Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial

Modifying Risk Factors for Total Joint Arthroplasty: Strategies That Work Nicotine

Smoking and nicotine use remain a major health care crisis in the United States. Although rates have dropped dramatically over the last 50 years, approximately 18% of the US adult population still smokes. The musculoskeletal effects of nicotine and other byproducts of smoking place patients at increased risk for perioperative complications including medical complication, wound healing problems, infection, and death. A comprehensive behavioral modification program with or without the use of nicotine replacement therapy has been shown to be most effective at smoking cessation around the time of planned surgery. Although literature suggests that smoking cessation 4-6 weeks before surgery can diminish risk, both current and former smokers are at increased risk for perioperative complications compared with those that have never smoked. Cotinine, a metabolite of nicotine, can be used to monitor smoking cessation before surgery.

Preinjury Aerobic Fitness Predicts Postoperative Outcome and Activity Level After Acetabular Fracture Fixation

OBJECTIVES

To investigate whether aerobic fitness as determined by preoperative metabolic equivalents (METS) better predicts postoperative functional outcomes after open reduction and internal fixation (ORIF) of acetabular fractures than chronologic age.

DESIGN

Retrospective review.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

A total of 157 patients underwent open surgical treatment for acetabular fracture between January 2005 and December 2013 with age ≥18 years and minimum 1-year follow-up inclusive of imaging, functional outcome scores, and complications.

INTERVENTION

ORIF of acetabular fracture.

MAIN OUTCOME MEASUREMENTS

Final postoperative functional outcomes as assessed with the University of California Los Angeles activity score and the Western Ontario and McMaster Universities Osteoarthritis Index.

RESULTS

Multivariate logistic regression analysis demonstrated elevated preinjury METS, female gender, and lower injury severity score (<18) to be significant independent factors predictive of improved functional outcome per the University of California Los Angeles score. Similarly, preinjury METS were identified as significant predictors for improved Western Ontario and McMaster Universities Osteoarthritis Index scores for both the stiffness and physical function components. Chronologic age was not a significant predictor for any functional outcome score. Furthermore, a Pearson correlation analysis demonstrated a weak relationship between preoperative METS and chronologic age (r = -0.346).

CONCLUSIONS

Pre-operative aerobic fitness as determined by METS may prove to be a superior prognostic factor for predicting postoperative functional outcome after acetabular fracture fixation than chronologic age. Consideration of aerobic fitness, in addition to other established prognostic factors, may be useful to patients and surgeons for injury counseling purposes.

LEVEL OF EVIDENCE

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

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

BACKGROUND

Smoking 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.

METHODS

Single-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.

RESULTS

One 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).

CONCLUSIONS

Compared 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.

Effects of Smoking Status on Device Survival Among Individuals Undergoing Artificial Urinary Sphincter Placement

Smoking is an established risk factor for wound complications. There is limited data on the impact of smoking on artificial urinary sphincter (AUS) outcomes. Thus, the aim of this study was to assess AUS device survival outcomes based on smoking status. From 1985 to 2014, 1,270 patients underwent AUS placement with 728 having smoking status available for review. Smoking status was categorized as never, prior, and active smokers. Kaplan-Meier analysis was performed to evaluate differences in survival, including overall device and erosion/infection-free survival. Hazard regression analysis was utilized to determine the association between smoking and device outcomes. Of the 728 patients in the study, 401 had a history of smoking with 41 active smokers and 360 never smokers at the time of AUS implant. When compared with nonsmokers, past smokers had a higher rate of hypertension and prior transient ischemic attack. Clinical comorbidities were similar between nonsmokers and active smokers. On univariate analysis, patient age, history of transient ischemic attack, diabetes, and coronary artery disease were significantly associated with infection/erosion rate, but prior or active smoking statuses were not. Likewise, when comparing smokers (past or active) with lifelong nonsmokers, there was no significant difference in 1- and 5-year overall device survival. There was no evidence for adverse AUS outcomes in current or past smokers compared with nonsmokers. Given the established risk of perioperative complications secondary to smoking, the recommendation should still be to counsel patients to quit prior to undergoing AUS placement. External validation of these findings is needed.

Behavior, knowledge, and attitude of surgeons and patients toward preoperative smoking cessation

INTRODUCTION:

Tobacco smoking is a well-known risk factor for postoperative complications. Quitting smoking prior to surgery helps overcome those complications.

PROBLEM:

Surgeons' attention for educating their patients about the importance of smoking cessation prior to surgery is one of the most effective ways to reduce smoking-related surgical complications. The extent of advised patients by their surgeons has not been identified.

METHODS:

A descriptive, comparative cross-sectional study using a survey was conducted in 2013 including eligible patients in King Khalid University Hospital. Simultaneously, 69 surgeons were included. All participant data were randomly collected and analyzed using Chi-square analysis.

RESULTS:

The frequency of smokers is more in surgical patients (37.5%) when compared to ex-smokers (12.5%) and passive smokers (8.3%), which were ex- and passive smokers, and it demonstrated an increased risk (P = 0.001) for surgery group compared to the nonsurgery group (P = 0.001). When comparing with nonsurgery group, most surgical patients agreed to quit smoking before surgery (95.3%). More than half (58.8%) of the patients said that they have been advised by their treating surgeons to quit smoking before surgery. Concerning the surgeons, 66 nonvascular and nonpediatric surgeons responded to the questionnaire (response rate: 22.83%). The majority of the surgeons (60.9%) were interacting with smoker patients. With regard to smoking cessation, 69.6% surgeons have advised smoker patients to stop smoking for more than 2 weeks before surgery. More than half of the surgeons (53.6%) believed that patients quit smoking after preoperative smoking cessation advice.

CONCLUSION:

The surgeons and patients who participated in this study were aware that smoking cessation improves outcomes, but most of the surgeons did not provide brief advice about time duration to stop smoking.

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.

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

STUDY DESIGN

A retrospective review of prospectively collected data.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

3.

Clinical pathway for thoracic surgery in the United States

The paradigm for postoperative care for thoracic surgical patients in the United States has shifted with efforts to reduce hospital length of stay and improve quality of life. The increasing usage of minimally invasive techniques in thoracic surgery has been an important part of this. In this review we will examine our standard practices as well as the evidence behind both general contemporary postoperative care principles and those specific to certain operations.

Using implementation science to help integrate preoperative evidence-based measures into practice for vascular surgery patients

The preoperative workup is a necessary and crucial evaluation for patients undergoing major vascular surgery. It is important to assess for likelihood of perioperative adverse events and then implement evidence-based measures to reduce identified medical comorbidities and improve the quality of patient care and outcomes after surgery. Although there are numerous opportunities to implement evidence-based processes during the preoperative period, there are many barriers that can prevent vascular surgeons from achieving these goals. This review will discuss how an implementation science-based approach can be used by members of the vascular surgery team to identify appropriate preoperative evidence-based interventions for diverse practice settings and to overcome barriers and allow integration of these interventions as part of the routine preoperative workup.

Infection in Orthopaedics

Infection in orthopaedic trauma patients is a common problem associated with significant financial and psychosocial costs, and increased morbidity. This review outlines technologies to diagnose and prevent orthopaedic infection, examines implant-related infection and its management, and discusses the treatment of post-traumatic osteomyelitis. The gold standard for diagnosing infection has a number of disadvantages, and thus new technologies to diagnose infection are being explored, including multilocus polymerase chain reaction with electrospray ionization-mass spectrometry and optical imaging. Numerous strategies have been employed to prevent orthopaedic infection, including use of antibiotic-impregnated implant coatings and cement; however, further research is required to optimize these technologies. Biofilm formation on orthopaedic implants is attributed to the glycocalyx-mediated surface mode of bacterial growth and is usually treated through a secondary surgery involving irrigation, debridement and the appropriate use of antibiotics, or complete removal of the infected implant. Research into the treatment of post-traumatic osteomyelitis has focused on developing an optimal local antibiotic delivery vehicle, such as antibiotic-impregnated polymethylmethacrylate (PMMA) cement beads or bioabsorbable bone substitute (BBS) delivery systems. As these new technologies to diagnose, prevent and treat orthopaedic infection advance, the incidence of infection will decrease and patient care will be optimized.

Risk Factors for Infection Following Total Knee Arthroplasty: A Series of 3836 Cases from One Institution

Higher PJI rates may be related to identifiable risk factors, which may or may not be modifiable. Identifying risk factors preoperatively provides opportunities for modification and potentially decreasing the incidence of PJI. The purposes of this study were to: (1) retrospectively identify and quantify risk factors for PJI following primary TKA, and (2) to classify those significant risk factors as either non-modifiable or modifiable for intervention prior to surgery. Optimization of modifiable risk factors such as Staphylococcus aureus colonization, and tobacco use prior to primary TKA may decrease the incidence of periprosthetic joint infection after primary TKA, thereby reducing morbidity and the costs associated with treating those infections.

Identifying and recruiting smokers for preoperative smoking cessation--a systematic review of methods reported in published studies

BACKGROUND

Smoking cessation before surgery reduces postoperative complications, and the benefit is positively associated with the duration of being abstinent before a surgical procedure. A key issue in providing preoperative smoking cessation support is to identify people who smoke as early as possible before elective surgery. This review aims to summarise methods used to identify and recruit smokers awaiting elective surgery.

METHODS

We searched MEDLINE, EMBASE, CINAHL, and PsycINFO, and references of relevant reviews (up to May 2014) to identify prospective studies that evaluated preoperative smoking cessation programmes. One reviewer extracted and a second reviewer checked data from the included studies. Data extracted from included studies were presented in tables and narratively described.

RESULTS

We included 32 relevant studies, including 18 randomised controlled trials (RCTs) and 14 non-randomised studies (NRS). Smokers were recruited at preoperative clinics (n = 18), from surgery waiting lists (n = 6), or by general practitioners (n = 1), and the recruitment methods were not explicitly described in seven studies. Time points of preoperative recruitment of smokers was unclear in four studies, less than 4 weeks before surgery in 17 studies, and at least 4 weeks before surgery in only 11 studies. The recruitment rate tended to be lower in RCTs (median 58.2 %, range 9.1 to 90.9 %) than that in NRS (median 99.1 %, range 12.3 to 100 %) and lower in preoperative clinic-based RCTs (median 54.4 %, range 9.1 to 82.4 %) than that in waiting list-based RCTs (median 70.1 %, range 36.8 to 85.0 %). Smokers were recruited at least 4 weeks before surgery in four of the six waiting list-based studies and in only three of the 18 preoperative clinic-based studies.

CONCLUSIONS

Published studies often inadequately described the methods for recruiting smokers into preoperative smoking cessation programmes. Although smoking cessation at any time is beneficial, many programmes recruited smokers at times very close to scheduled surgery so that the benefit of preoperative smoking cessation may have not been fully effected. Optimal delivery of preoperative smoking cessation remains challenging, and further research is required to develop effective preoperative cessation programmes for smokers awaiting elective operations.

Patient-related medical risk factors for periprosthetic joint infection of the hip and knee

Despite advancements and improvements in methods for preventing infection, periprosthetic joint infection (PJI) is a significant complication following total joint arthroplasty (TJA). Prevention is the most important strategy to deal with this disabling complication, and prevention should begin with identifying patient-related risk factors. Medical risk factors, such as morbid obesity, malnutrition, hyperglycemia, uncontrolled diabetes mellitus, rheumatoid arthritis (RA), preoperative anemia, cardiovascular disorders, chronic renal failure, smoking, alcohol abuse and depression, should be evaluated and optimized prior to surgery. Treating patients to get laboratory values under a specified threshold or cessation of certain modifiable risk factors can decrease the risk of PJI. Although significant advances have been made in past decades to identify these risk factors, there remains some uncertainty regarding the risk factors predisposing TJA patients to PJI. Through a review of the current literature, this paper aims to comprehensively evaluate and provide a better understanding of known medical risk factors for PJI after TJA.

Smoking cessation strategies in vascular surgery

Tobacco abuse is a highly prevalent modifiable risk factor in vascular surgery patient populations. Despite the known benefits of smoking cessation, quitting smoking is difficult for most patients. Physician advice to stop smoking can help, though more intensive or multifactorial interventions have greater impact. Smoking cessation initiatives based in vascular clinics are feasible, although currently there is significant variation in physician delivery of smoking cessation interventions. Vascular surgeons are optimally poised to be able to capitalize on the "teachable moment" of the vascular procedure to encourage smoking cessation. Concise and effective smoking cessation strategies include standardized physician "very brief advice" (a standardized advice delivery developed and validated by the National Health Service), referral to telephone counseling, and prescription of pharmacotherapy, all of which are best utilized together. This review will discuss different smoking cessation strategies, as well as their inclusion in multicenter trials designed to study delivery of smoking cessation interventions in vascular surgery patients.

Perioperative smoking cessation in vascular surgery: challenges with a randomized controlled trial

Background

The effect of intensive smoking cessation programs on postoperative complications has never before been assessed in soft tissue surgery when smoking cessation is initiated on the day of surgery.

Methods

A single-blinded randomized clinical trial conducted at two vascular surgery departments in Denmark. The intervention group was offered the Gold Standard Program (GSP) for smoking cessation intervention. The control group was offered the departments’ standard care. Inclusion criteria were patients with planned open peripheral vascular surgery and who were daily smokers. According to the power calculation a total of 144 patients were needed in the trial.

Results

Due to slow patient inclusion, the trial was terminated prior to fulfilling the power calculation. Thirty-two patients were included in the trial from March 2011 to September 2012. Of these, 11 were randomized to the GSP intervention and 21 as controls. There was no difference in 30-day complication rates or 6-week abstinence rates between the two groups.

Conclusions

A trial assessing the effect of smoking cessation on postoperative complications on the day of soft tissue surgery is still needed. If another trial is to be planned it must be more pragmatic with less extended inclusion criteria and conducted nationally or internationally to ensure enough patients for the trial.

Trial registration

ClinicalTrials.gov (NCT01469091). Registration date: 27 October 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0965-x) contains supplementary material, which is available to authorized users.

Preoperative smoking cessation can reduce postoperative complications in gastric cancer surgery

BACKGROUND

Despite the close link between cigarette smoking and the development of gastric cancer, little is known about the effects of cigarette smoking on surgical outcomes after gastric cancer surgery. The aim of this study was to investigate whether preoperative smoking status and the duration of smoking cessation were associated with short-term surgical consequences in gastric cancer surgery.

METHODS

Among 1,489 consecutive patients, 1,335 patients who underwent curative radical gastrectomy at the Samsung Medical Center between January and December 2009 were included in the present study. The smoking status was determined using questionnaires before surgery. Smokers were divided into four groups according to the duration of smoking cessation preoperatively (<2, 2-4, 4-8, and >8 weeks). The primary endpoint was postoperative complications (wound, lung, leakage, and bleeding); secondary endpoints were 3-year recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Five hundred twenty-two patients (39.1 %) were smokers. Smokers had a significantly higher overall incidence of postoperative complications than nonsmokers (12.3 vs. 5.2 %, P < 0.001, respectively), especially in impaired wound healing, pulmonary problems, and leakage. Smokers also had more severe complications than nonsmokers. After adjusting for other risk factors, the odds ratio (95 % CI) for the development of postoperative complications in the subgroups who stopped smoking <2 weeks, 2-4, 4-8, and >8 weeks preoperatively were 3.35 (1.92-5.83), 0.99 (0.22-4.38), 2.18 (1.00-4.76), and 1.32 (0.70-2.48), respectively, compared with the nonsmokers. There were no significant differences in 3-year RFS (P = 0.884) and OS (P = 0.258) between smokers and nonsmokers.

CONCLUSIONS

Preoperative smoking cessation for at least 2 weeks will help to reduce the incidence of postoperative complications in gastric cancer surgery.

Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care in Geriatric Patients

Introduction:

We examined rates of smoking cessation and the effect of smoking cessation on pain and disability scores in a geriatric patient population.

Methods:

Prospectively maintained database records of 6779 patients treated for painful spinal disorders were examined. The mean duration of care was 8 months. Multivariate statistical analysis was performed with independent variables including smoking status, secondary gain status, gender, treatment type, depression, and age.

Results:

Of the patients seeking care for painful spinal disorders, 8.9% over the age of 55 smoked compared with 23.9% of those under 55 years of age. Rates of smoking cessation did not differ for those older than 55 years (25.1%) and younger patients (26.1%). Current smokers in both age-groups reported greater pain than those who had never smoked in all pain ratings (P < .001). Mean improvement in reported pain over the course of treatment was significantly different in nonsmokers and current smokers in both age-groups (P < .001). Those who quit smoking during the course of care reported greater improvement in pain than those who continued to smoke. The mean improvement in pain ratings was clinically significant in patients in all 3 groups of nonsmokers whereas those who continued to smoke had no clinically significant improvement in reported pain.

Conclusion:

The results support the need for smoking cessation programs, given a strong association between improved patient-reported pain and smoking cessation. Fewer older patients smoke but they are equally likely to quit.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Decision Aid for Cigarette Smokers Scheduled for Elective Surgery

BACKGROUND

Decision aids can increase patient involvement in decision-making about health care. The study goal was to develop and test a decision aid for use by clinicians in discussion options for changing smoking behavior before and after elective surgery.

METHODS

In formative work, a decision aid was designed to facilitate patient-clinician discussion regarding three options: continue smoking, attempt a period of temporary abstinence, and attempt to quit smoking for good. A randomized, two-group pilot study was then conducted in smokers evaluated in preparation for elective surgery in a preoperative clinic to test the hypothesis that the decision aid would improve measures of decisional quality compared with usual care.

RESULTS

The final decision aid consisted of three laminated cards. The front of each card included a colorful graphic describing each choice; the reverse including two to three pros and cons for each decision, a simple graphic illustrating the effects of smoking on the body, and a motivational phrase. In the randomized trial of 130 patients, the decision aid significantly (P < 0.05) improved measures of decisional quality and patient involvement in decision making (Cohen's d effect sizes of 0.76 and 1.20 for the Decisional Conflict Scale and Observing PatienT involvement In decisiON-making scale, respectively). However, the decision aid did not affect any aspect of perioperative smoking behavior, including the distribution of or adherence to choices.

CONCLUSIONS

Although the use of a decision aid to facilitate clinician-patient discussions regarding tobacco use around the time of surgery substantially improved measures of decisional quality, it alone did not change perioperative tobacco use behavior.

Predictive factors of length of hospital stay after primary total knee arthroplasty

PURPOSE

To reduce post-operative length of hospital stay (PLOS) after primary total knee arthroplasty (TKA), the fast-track method was introduced which focusses on mobilising the patient within 2 h after surgery. The aim of this prospective study was to identify the factors that predict PLOS using the fast-track method.

METHODS

In a consecutive series from July 2012 to November 2012, all patients who were admitted for a primary TKA (Genesis II prosthesis, Smith and Nephew, Memphis, TN) were included in a prospective study. Demographic and relevant preoperative, perioperative and post-operative parameters for PLOS were collected. Multivariate linear regression analysis was performed to identify predictive factors.

RESULTS

In total, 240 patients were included (59.6% female) with a median age of 64.1 years (range 38-90). Median PLOS was 5 days (range 3-19). The predictive model suggested that ASA score (American Society of Anesthesiologists' physical status classification) wound exudate and range of motion (ROM) at the day of surgery (day 0) were significant predictive factors for PLOS using the fast-track procedure after TKA (adjusted R(2) = 0.43).

CONCLUSIONS

Predictive factors for PLOS after TKA were ASA score, wound exudate and ROM at day 0. Adjustments in patient counselling, nursing ward, mode of physiotherapist training and discharge criteria regarding wound exudate may result in a further reduction of post-operative length of hospital stay.

LEVEL OF EVIDENCE

Prognostic studies: high-quality prospective cohort study, Level I.

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.

Cigarette smoking increases complication rate in forefoot surgery

BACKGROUND

Cigarette smoking is known to increase perioperative complication rates, but no study to date has examined its effect specifically in forefoot surgery. The purpose of this study was to determine whether cigarette smoking increased complications after forefoot surgery.

METHODS

The records of 602 patients who had forefoot surgery between 2008 and 2010, and for whom smoking status was known, were reviewed. Patients were categorized into 3 groups based on smoking status: active smoker, smoker in the past, or nonsmoker. Medical records were reviewed for occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain.

RESULTS

Active smokers were found to have a notably higher complication rate (36.4%) after forefoot surgery than patients who previously (16.5%) or never (8.5%) smoked. Patients who continued to smoke in the perioperative period had the highest percentage of delayed union (3.0%), infection (9.1%), delayed wound healing (10.6%), and persistent pain (15.2%). Active cigarette smokers were 4.3 times more likely to have a complication than nonsmokers. Patients who smoked at any point in the past but quit prior to surgery were 1.9 times more likely than nonsmokers to incur a complication. The average time of smoking cessation for patients who had smoked at any point in the past but had quit prior to surgery was 17 years. For active smokers, those with a complication smoked an average of 18 cigarettes daily, while those without a complication smoked 14 cigarettes daily.

CONCLUSIONS

Before forefoot surgery, surgeons should educate patients who smoke about their increased risk of complications and encourage smoking cessation.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

What is the role of lifestyle behaviour change associated with non-communicable disease risk in managing musculoskeletal health conditions with special reference to chronic pain?

Background

Other than activity and exercise, lifestyle practices such as not smoking and healthy nutrition, well established for preventing and managing lifestyle-related non-communicable diseases (i.e., heart disease, cancer, hypertension, stroke, obstructive lung disease, diabetes, and obesity), are less emphasized in the physical therapy guidelines for addressing chronic pain, e.g., back pain. This state-of-the-art review examines the relationships between lifestyle behaviours and musculoskeletal health, with special reference to chronic pain, and their clinical and research implications.

Discussion

A state-of-the-art review was conducted to synthesize evidence related to lifestyle factors (not smoking, healthy diet, healthy weight, optimal sleep and manageable stress, as well as physical activity) and musculoskeletal health, with special reference to chronic pain. The findings support that health behaviour change competencies (examination/assessment and intervention/treatment) may warrant being included in first-line management of chronic pain, either independently or in conjunction with conventional physical therapy interventions. To address knowledge gaps in the literature however three lines of clinical trial research are indicated: 1) to establish the degree to which traditional physical therapy interventions prescribed for chronic pain augment the benefits of lifestyle behaviour change; 2) to establish the degree to which adopting healthier lifestyle practices, avoids or reduces the need for conventional physical therapy; and 3) to establish whether patients/clients with healthier lifestyles and who have chronic pain, respond more favourably to conventional physical therapy interventions than those who have less healthy lifestyles.

Summary

Lifestyle behaviour change is well accepted in addressing lifestyle-related non-communicable diseases. Compelling evidence exists however supporting the need for elucidation of the role of negative lifestyle behaviours on the incidence of chronic pain, and the role of positive lifestyle behaviours on its incidence and effective management. Addressing lifestyle behaviour change in patients/clients with chronic pain, e.g., back pain, as a first-line intervention might not only constitute a novel approach, but also reduce the socioeconomic burden related to chronic pain as well as non-communicable diseases.

Risk of perioperative respiratory complications and postoperative morbidity in a cohort of adults exposed to passive smoking

OBJECTIVE

To evaluate the risks of perioperative respiratory complications and postoperative morbidity associated with active and passive cigarette smoking.

BACKGROUND

Environmental tobacco smoke is associated with perioperative respiratory events in children, but its effect in adults is unknown.

METHODS

We conducted a cohort study of 736 adult patients receiving general anesthesia for major elective surgery. Patients were classified according to their self-reported smoking history and urinary cotinine concentration within 48 hours before surgery. The main outcomes were composite measures of perioperative respiratory complications and postoperative morbidity on the third day after surgery.

RESULTS

There were 313 (42.5%) never-smokers (reference group), 92 (12.5%) passive nonsmokers, 157 (21.3%) ex-smokers without environmental tobacco smoke exposure, 53 (7.2%) passive ex-smokers, and 121 (16.4%) smokers. The incidence of perioperative respiratory complications and postoperative morbidity was 9.5% [95% confidence interval (CI), 7.5-11.8] and 29.2% (95% CI, 26.0-32.6), respectively. Smoking was significantly associated with an increased risk of perioperative respiratory complications [relative risk (RR), 4.40; 95% CI, 2.20-8.80] and postoperative morbidity (RR, 1.86; 95% CI, 1.22-2.83). Although passive smoking was not associated with the risk of perioperative respiratory complications, the risk of postoperative morbidity was increased in passive nonsmokers (RR, 1.51; 95% CI, 1.04-2.21) and passive ex-smokers (RR, 2.21; 95% CI, 1.39-3.50).

CONCLUSIONS

One in 5 adults was exposed to environmental tobacco smoke before surgery. Passive cigarette smoking showed very little, if any, increased risk of perioperative respiratory complications. Both active exposure and passive exposure to cigarette smoke increased the risk of postoperative morbidity.

Factors associated with conversion from laparoscopic to open colectomy using the National Surgical Quality Improvement Program (NSQIP) database

AIM

Conversion rates from laparoscopic to open colectomy and associated factors are traditionally reported in clinical trials or reviews of outcomes from experienced institutions. Indications and selection criteria for laparoscopic colectomy may be more narrowly defined in these circumstances. With the increased adoption of laparoscopy, conversion rates using national data need to be closely examined. The purpose of this study was to use data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify factors associated with conversion of laparoscopic to open colectomy at a national scale in the United States.

METHOD

The ACS-NSQIP Participant Use Data Files for 2006-2011 were used to identify patients who had undergone laparoscopic colectomy. Converted cases were identified using open colectomy as the primary procedure and laparoscopic colectomy as 'other procedure'. Preoperative variables were identified and statistics were calculated using sas version 9.3. Logistic regression was used to model the multivariate relationship between patient variables and conversion status.

RESULTS

Laparoscopy was successfully performed in 41 585 patients, of whom 2508 (5.8%) required conversion to an open procedure. On univariate analysis the following factors were significant: age, body mass index (BMI), American Society of Anesthesiologists (ASA) class, presence of diabetes, smoking, chronic obstructive pulmonary disease, ascites, stroke, weight loss and chemotherapy (P < 0.05). The following factors remained significant on multivariate analysis: age, BMI, ASA class, smoking, ascites and weight loss.

CONCLUSION

Multiple significant factors for conversion from laparoscopic to open colectomy were identified. A novel finding was the increased risk of conversion for underweight patients. As laparoscopic colectomy is become increasingly utilized, factors predictive of conversion to open procedures should be sought via large national cohorts.

Surgical site infections (SSIs) after stoma reversal (SR): risk factors, implications, and protective strategies

BACKGROUND

Stoma reversals (SRs) are commonly performed with potentially significant postoperative complications including surgical site infections (SSIs). Our aim was to determine the incidence and risk factors for SSIs in a large cohort of SR patients.

DESIGN

We reviewed our institutional 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 30-day SSIs in patients undergoing SR. Records were additionally reviewed for 10 non-ACS-NSQIP variables. The primary outcome was SSI after SR. Secondary outcomes were additional 30-day postoperative complications and length-of-stay. Predictors of SSIs were identified using multivariable logistic regression.

RESULTS

From 528 SR patients, 36 patients developed a SSI (6.8 %). Most patients underwent SR for loop ileostomies (76.5 %) after index operations for ulcerative colitis (38.6 %) and colorectal cancer (27.8 %). SSI patients had fewer subcutaneous drains compared to patients with no SSI and had significantly higher rates of smoking, ASA 3-4 classification and laparotomies at SR (p < 0.05). Patients with SSI had increased length-of-stay and 30-day morbidities including sepsis and returns to the operating room (p < 0.05) compared to no-SSI patients. On multivariable analysis, subcutaneous drain placement was suggestive of SSI protection (odds ratio [OR] 0.52, 95 % confidence interval [CI] 0.2-1.1), but only smoking was significantly associated with an increased risk for SSI (OR 2.4, 95 % CI 1.1-5.4).

CONCLUSIONS

Smoking increased the risk of SR SSIs in patients by over twofold, and SR SSIs are associated with additional significant morbidities. Smoking cessation should be an important part of any SSI risk-reduction strategy.

Cigarette smoking increases risk of early morbidity after hepatic resection in patients with hepatocellular carcinoma

AIMS

Cigarette smoking is an important risk factor for the development of postoperative pulmonary complications after major surgical procedures. The objective of this study was to investigate whether preoperative smoking has any impact on early morbidity after liver resection for hepatocellular carcinoma (HCC).

METHODS

Data of 425 consecutive patients undergoing partial hepatectomy for HCC was retrospectively reviewed. Smoking and drinking habits, biochemical tests, tumor status, operation data, and any postoperative complications occurring before discharge from the hospital were documented. The risk factors promoting postoperative complications were analyzed by univariate and multivariate methods.

RESULTS

The overall morbidity rate was 40% (170 of 425). 166 patients were current smokers (39%). By multivariate analysis, liver cirrhosis (Risk Ratio (RR) 4.0, 95% confidence interval (CI) 2.0-8.0), smoking status (RR 3.0, 95% CI 1.7-5.1), PY of smoking (RR 1.3, 95% CI 1.1-1.9), preoperative platelet count (RR 1.6, 95% CI 1.4-2.0) and major hepatectomy (RR 1.4, 95% CI 1.1-1.8) were independent risk factors of postoperative morbidity (all p < 0.05). Liver failure, bile leakage, intractable ascites, chest and wound infection were more frequently occurred in smokers than non-smokers. Current smokers had higher postoperative morbidity than non- & former smokers in patients with normal liver and those with liver cirrhosis (p = 0.047 and p < 0.001, respectively).

CONCLUSIONS

Cigarette smoking is an independent risk factor for the development of liver-related and infectious complications in patients undergoing partial hepatectomy for HCC, especially in those with liver cirrhosis.

Perioperative Microbiologic Monitoring of Sputum on Postoperative Day One as a Predictor of Pneumonia After Hepatectomy

BACKGROUND

The purpose of this study was to retrospectively evaluate microbial examination of sputum on postoperative day one (POD1) and to determine risk factors for postoperative pneumonia (POP) after hepatectomy.

METHODS

Two hundred ninety-four patients who expectorated sputum on POD1 after hepatectomy between 2003 and 2014 were investigated. Sputum samples were submitted for microbial examination. Risk factors for POP were identified using multivariable analysis.

RESULTS

One hundred fifty-eight (53.7%) of 294 patients had bacteria in their sputum on POD1. POP was observed in 24 (8.2%) patients, with increased mortality in the patients with POP (0.74 vs 12.5%, p < 0.01). Multivariate analysis demonstrated that a Brinkman index of >400 and bacteria in sputum on POD1 were independent risk factors for POP. Bacterial homology in sputum obtained on POD1 and onset day of POP was found in 13 of the 24 (54.2%) patients with POP. In particular, in 13 patients with POP caused by methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa, homology was confirmed in 9 patients (69.2%).

CONCLUSION

A Brinkman index ≥400 and bacteria in sputum on POD1 increased the risk of POP. Presence of bacteria in sputum on POD1 may be useful in determining early treatment against POP after hepatectomy.

Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter?

BACKGROUND

Recent studies have questioned the efficacy of meniscectomy in older patients with and without evidence of osteoarthritis; however, it continues to be frequently performed. There is limited information about age and other risk factors for adverse events and readmission after the procedure. This knowledge is vital to understand the true risk profile of this common surgery.

PURPOSE

To investigate if age and medical comorbidities were risk factors for postoperative adverse events and readmission after meniscectomy.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients who underwent arthroscopic meniscectomy between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Age≥65 years and medical comorbidities were evaluated as risk factors for any adverse event (AAE), severe adverse events (SAEs), and readmission after meniscectomy using univariate and multivariate analyses.

RESULTS

A total of 17,774 patients who underwent meniscectomy were identified. The mean age was 53.0±13.6 years. A total of 3420 patients (19.2%) were ≥65 years. Overall, 208 patients (1.17%) had AAE, 203 patients (1.14%) had an SAE, and 102 patients were readmitted (0.97%). Multivariate logistic regression analyses demonstrated no significant differences between age groups for the occurrence of AAE, SAEs, and readmission. Patients with American Society of Anesthesiologists classification≥3 had increased odds of AAE (odds ratio [OR], 1.58), SAEs (OR, 1.59), and readmission (OR, 1.99). Patients with diabetes had increased odds of AAE (OR, 1.57) and SAEs (OR, 1.51). Smokers had increased odds of readmission (OR, 1.67). Patients with pulmonary disease had increased odds of AAE (OR, 1.76) and SAEs (OR, 1.70).

CONCLUSION

Meniscectomy is a safe procedure in older patients, as age over 65 years did not increase the odds of any of the adverse events studied. However, regardless of age, patients with an increased comorbidity burden and those with a history of smoking are at increased risk of adverse events and/or readmission after the procedure.

CLINICAL RELEVANCE

Knowledge of these risk factors for adverse events and readmission provides essential information for patient selection and preoperative counseling.

Surgical site infections

Surgical site infections are a major contributor to morbidity and mortality in postsurgical care. Risk for surgical site infection is multifactorial and includes a host of microbial, patient-related, and procedure-related factors. Prevention of surgical infection relies on optimization of patient factors and use of a variety of evidence-based pharmacologic and nonpharmacologic measures. At the forefront of these measures is antimicrobial prophylaxis, which has been shown to be effective at reducing risk of surgical site infection. As guidelines for prevention of surgical site infection become increasingly complex and nuanced, surgical infection outcomes are increasing tied to quality outcome and performances measures.

Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy.

METHODS

An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'.

RESULTS

The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations.

CONCLUSION

The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.

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.

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

OBJECT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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