Postoperative Complications Caused By Smoking

Postoperative Complications

As of 2014, roughly 19% of the adult population in the United States are smokers of cigarettes or other combustible tobacco products, including cigars and cigarillos, pipes, and water pipes (1). However, tobacco usage remains one of the greatest global risk factors for overall mortality and morbidity. Since its inception, the World Health Organization Framework Convention on Tobacco Control has aimed to reduce both the demand and the supply of tobacco around the world through educational, political, and legislative means (1). Smoking has numerous adverse effects on health, such as increasing the risk of cancer, lung disease, and hypertension. Smoking also affects surgery outcomes and the risk of postoperative complications.

In 2009, a brief statement about smoking impacting on wound healing was published by the American Society of Anesthesiologists’ Task Force on Smoking Cessation. Because smoking has a definitive and direct impact on postoperative outcomes, the statement advised that patients receiving elective surgery should abstain from smoking for as long as possible before and after surgery. More recently in 2020, a consensus statement on perioperative smoking cessation by the Society for Perioperative Assessment and Quality Improvement (SPAQI) mentioned that smoking cessation should be done as soon as possible with surgical scheduling (2). Some of the adverse effects of cigarette smoking include cutaneous vasoconstriction (reducing skin blood flow), local thrombosis, and reduced oxygen-carrying capacity, all of which can delay tissue repair (1). Impaired clearance of secretions, altered immune function, altered collagen synthesis, and the influence of conditions related to smoking (e.g., COPD and altered cardiovascular function) also contribute to postoperative complications.

A 2002 study of 489 adult patients undergoing ambulatory (same-day) surgery demonstrated that smokers have a significantly higher rate of respiratory complications (32.8% in smokers vs. 25.9% in nonsmokers) and wound infections (3.6% in smokers vs. 0.6% in nonsmokers) (3). Similarly, causes of major pulmonary events after pneumonectomy (lung removal) were sought in a retrospective analysis of 261 patients. It was found that patients who continued to smoke within 1 month of operation were determined to be at an increased risk of adverse pulmonary events, which was associated with increased postoperative mortality (1). On another note, cigarette smoking is associated with an increased risk of hepatic artery thrombosis after liver transplantation, and cessation 2 years before transplantation was associated with a decreased risk. Similar data exist regarding renal transplantation and allograft survival in smokers compared to nonsmokers. Recent studies describe substantially increased risk of postoperative complications in elective plastic surgery procedures, wound complications after coronary bypass surgery, and marginal ulcers after Roux-en-Y gastric bypass related to smoking (1).

Given the aforementioned consequence of cigarette smoking, it is a natural conclusion that smoking cessation substantially reduces postoperative complications. To empirically evaluate this assumption, Moller and colleagues published the results of a randomized, controlled trial of smokers awaiting elective hip or knee surgery at three hospitals in Copenhagen (4). They compared 56 patients in a smoking cessation intervention arm (83% stopped or reduced smoking) versus 62 patients in a usual care arm. The overall complication rate was 18% in the intervention arm and 52% in the control group, a highly significant difference. The greatest differences were seen in wound complication rates (5% vs. 31%) and cardiovascular complications (0% vs. 2%) (4). The optimal window for smoking cessation intervention may be at 8 weeks before elective surgery, as suggested by data that patients who had stopped smoking at least 2 months preoperatively had nearly maximal reduction in postoperative respiratory complications. A meta-analysis of six trials of smoking cessation found that cessation reduced postoperative complications by 41% and that each week of cessation increased the magnitude of benefit by 19% (1).

References

  1. Benowitz NL, Brunetta PG. 46 – Smoking Hazards and Cessation. In: Broaddus VC, Mason RJ, Ernst JD, et al., eds. Murray and Nadel’s Textbook of Respiratory Medicine (Sixth Edition). W.B. Saunders; 2016:807-821.e3. doi:https://doi.org/10.1016/B978-1-4557-3383-5.00046-4
  2. Fan Chiang YH, Lee YW, Lam F, Liao CC, Chang CC, Lin CS. Smoking increases the risk of postoperative wound complications: A propensity score-matched cohort study. Int Wound J. 2023;20(2):391-402. doi:10.1111/iwj.13887
  3. Myles PS, Iacono GA, Hunt JO, et al. Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus nonsmokers. Anesthesiology. 2002;97(4):842-847. doi:10.1097/00000542-200210000-00015
  4. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359(9301):114-117. doi:10.1016/S0140-6736(02)07369-5