0.17 (0.04-0.75), 0.17 (0.05-0.60), and 0.11 (0.03-0.51), respectively, compared with the smokers.     

Determination of the duration of preoperative smoking cessation to improve wound healing after head and neck surgery

BACKGROUND: Preoperative smoking cessation has been suggested to be effective in reducing various postoperative complications. However, the optimal duration of preoperative smoking cessation for reducing wound complications is unclear. METHODS: One hundred eighty-eight consecutive patients who underwent reconstructive head and neck surgery at the authors' institution were included in this retrospective study. Information on preoperative smoking habits was obtained from the patients' medical records. Smokers were defined as having smoked within 7 days before surgery. Late, intermediate, and early quitters were defined as patients whose duration of abstinence from smoking was 8-21, 22-42, and 43 days or longer before the operation, respectively. Patients who required postoperative debridement, resuture, or reconstruction of their flap before hospital discharge were defined as having had impaired wound healing. RESULTS: The incidences (95% confidence intervals) of impaired wound healing among the late, intermediate, and early quitters and nonsmokers were 67.6% (52-83%), 55.0% (33-77%), 59.1% (47-71%), and 47.5% (32-63%), respectively, and the incidence of impaired wound healing was significantly lower among the intermediate quitters, early quitters, and nonsmokers than among the smokers (85.7% [73-97%]). After controlling for sex, age, American Society of Anesthesiologists physical status, operation time, history of diabetes mellitus, chemotherapy, radiation therapy, and the type of flap, the odds ratios (95% confidence intervals) for development of impaired wound healing in the late, intermediate, early quitters, and nonsmokers were 0.31 (0.08-1.24), 0.17 (0.04-0.75), 0.17 (0.05-0.60), and 0.11 (0.03-0.51), respectively, compared with the smokers. CONCLUSIONS: Preoperative smoking abstinence of longer than 3 weeks reduces the incidence of impaired wound healing among patients who have undergone reconstructive head and neck surgery.     

Smoking and cardiovascular outcomes in dialysis patients: the United States Renal Data System Wave 2 study

BACKGROUND: Smoking has received surprisingly little research attention in dialysis populations, a group at monumental cardiovascular risk. METHODS: Medicare claims data were used to study associations between smoking and new-onset cardiovascular outcomes, and death in the prospective, inception Wave 2 cohort (N = 4024), assembled in 1996 and 1997. RESULTS: Of the participants, 56.4% were lifetime nonsmokers, 3.6% were smokers with unknown current status, 20.0% had quit for more than 1 year, 5.8% had quit less than 1 year ago, and 14.2% were current smokers. Subjects with cardiovascular disease at baseline were more likely to be former smokers, less likely never to have smoked and less likely to be current smokers (P < 0.001). Patients were followed until December 31, 1998. When adjustment was made for baseline age, demographic variables, mode of dialysis therapy, and comorbidity, smoking status was associated with new-onset congestive heart failure (adjusted hazards ratio 1.59 comparing current to nonsmokers, P = 0.004), new-onset peripheral vascular disease (adjusted hazards ratio 1.68, P < 0.001), and mortality (adjusted hazards ratio 1.37, P < 0.001). Former smokers, in contrast, had adjusted event risks similar to lifelong nonsmokers. CONCLUSION: Smoking is a major, modifiable, cardiovascular risk factor in patients starting dialysis therapy.     

Cholecystectomy and Wound Complications: Smoking Worsens Risk

Background

In the United States, approximately 800,000 cholecystectomies are performed annually. We sought to determine the influence of preoperative smoking on postcholecystectomy wound complication rates.

Materials and methods

Using the National Surgical Quality Improvement Program database (2005–2011), patients aged ≥18 y who underwent elective open or laparoscopic cholecystectomy (LC) for benign gallbladder disease were identified using current procedural terminology codes. Multivariate regression was performed to determine the association between smoking status and wound complications, by surgical approach.

Results

Of 143,753 identified patients, 128,692 (89.5%) underwent LC, 27,788 (19.3%) were active smokers, and 100,710 (70.2%) were females. Active smokers were younger than nonsmokers (mean + standard deviation age: 44.2 (14.9) versus 51.6 (17.9) years); P < 0.001) and had fewer comorbidities. Within 30-d postcholecystectomy, wound complications were reported in 2011 (1.4%) patients. Compared with nonsmokers, active smokers demonstrated increased odds of wound complications after both open cholecystectomy (odds ratio 1.28; P = 0.010) and LC (odds ratio 1.20; P = 0.020) after adjustment for demographic and clinical characteristics. Having wound complications increased the average postoperative length of stay by 2–4 d (P <0.001).

Conclusions

Active smokers are more likely to develop wound complications after cholecystectomy, regardless of surgical approach. Occurrence of wound complications consequently increases postoperative length of stay. Smoking abstinence before cholecystectomy may reduce the burden associated with wound complications.     

Smokers, Risks, and Complications in Abdominal Dermolipectomy

Cigarette smoke has many detrimental effects on health, with consequences such as cardiovascular diseases, respiratory diseases, and tumors. In plastic surgery, these effects appear during the wound healing process. This retrospective study showed wound healing in 57 patients who had undergone abdominal dermolipectomy surgery. The patients were divided into two groups: smokers and nonsmokers. According to the results, smokers face a great complication risk for surgical wounds, which cause aesthetically more undesirable scars than observed in nonsmokers. The authors hypothesize that abstinence from smoking for 4 to 12 weeks before surgery would improve the quality of the scars.     

Wound healing in reconstructive head and neck surgery

BACKGROUND: Smoking cessation and shorter operative duration are known as factors to improve wound healing in reconstructive head and neck surgery. We investigated the other factors associated with wound healing. METHODS: Informations on age, sex, body mass index, smoking status, serum albumin level, diabetes mellitus, chronic obstructive pulmonary diseases, preoperative steroid therapy, preoperative chemotherapy, preoperative radiation therapy, preoperative starvation care, American Society of Anesthesiologists physical status (ASA-PS), intraoperative administration of prostaglandin E1, operative duration, and type of flap were obtained from the medical records of 370 patients. Requirements of postoperative intervention were also recorded. Factors associated with wound healing were estimated by multivariate analysis. RESULTS: Compared with smokers, 22 to 42 day smoking quitters, over 43 day smoking quitters, and non-smokers had lower incidence of wound complications; odds ratio; 95% confidence intervals (CI) were 0.20; 0.06-0.68, 0.19; 0.07-0.51, and 0.15; 0.05-0.45, respectively. Other factors and odds ratios (95% CI) associated with wound complications were preoperative chemotherapy; 3.02 (1.09-8.41), preoperative starvation; 0.23 (0.06-0.84), every one minute of operation duration; 1.01 (1.00-1.01). CONCLUSIONS: Preoperative smoking cessation, preoperative chemotherapy, preoperative starvation care, and operation duration were significantly associated with wound healings.     

Risk reduction: perioperative smoking intervention

Smoking is a well-known risk factor for perioperative complications. Smokers experience an increased incidence of respiratory complications during anaesthesia and an increased risk of postoperative cardiopulmonary complications, infections and impaired wound healing. Smokers have a greater risk of postoperative intensive care admission. Even passive smoking is associated with increased risk at operation. Preoperative smoking intervention 6-8 weeks before surgery can reduce the complications risk significantly. Four weeks of abstinence from smoking seems to improve wound healing. An intensive, individual approach to smoking intervention results in a significantly better postoperative outcome. Future research should focus upon the effect of a shorter period of preoperative smoking cessation. All smokers admitted for surgery should be informed of the increased risk, recommended preoperative smoking cessation, and offered a smoking intervention programme whenever possible.     

Smoking Cessation has no Influence on Quality of Life in Patients with Peripheral Arterial Disease 5 Years Post-vascular Surgery

ObjectivesSmoking is an important modifiable risk factor in patients with peripheral arterial disease (PAD). We investigated differences in quality of life (QoL) between patients who quitted smoking during follow-up and persistent smokers.DesignCohort study.MethodsData of 711 consecutively enrolled patients undergoing vascular surgery were collected in 11 hospitals in the Netherlands. Smoking status was obtained at baseline and at 3-year follow-up. A 5-year follow-up to measure QoL was performed with the EuroQol-5D (EQ-5D) and Peripheral Arterial Questionnaire (PAQ).ResultsAfter adjusting for clinical risk factors, patients, who quit smoking within 3 years after vascular surgery, did not report an impaired QoL (EQ-5D: odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.28–1.43; PAQ: OR = 0.76, 95% CI = 0.35–1.65; visual analogue scale (VAS): OR = 0.88, 95% CI = 0.42–1.84) compared with patients, who continued smoking. Current smokers were significantly more likely to have an impaired QoL (EQ-5D: OR = 1.86, 95% CI = 1.09–3.17; PAQ: OR = 1.63, 95% CI = 1.00–2.65), although no differences in VAS scores were found (OR = 1.17, 95% CI = 0.72–1.90).ConclusionsThere was no effect of smoking cessation on QoL in PAD patients undergoing vascular surgery. Nevertheless, given the link between smoking, complications and mortality in this patient group, smoking cessation should be a primary target in secondary prevention.     

Adverse events in ambulatory surgery. A comparison between elderly and younger patients

PURPOSE: An increasing number of elderly patients are undergoing ambulatory surgery. We examined whether ambulatory surgery carries a higher risk for the elderly than for younger patients. METHODS: A total of 17,638 consecutive ambulatory surgical patients were enrolled in a prospective cohort study during a three-year period. Preoperative, intraoperative, and postoperative information was collected. Twenty-seven percent of the enrolled patients were 65 yr or older. Incidence rates of intraoperative and postoperative adverse events among the elderly were compared with those among younger patients; we controlled for sex, ASA physical status, body mass index, type of surgery, and duration of procedure, using multiple logistic regression models. RESULTS: Elderly patients had a higher incidence of any intraoperative event (adjusted odds ratio, 1.4; 99.7% confidence interval [CI], 1.0-2.0) and of intraoperative cardiovascular events (adjusted odds ratio, 2.0; 99.7% CI, 1.3-3.0). They also had a lower incidence of any postoperative event (adjusted odds ratio, 0.4; 99.7% CI, 0.3-0.6) and of postoperative pain (adjusted odds ratio, 0.2; 99.7% CI, 0.1-0.4), nausea and vomiting (adjusted odds ratio, 0.3; 99.7% CI, 0.1-0.6), and dizziness (adjusted odds ratio, 0.4; 99.7% CI, 0.2-1.0). CONCLUSION: The risks reported do not constitute a contraindication for elderly patients to undergo ambulatory surgery but this population may require more careful intraoperative cardiovascular management.     

Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis

Purpose

The literature was reviewed to determine the risks or benefits of short-term (less than four weeks) smoking cessation on postoperative complications and to derive the minimum duration of preoperative abstinence from smoking required to reduce such complications in adult surgical patients.

Source

We searched MEDLINE, EMBASE, Cochrane, and other relevant databases for cohort studies and randomized controlled trials that reported postoperative complications (i.e., respiratory, cardiovascular, wound-healing) and mortality in patients who quit smoking within six months of surgery. Using a random effects model, meta-analyses were conducted to compare the relative risks of complications in ex-smokers with varying intervals of smoking cessation vs the risks in current smokers.

Principal findings

We included 25 studies. Compared with current smokers, the risk of respiratory complications was similar in smokers who quit less than two or two to four weeks before surgery (risk ratio [RR] 1.20; 95% confidence interval [CI] 0.96 to 1.50 vs RR 1.14; CI 0.90 to 1.45, respectively). Smokers who quit more than four and more than eight weeks before surgery had lower risks of respiratory complications than current smokers (RR 0.77; 95% CI 0.61 to 0.96 and RR 0.53; 95% CI 0.37 to 0.76, respectively). For wound-healing complications, the risk was less in smokers who quit more than three to four weeks before surgery than in current smokers (RR 0.69; 95% CI 0.56 to 0.84). Few studies reported cardiovascular complications and there were few deaths.

Conclusion

At least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications. Short-term (less than four weeks) smoking cessation does not appear to increase or reduce the risk of postoperative respiratory complications.     

Smoking is Associated with Increased Blood Loss and Transfusion Use After Lumbar Spinal Surgery

Background

Little is known about the association between smoking and intraoperative blood loss and perioperative transfusion use in patients undergoing spinal surgery. However, we found that although many of the common complications and deleterious effects of smoking on surgical patients had been well documented, the aspect of blood loss seemingly had been overlooked despite data reported in nonorthopaedic sources to suggest a possible connection.

Questions/Purposes

We asked: (1) Is smoking associated with increased estimated blood loss during surgery in patients undergoing lumbar spine surgery? (2) Is smoking associated with increased perioperative transfusion usage?

Methods

Between 2005 and 2009, 581 lumbar decompression procedures (with or without fusion) were performed at one academic spine center. Of those, 559 (96%) had sufficient chart documentation to categorize patients by smoking status, necessary intra- and postoperative data to allow analysis with respect to bleeding and transfusion-related endpoints, and who did not meet exclusion criteria. Exclusion criteria included: patients whose smoking status did not fit in our two categories, patients with underlying coagulopathy, patients receiving anticoagulants (including aspirin and platelet inhibitors), history of hepatic disease, history of platelet disorder or other blood dyscrasias, and patient or family history of any other known bleeding disorder. Smoking history in packs per day was obtained for all subjects. We defined someone as a smoker if the patient reported smoking up until the day of their surgical procedure; nonsmokers were patients who quit smoking at least 6 weeks before surgery or had no history of smoking. We used a binomial grouping for whether patients did or did not receive a transfusion perioperatively. Age, sex, number of levels of discectomies, number of levels decompressed, number of levels fused, and use of instrumentation were recorded. The same approaches were used for transfusions in all patients regardless of smoking history; decisions were made in consultation between the surgeon and the anesthesia team. Absolute indications for transfusion postoperatively were: a hemoglobin less than 7 g/dL, continued symptoms of dizziness, tachycardia, decreased exertional tolerance, or hypotension that failed to respond to fluid resuscitation. Multiple linear regression analyses correcting for the above variables were performed to determine associations with intraoperative blood loss, while logistic regression was used to analyze perioperative transfusion use.

Results

After controlling for potentially relevant confounding variables noted earlier, we found smokers had increased estimated blood loss compared with nonsmokers (mean, 328 mL more for each pack per day smoked; 95% CI, 249–407 mL; p < 0.001). We also found that again correcting for confounders, smokers had increased perioperative transfusion use compared with nonsmokers (odds ratio, 13.8; 95% CI, 4.59–42.52).

Conclusions

Smoking is associated with increased estimated surgical blood loss and transfusion use in patients undergoing lumbar spine surgery. Patients who smoke should be counseled regarding these risks and on smoking cessation before undergoing lumbar surgery.

Level of Evidence

Level III, therapeutic study.     

Effect of smoking on early complications after elective orthopaedic surgery

Smoking is an important risk factor for the development of postoperative pulmonary complications after major surgical procedures. We studied 811 consecutive patients who had undergone hip or knee arthroplasty, recording current smoking and drinking habits, any history of chronic disease and such intraoperative factors as the type of anaesthesia and the type and duration of surgery. We recorded any postoperative complications occurring before discharge from hospital. There were 232 smokers (28.6%) and 579 non-smokers. We found that smoking was the single most important risk factor for the development of postoperative complications, particularly those relating to wound healing, cardiopulmonary complications, and the requirement of postoperative intensive care. A delay in discharge from hospital was usual for those suffering a complication. In those patients requiring prolonged hospitalisation (>15 days) the proportion of smokers with wound complications was twice that of non-smokers.     

Smoking and Total Hip Arthroplasty: Increased Inpatient Complications,Costs, and Length of Stay

BackgroundSmoking is a potentially modifiable risk factor that may impact the overall outcomes of total hip arthroplasty (THA). In an era of bundled payments for THA, the purpose of this study was to evaluate, on a national level, the inpatient complications and additional costs of smokers undergoing THA.MethodsThe Nationwide Inpatient Sample was used to identify all primary elective THAs performed in the United States in 2014. This cohort was further stratified by smoking status. Inpatient hospital characteristics, costs, and complications rates were assessed.ResultsThe Nationwide Inpatient Sample had 63,446 admissions recorded for primary THAs in 2014, corresponding to an estimated 317,230 cases nationwide. The smoking rate was 20.7%. Smokers were slightly yet significantly younger than nonsmokers (63.5 years vs 64.8 years; P < .0001). The smoking group had a significantly longer hospital stay and higher total hospital costs (both P < .0001). After using a multivariable logistic model adjusting for age, gender, and comorbidities, smokers were found to have a significantly higher odds ratio (OR [95% confidence interval {CI}]) for myocardial infarction (15.5 [5.0-47.5]), cardiac arrest (10.1 [2.2-47.6]), pneumonia (4.7 [2.4-9.1]), urinary tract infection (1.9 [1.4-2.7]), sepsis (13.1 [3.5-49.0]), acute renal failure (2.9 [2.2-3.7]), discharge to a skilled nursing facility (1.3 [1.2-1.4]), and mortality (11.7 [2.0-70.5]).ConclusionsSmoking remains a highly prevalent and important risk factor for complications in elective primary THA in the United States. Patients who smoke have a significantly higher rate of complications and generate significantly higher postoperative inpatient costs. These findings are important for risk stratification, bundled payment considerations, as well as perioperative patient education and intervention.     

Is it justified to refuse breast reduction to smokers?

INTRODUCTION AND AIMS: There are several studies in the literature suggesting that smoking increases the complication rate in various plastic surgery operations. We did a study on 402 patients to see the effect of smoking on breast reduction. The objective was to raise the controversial issue of whether breast reduction could be refused to smokers who fail to stop smoking in the peri-operative period. MATERIALS AND METHODS: The records of patients who had undergone breast reductions between April 1999 and May 2004 at the Leicester Royal Infirmary, Leicester were reviewed retrospectively for age, body mass index, smoking habits and wound-related complications. RESULTS: A total of 764 breast reductions were performed in 402 patients during this period. Twenty-eight per cent (112) of these patients were smokers. The mean age was 33.9 (range 19-68)+9.5 years in smokers and 34.4 (range 16-73)+10.6 years in non-smokers. About 90% of patients had bilateral breast reductions. Wound-related complications were seen in 35% of smokers as against 13% of non-smokers, P value<0.001. Overall, smokers had a 2.3 x higher chance of developing a complication. The probability of a smoker developing wound infection was 3.3 x more in comparison to a non-smoker. Smokers were also three times more likely to develop T-junction necrosis. CONCLUSION: Smoking increases the complication rate of breast reduction significantly. Hence, patients must be strongly encouraged to quit smoking before surgery and abstain until the wound has completely healed. Stoppage of smoking in the peri-operative period should be adopted as an essential eligibility criterion for breast reduction.     

SMOKING INCREASES THE RISK OF LARGE SCALE FLUID ABSORPTION DURING TRANSURETHRAL PROSTATIC RESECTION

PURPOSE: We studied the association between smoking habits and absorption during transurethral prostatic resection in healthy patients, and in those with medical disease and prostate cancer. MATERIALS AND METHODS: Smoking habits and the presence of medical disease and prostate cancer in 1,034 patients who underwent transurethral prostatic resection were compared with fluid absorption levels. These levels were measured by the ethanol method and surgical blood loss, as determined by a photometer. RESULTS: The incidence of fluid absorption greater than 1,000 ml. was 15.7% in the present smokers, 15.5% in the past and present smokers, and 8.8% in those who had never smoked. Compared to nonsmokers, the relative risk of 1,000 to 2,000 ml. fluid absorbed in past and present smokers was 1.8 (95% confidence interval 1.1 to 2.9). The corresponding relative risk of absorption greater than 2,000 ml. was 2.1 (95% confidence interval 1.1 to 4.3), with the greatest excess risk in present smokers, which was 2.8 (1.3 to 5.9). These differences between smokers and nonsmokers were even greater in the healthiest patients, while being relatively smaller in those with medical disease or prostate cancer. Fluid absorption correlated with the amount of blood lost but the demonstrated association between smoking and fluid absorption (p <0.024) could not be explained by an effect on blood loss. CONCLUSIONS: Past and present smoking increases the risk of large scale fluid absorption during transurethral prostatic resection. A possible reason is that smoking alters vascular growth in the gland.     

Orthopaedic trauma patients and smoking: Knowledge deficits and interest in quitting

BackgroundSmoking is associated with increased complications in fracture care. Smoking cessation has a positive impact on outcomes. It is unknown whether orthopaedic trauma patients understand the ill effects of smoking on fracture care and whether knowledge can improve cessation interest. We hypothesized that (1) smokers less fully understand the negative effects of smoking than do nonsmokers, (2) an increased proportion of orthopaedic trauma patients are further in the process of change to quit smoking, (3) increased knowledge predicts increased readiness to quit, and (4) minimal education through a survey can improve interest in smoking cessation.MethodsSingle-centre cross-sectional cohort survey study. Patients were approached consecutively for participation. Patients 18 years or older with a new fracture in our clinic for follow-up were eligible. Smokers and nonsmokers were included and surveyed regarding demographics. Smokers were asked questions about fractures and general knowledge questions regarding the effects of smoking on health. Smokers’ interest in smoking cessation was assessed with direct questions, and transtheoretical model stage of change was queried before and after survey administration.ResultsOne hundred twelve patients participated (44 smokers, 68 nonsmokers; 75 male patients, 37 female patients). Forty-eight percent of smokers stated that the fracture made them more likely to quit. Smokers answered more questions incorrectly than did nonsmokers (p = 0.003). An increased percentage of smokers were in favourable stages of change compared with a population-based tobacco survey (68% versus 54%, p = 0.008). Survey administration increased interest in quitting in 48%, and 11% modified their stage of change towards quitting. Smokers scoring higher on knowledge questions had more than 2-fold increased odds of being in a favourable stage of change (p = 0.013; odds ratio, 2.13; 95% confidence interval, 1.744–3.855).ConclusionsCompared with nonsmokers, smokers less fully understand the negative effects of smoking on fracture care and general health. A large proportion of orthopaedic trauma patients who smoke are interested in smoking cessation and are possibly further along the pathway to change than expected. Brief education through a survey can increase interest in quitting. Formal education intervention may improve cessation rates and fracture outcomes.     

Smoking is a risk factor for incisional hernia

HYPOTHESIS: A number of risk factors for incisional hernia have been identified, but the pathogenesis remains unclear. Based on previous findings of smoking as a risk factor for wound complications and recurrence of groin hernia, we studied whether smoking is associated with incisional hernia. DESIGN: Cohort study. Clinical follow-up study for incisional hernia 33 to 57 months following laparotomy for gastrointestinal disease. Variables predictive for incisional hernia were assessed by multiple regression analysis. SETTING: Department of Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark. PATIENTS: All 916 patients undergoing laparotomy from 1997 through 1998. Surgeons performed clinical examination in 310 patients; patients who failed to meet for examination, died, or were lost to follow-up were excluded. MAIN OUTCOME MEASURES: Thirty-four variables related to patient history, preoperative clinical condition, operative severity and findings, and the surgeon's training. RESULTS: The incidence of incisional hernia was 26% (81/310). Smokers had a 4-fold higher risk of incisional hernia (odds ratio [OR], 3.93 [95% confidence interval (CI), 1.82-8.49]) independent of other risk factors and confounders. Relaparotomy was the strongest factor associated with hernia (OR, 5.89 [95% CI, 1.78-19.48]). Other risk factors were postoperative wound complications (OR, 3.91 [95% CI, 1.99-7.66]), age (OR, 1.04 [95% CI, 1.02-1.06]), and male sex (OR, 2.17 [95% CI, 1.21-3.91]). CONCLUSION: Smoking is a significant risk factor for incisional hernia in line with relaparotomy, postoperative wound complications, older age, and male sex.