Perioperative complications of abdominal surgery in smokers

Association between SII and postoperative pulmonary infection in elderly patients undergoing laparoscopic abdominal surgery

Objectives

This study aimed to identify the contributing factors, including systemic immune-inflammation index (SII), for pulmonary infections in elderly patients undergoing laparoscopic abdominal surgery with tracheal intubation under general anesthesia.

Methods

A total of 356 eligible elderly patients were monitored post-surgery for pneumonia. Pathogens were identified from sputum samples, and factors like age, smoking, chronic obstructive pulmonary disease (COPD), intubation, anesthesia duration, and SII were analyzed for their influence on infection risk.

Results

The pathogens were predominantly Gram-negative bacteria, with Klebsiella pneumoniae being the most common (26%). Significant risk factors for developing pneumonia included advanced age, smoking, COPD, prolonged intubation, and extended anesthesia. A higher preoperative SII was associated with an increased risk of pneumonia and correlated with infection severity and elevated levels of inflammatory markers. Multivariate analysis identified age over 70 (OR = 1.273, p = 0.021), age over 80 (OR = 2.085, p < 0.001), COPD (OR = 1.528, p = 0.009), prolonged intubation >2 h (OR = 2.187, p < 0.001), general anesthesia >4 h (OR = 1.846, p = 0.006), operative time > 2 h (OR = 1.415, p = 0.016), and preoperative SII >489.3 (OR = 1.403, p = 0.012) as independent risk factors for postoperative pulmonary infection.

Conclusion

Our study highlighted critical risk factors for postoperative pulmonary infections in elderly patients undergoing laparoscopic abdominal surgery. Preoperative SII could be a novel predictor, offering potential for improved pre-surgical risk assessment.

Smoking and Complications After Cancer Surgery: A Systematic Review and Meta-Analysis

Importance

Surgical cancer treatments may be delayed for patients who smoke over concerns for increased risk of complications. Quantifying risks for people who had recently smoked can inform any trade-offs of delaying surgery.

Objective

To investigate the association between smoking status or smoking cessation time and complications after cancer surgery.

Data Sources

Embase, CINAHL, Medline COMPLETE, and Cochrane Library were systematically searched for studies published from January 1, 2000, to August 10, 2023.

Study Selection

Observational and interventional studies comparing the incidence of complications in patients undergoing cancer surgery who do and do not smoke.

Data Extraction and Synthesis

Two reviewers screened results and extracted data according to the Meta-Analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Data were pooled with a random-effects model and adjusted analysis was performed.

Main Outcomes and Measures

The odds ratio (OR) of postoperative complications (of any type) for people who smoke currently vs in the past (4-week preoperative cutoff), currently smoked vs never smoked, and smoked within shorter (2-week cutoff) and longer (1-year cutoff) time frames.

Results

The meta-analyses across 24 studies with a pooled sample of 39 499 participants indicated that smoking within 4 weeks preoperatively was associated with higher odds of postoperative complications compared with ceasing smoking for at least 4 weeks (OR, 1.31 [95% CI, 1.10-1.55]; n = 14 547 [17 studies]) and having never smoked (OR, 2.83 [95% CI, 2.06-3.88]; n = 9726 [14 studies]). Within the shorter term, there was no statistically significant difference in postoperative complications between people who had smoked within 2 weeks preoperatively and those who had stopped between 2 weeks and 3 months in postoperative complications (OR, 1.19 [95% CI, 0.89-1.59]; n = 5341 [10 studies]), although the odds of complications among people who smoked within a year of surgery were higher compared with those who had quit smoking for at least 1 year (OR, 1.13 [95% CI, 1.00-1.29]; N = 31 238 [13 studies]). The results from adjusted analyses were consistent with the key findings.

Conclusions and Relevance

In this systematic review and meta-analysis of smoking cessation and complications after cancer surgery, people with cancer who had stopped smoking for at least 4 weeks before surgery had fewer postoperative complications than those smoking closer to surgery. High quality, intervention-based evidence is needed to identify the optimal cessation period and inform clinicians on the trade-offs of delaying cancer surgery.

Rates of Adverse Events in Patients With Ulcerative Colitis Undergoing Colectomy During Treatment With Tofacitinib vs Biologics: A Multicenter Observational Study

INTRODUCTION

Patients with ulcerative colitis (UC) receiving immunosuppressive drugs are at substantial risk of colectomy. We aimed to assess the risk of postoperative complications of tofacitinib exposure before colectomy in comparison with biologics.

METHODS

A multicenter, retrospective, observational study was conducted in patients with UC who underwent total colectomy for medically refractory disease, exposed to tofacitinib or a biologic before surgery. Primary outcome was the occurrence of any complication within 30 (early) and 90 (late) days after surgery. Secondary outcomes were the occurrence of infections, sepsis, surgical site complications, venous thromboembolic events (VTE), hospital readmissions, and redo surgery within the same timepoints.

RESULTS

Three hundred one patients (64 tofacitinib, 162 anti-tumor necrosis factor-α agents, 54 vedolizumab, and 21 ustekinumab) were included. No significant differences were reported in any outcome, except for a higher rate of early VTE with anti-tumor necrosis factor-α agents ( P = 0.047) and of late VTE with vedolizumab ( P = 0.03). In the multivariate analysis, drug class was not associated with a higher risk of any early and late complications. Urgent colectomy increased the risk of any early (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.06-3.48) complications, early hospital readmission (OR 4.79, 95% CI 1.12-20.58), and early redo surgery (OR 7.49, 95% CI 1.17-47.85). A high steroid dose increased the risk of any early complications (OR 1.96, 95% CI 1.08-3.57), early surgical site complications (OR 2.03, 95% CI 1.01-4.09), and early redo surgery (OR 7.52, 95% CI 1.42-39.82). Laparoscopic surgery decreased the risk of any early complications (OR 0.54, 95% CI 0.29-1.00), early infections (OR 0.39, 95% CI 0.18-0.85), and late hospital readmissions (OR 0.34, 95% CI 0.12-1.00).

DISCUSSION

Preoperative tofacitinib treatment demonstrated a postoperative safety profile comparable with biologics in patients with UC undergoing colectomy.

A Prospective Study on the Outcome After Mass Closure of Post-laparotomy Wound Dehiscence in a Tertiary Care Hospital, Tamil Nadu, India

Introduction The ideal abdominal wound closure provides strength and a barrier to infection. The major cause of morbidity following any laparotomy is abdominal wound dehiscence. For prompt patient recovery and outcome factors influencing wound healing following mass closure of post-laparotomy, wound dehiscence patients are evaluated in this present study. The aim of the study was to evaluate the outcome and various complications following mass closure of post-laparotomy wound dehiscence. Materials and methods A prospective study was conducted among 50 patients admitted to the Department of General Surgery, Tamil Nadu, India, with wound dehiscence following emergency and elective laparotomy surgeries managed with mass closure during the study period from 2021 to 2022. The chi-square test and Fischer's exact test were done. Results Mass closure of post-laparotomy wound dehiscence was more common among males (74%, n=37) and less common in the age group 20-30 years (12%, n=6). Prolonged bleeding time and clotting time post-surgery were associated with the type of surgery with a significant p-value of 0.007 and 0.001, respectively, by Fischer's exact test. The presence of urine albumin was also associated with the type of surgery with a significant p-value of 0.02. Surgical site infection (postoperative complication) was associated with the type of surgery and operating time with a significant p-value of 0.004 and 0.03, respectively. Conclusion Abdominal wound dehiscence is a serious and challenging postoperative complication that necessitates immediate intervention. Strict postoperative care places emphasis on reducing the risk of wound infection and other factors related to wound dehiscence.

[Perioperative smoking cessation (conventional smoking and e-cigarettes) in 2023. A narrative review of the literature]

INTRODUCTION

Tobacco addiction is the leading cause of preventable death. During the perioperative period, patients who smoke are at increased risk of systemic as well as surgical site complications.

STATE OF THE ART

Surgery is an ideal time for change of lifestyle habits. It is vital to seize this opportunity to improve the patient's health in the long- as well as the short-term. Smoking cessation should be encouraged in all surgical patients. Initiating smoking cessation combines pharmacological treatment and a behavioral approach. In this field, significant advances have been recorded over the last decade. This review proposes a practical approach that every practitioner will be able to apply.

PERSPECTIVES

In this review, we will also examine ongoing research, particularly as regards vaccination and the place of biomarkers.

CONCLUSIONS

Smoking represents a major source of health-related complications. Smoking cessation must therefore remain a priority in the management of medical and surgical patients.

Impact of preoperative intervention for smoking cessation on postoperative length of stay and cost for spine surgery patients: Propensity score matching analysis

BACKGROUND

Preoperative intervention for smoking cessation reduces the prevalence of postoperative complications in spine surgery. To date, however, the impact of these interventions on the length of stay (LOS) and cost for patients is unclear.

PATIENTS/METHODS

This retrospective cohort study analyzed data from 317 patients who were current smokers and underwent spine surgery between January 2014 and December 2019 at a single facility in Tokyo, Japan. Most patients (262) received preoperative intervention for smoking cessation within 60 days before spine surgery; the remaining 55 patients did not receive the intervention. The postoperative LOS was compared using propensity score matching. Patients were matched for age, gender, body mass index, surgical plan (cervical surgery, anterior approach surgery, minimally invasive surgery), preoperative comorbidities (diabetes mellitus, hypertension, ischemic cardiac disease, chronic lung disease), and recent history of steroid therapy, which yielded 48 pairs of patients.

RESULTS

The length of postoperative hospital stay was significantly shorter in the intervention group (-10.60 days, [95% CI, -15.79 to -5.42]). The cost for service was significantly lower in the intervention group (coefficient, Japanese yen [JPY] -1,515,529; [95% CI, -2,130,631 to -900,426]; 110 JPY equivalent to 1 United States dollar).

CONCLUSIONS

Preoperative interventions for smoking cessation may decrease postoperative hospital stay and hospitalization costs.

Smoking Cessation for Preoperative Optimization

Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

How and why tobacco use affects reconstructive surgical practice: a contemporary narrative review

Background and Objective

The overall negative impact of tobacco use on an individual's health has been well documented but the literature on tobacco's impact on post-surgical outcomes, specifically the outcomes after urologic surgery, is not as clear cut. The aim of this narrative review is to provide urologists with the information needed to have a nuanced pre-operative counseling conversation with patients about tobacco use. Here we combine publications on the histologic and physiologic changes induced by nicotine and tobacco use with publications from the wider surgical literature on post-operative outcomes in tobacco users.

Methods

A literature search of PubMed, Google Scholar and Medline was performed using iterations of the following terms: tobacco, nicotine, changes, physiologic, histology, post-operative, and surgical. Non-English publications and abstracts were excluded. Inclusion required agreement from all authors and preference was given to human specimens over animal models for the basic science manuscripts and large database and meta-analyses over single institution experiences.

Key Content and Findings

Tobacco use results in measurable changes in nearly every organ system in the body. While smokers have increased wound complications, there is no evidence that reconstructive surgery using grafts or flaps fail more frequently in tobacco users. Smokers have an increased risk of respiratory complications following endotracheal intubation.

Conclusions

Surgeries should not be canceled due to a patient's inability to cease tobacco use. Urologists and patients should engage in joint decision making regarding the timing and pursuit of elective operations.

Exploring the roles of intestinal flora in enhanced recovery after surgery

Striving to optimize surgical outcomes, the Enhanced Recovery After Surgery (ERAS) pathway mitigates patients' stress through the implementation of evidence-based practices during the pre-, intra-, and postoperative periods. Intestinal flora is a sophisticated ecosystem integrating with the host and the external environment, which serves as a mediator in diverse interventions of ERAS to regulate human metabolism and inflammation. This review linked gut microbes and their metabolites with ERAS interventions, offering novel high-quality investigative proponents for ERAS. ERAS could alter the composition and function of intestinal flora in patients by alleviating various perioperative stress responses. Modifying gut flora through multiple modalities, such as diet and nutrition, to accelerate recovery might be a complementary approach when exploring novel ERAS initiatives. Meanwhile, the pandemic of COVID-19 and the availability of promising qualitative evidence created both challenges and opportunities for the establishment of ERAS mode.

Impact of preoperative smoking on patients undergoing right hemicolectomies for colon cancer

Purpose

The tobacco epidemic is one of the biggest global public health issues impacting quality of life and surgical outcomes. Although 30% of colon cancers warrant a right hemicolectomy (RH), there is no specific data on the influence of smoking on postoperative complications following RH for cancer. The aim of this study was to determine its effect on post-surgical outcomes.

Methods

Patients who underwent elective RH for colon cancer between 2016 and 2019 were identified from the ACS-NSQIP database. Propensity score matching (PSM) was used with a maximum absolute difference of 0.05 between propensity scores. Primary outcome was to assess the 30-day complication risk profile between smokers and non-smokers. Secondary outcomes included smoking impact on wound and major medico-surgical complication rates, as well as risk of anastomotic leak (AL) using multivariable logistic regression models.

Results

Following PSM, 5652 patients underwent RH for colon cancer with 1,884 (33.3%) identified as smokers. Smokers demonstrated a higher rate of organ space infection (4.1% vs 3.1%, p = 0.034), unplanned return to theatre (4.8% vs 3.7%, p = 0.045) and risk of AL (3.5% vs 2.1%, p = 0.005). Smoking was found to be an independent risk factor for wound complications (OR 1.32, 95% CI 1.03–1.71, p = 0.032), primary pulmonary complications (OR 1.50, 95% CI 1.06–2.13, p = 0.024) and AL (OR 1.66, 95% CI 1.19–2.31, p = 0.003).

Conclusion

Smokers have increased risk of developing major post-operative complications compared to non-smokers. Clinicians and surgeons must inform smokers of these surgical risks and potential benefit of smoking cessation prior to undergoing major colonic resection.

Risk Factors and Preventive Measures for Anastomotic Leak in Colorectal Cancer

Anastomotic leak (AL) represents one of the most detrimental complications after colorectal surgery. The patient-related factors and surgery-related factors leading to AL have been identified in previous studies. Through early identification and timely adjustment of risk factors, preventive measures can be taken to reduce potential AL. However, there are still many problems associated with AL. The debate about preventive measures such as preoperative mechanical bowel preparation (MBP), intraoperative drainage, and surgical scope also continues. Recently, the gut microbiota has received more attention due to its important role in various diseases. Although the underlying mechanisms of gut microbiota on AL have not been validated completely, new strategies that manipulate intrinsic mechanisms are expected to prevent and treat AL. Moreover, laboratory examinations for AL prediction and methods for blood perfusion assessment are likely to be promoted in clinical practice. This review outlines possible risk factors for AL and suggests some preventive measures in terms of patient, surgery, and gut microbiota.

Fascial Dehiscence and Incisional Hernia Prediction Models: A Systematic Review and Meta-analysis

BACKGROUND

Fascial dehiscence (FD) and incisional hernia (IH) pose considerable risks to patients who undergo abdominal surgery, and many preventive strategies have been applied to reduce this risk. An accurate predictive model could aid identification of high-risk patients, who could be targeted for particular care. This study aims to systematically review existing FD and IH prediction models.

METHODS

Prediction models were identified using pre-specified search terms on SCOPUS, PubMed, and Web of Science. Eligible studies included those conducted in adult patients who underwent any kind of abdominal surgery, and reported model performance. Data from the eligible studies were extracted, and the risk of bias (RoB) was assessed using the PROBAST tool. Pooling of C-statistics was performed using a random-effect meta-analysis. [Registration: PROSPERO (CRD42021282463)].

RESULTS

Twelve studies were eligible for review; five were FD prediction model studies. Most included studies had high RoB, especially in the analysis domain. The C-statistics of the FD and IH prediction models ranged from 0.69 to 0.92, but most have yet to be externally validated. Pooled C-statistics (95% CI) were 0.80 (0.74, 0.86) and 0.81 (0.75, 0.86) for the FD (external-validation) and IH prediction model, respectively. Some predictive factors such as body mass index, smoking, emergency operation, and surgical site infection were associated with FD or IH occurrence and were included in multiple models.

CONCLUSIONS

Several models have been developed as an aid for FD and IH prediction, mostly with modest performance and lacking independent validation. New models for specific patient groups may offer clinical utility.

Risk Factors and Patient Outcomes Associated With Immediate Post-operative Anasarca Following Major Abdominal Surgeries: A Prospective Observational Study From 2019 to 2021

Introduction: Anasarca is well-known and refers to generalized edema caused by underlying clinical conditions and unknown risk factors in the patient. However, it is a relatively unexplored postoperative symptom following major abdominal surgeries. It is associated with poor patient outcomes in terms of delayed recovery and associated severe complications. Pedal edema is an early sign of post-operative anasarca, which progresses into an unfavorable clinical condition due to generalized edema followed by multiple organ dysfunction. 

Aim: This study aimed to assess risk factors and complications associated with postoperative anasarca among patients undergoing major abdominal surgery.

Methods and material: The prospective observational study included 241 patients undergoing major abdominal surgeries from July 2019 to February 2021 in a tertiary care health centre in Rajasthan, India. Risk factors like age, nutritional parameters, addictions like smoking, alcohol intake, opium intake, leukocytosis, and Charlson Comorbidity Index were assessed. Postoperative complications were graded by the Clavien-Dindo grading system. Mean, standard deviation, percentages, Pearson’s Chi-square test and Student’s t-test were used to analyze the data. 

Results: The incidence of anasarca was found to be 29.87%. Nutritional risk screening (NRS) 2002 score, albumin, age > 60 years and raised leukocyte counts were found to significantly correlate (p-value <0.05) with the development of anasarca postoperatively. Postoperative complications, according to Clavien-Dindo grading, were 16.67% in grade I (p value=0.002), 13.89% in grade II (p-value =0.199), 1.39% in grade III (p value=0.049), 20.83% in grade IV (p value<0.001), and 41.67% in grade V (p value<0.001).

Conclusion: Higher NRS 2002 score, low albumin levels, age > 60 years and raised leukocyte counts are significantly correlated with the development of postoperative anasarca. Postoperative anasarca is found to be a significant predictor of poor prognosis of patients undergoing major abdominal surgery. 

Influence of albumin and physical activity on postoperative recovery in patients with colorectal cancer: An observational study

PURPOSE

The study explores the influences of nutrition-related factors (albumin, hemoglobin, and obesity) and lifestyles (physical activity, fruit and vegetable intake, smoking, and drinking) on the length of hospital stay in postoperative colorectal cancer patients.

METHODS

This study is a cross-sectional design. A convenience sample of 106 preoperative colorectal cancer patients was recruited from a medical center in Taiwan. Data were collected using self-reported questionnaires and from patients' medical records.

RESULTS

The median length of hospital stay was ten days with an interquartile range (IQR) of 8-11.25 days. The results of the log-link Gamma generalized linear model showed that albumin (B = -0.16, p = 0.007) and physical activity (B = -0.14, p = 0.001) were significant predictors of the length of hospital stay after controlling for demographics and disease characteristics. The influences of anemia, obesity, fruit and vegetable intake, smoking, and drinking on the length of hospital stay were insignificant.

CONCLUSIONS

Patients with hypoalbuminemia and a low level of physical activity undergo a more extended postoperative hospital stay. The study findings inform clinicians of the influencing factor of the patients' recovery and provide a foundation for developing interventions to decrease hospital stay length.