Post operative complications and slower healing

Most people, when thinking of smoking risks only think of diseases directly caused by smoking. But smoking can play a major risk in treating diseases and injuries that in a true sense are not caused by or have anything to do with smoking. I am referring to the risk of postoperative complications.
 
Many doctors will hold off doing elective or non-essential surgeries for as long as possible in order to give a patient time to be totally smoke free. This is not a practice done for arbitrary reasons. Surgery is much riskier to perform on a smoker.
 
Your risks of complications of anesthesia or postoperative complications are much higher while you smoke. These complications can be serious, making you suffer much longer and possibly putting your life at risk. The longer you are off prior to surgery, the lower the risk becomes.
 
One cardiologist I worked with in smoking cessation programs over 40 years ago studied the risk of postoperative complications at the hospital where he was then chief of cardiology and thoracic surgery.
 
At that time he found that in non-smokers the postoperative complication rate was 1 in 50. Smokers had a rate of 1 in 3. If the surgeries were elective and they could wait for the patient to quit, he found that if the smoker would quit for just a week, the rates were 1 in 12. Of course it wasn’t as good as a person who had been off for years but it was far superior to current smokers.
 
The longer people were off the closer the rate became to non-smokers levels. The important thing is to quit as far ahead of any procedure as soon as possible. The only way to get maximal benefit of longest-term cessation prior to any future surgery is to stay smoke free today and for as long as you live remember a day at a time to never take another puff!
 
Joel
Related articles and commentaries

Butt out or no surgery, smokers told

Doctor won’t operate unless they quit
Addiction too powerful, critics say

From the Toronto Star
4/11/03

LESLIE PAPP
FEATURE WRITER

Fed up with patients who won’t quit tobacco, a Northern Ontario surgeon is refusing to operate on smokers – even if it could save their lives.

And other doctors in the province have the right to do the same thing, says Ontario’s medical watchdog, the College of Physicians and Surgeons.

Ethicists label such refusals unfair. Smoking, they point out, is an addiction, and many in its grip don’t have the power to quit. They warn that targeting smokers is discriminatory, since lifestyle choices such as eating fatty food play a big role in other diseases, from heart problems to diabetes.

But Dr. Claudio de la Rocha, a chest surgeon who does all lung cancer operations in Timmins, has taken a stand. “Nobody goes under the knife without having quit smoking,” he says, tapping his desk with a forefinger.

It’s not known how many doctors reject tobacco users. A Winnipeg family physician, Dr. Frederick Ross, made headlines last year when he gave his patients three months to stop smoking or find another doctor.

And surgeons in Melbourne, Australia, have refused to give smokers heart or lung transplants, or life-saving bypass surgery, citing medical and moral grounds.

De la Rocha says that about one in five smokers coming to him are denied surgery; they’re unwilling, or unable, to give up tobacco.

Some are outraged by the very suggestion that they butt out. De la Rocha says angry patients have answered him with a one-finger salute and slammed his door so hard, the diplomas on his wall rattled.

“I’ve had people where I thought, `My God, is this guy going to jump across the desk?'”

Others quietly leave his office, promising to try quitting, and they don’t come back.

De la Rocha requires smokers to abandon their habit three to six weeks before a procedure, and he cites sound medical reasons for that.

Studies show that smokers don’t do as well as non-smokers on the operating table. Tobacco users are prone to risky complications, such as lung infections and blood clots, resulting in heart attack or stroke.

Smokers also consume valuable health-care resources, de la Rocha says. If society is going to spend thousands of dollars to treat them, it’s only fair to ask that they “take the first step” and quit their risky habit.

And there’s worry that bad outcomes, aggravated by smoking, could tarnish a surgeon’s reputation, de la Rocha says. In the United States, there’s extensive monitoring of surgeons’ performance, with “report cards” separating the profession’s stars from its screw-ups. A trend toward increased accountability is building here, too, making smokers less desirable to have as patients.

Performance report cards “are coming down the pipe,” de la Rocha says, elaborating on why he has rejected smokers. “If my reputation is on the line, it stands to reason I would take that step.”

According to the Ontario Medical Association, he is well within his rights.

The stop-smoking ultimatum “could be a reasonable thing to say,” says Dr. Ted Boadway, executive director of health policy for the OMA and a family physician for 13 years. “You have to look at the risks involved, and every surgeon has to make a decision.”

Boadway says he isn’t aware of other Ontario doctors refusing to treat smokers, but he has personally dropped patients because they were addicted to drugs or alcohol.

Their problems were “insoluble as long as they continued their behaviour,” he says. “You put a huge amount of effort into these folks. And every doctor has their breaking point.”

Doctors are free to drop smokers from their patient list as long as they steer them toward appropriate care from some other source, says Dr. Graeme Cunningham, head of the College of Physicians and Surgeons of Ontario.

Doctors ending their relationship with a patient need to give the departing person “a menu of choices,” he says. This could be as simple as a list of other doctors expert in treating a patient’s particular disease, or hospitals where help is available.

There’s no requirement to actually find another doctor for a patient who is sent away, and no policy on whether smokers should be denied treatment because of their addiction.

“We wouldn’t take a specific position around smoking and smoking cessation, and people needing lung or heart operations,” Cunningham says.

But ethicist Margaret Sommerville says refusing to treat smokers solely because of their addiction unfairly targets this population. It amounts to discrimination, “to the extent that an addiction is a physical and mental disability.”

De la Rocha’s reply: “I’d like to see that ethicist taking care of a patient in respiratory failure following surgery. That’s all.”

Doctors are clearly justified in refusing to do a procedure if they feel the risks of an operation outweigh the benefits. But undergoing surgery as a smoker doesn’t appear to be riskier than being denied treatment.

“There’s a risk in not getting the operation,” says Sommerville, founding director of the McGill Centre for Medicine, Ethics and Law in Montreal.

“As well, the physician must make sure that the refusal to treat would be a last-ditch option, that all other ways of solving this situation – such as offering support and addiction treatment – have been explored.”

De la Rocha says he tries to be flexible. He relies on family physicians to provide smoking-cessation services and to refer patients to other specialists. An emergency case is always treated. And sometimes, when a patient is a particularly heavy smoker and is desperately trying but unable to stop, he settles for a big drop in cigarette use – something like a 75 per cent reduction.

“That’s a good chunk.”

Those who fail to quit, or refuse, must find another surgeon. And that means going to Sudbury or Toronto.

“Can they find someone?” de la Rocha muses. “I have no idea. I don’t follow them up.”

Other doctors say they’ve been tempted to drop smokers.

“I have considered it,” admits Dr. Gail Darling, a chest surgeon at Toronto General Hospital who has operated on more than 1,000 lung cancer patients. But she has decided to continue treating tobacco users even if they don’t quit.

“Smoking is an addiction (and) addiction is a disease,” she says. “It’s a terrible thing.”

Dr. Jon Irish, chief of surgical oncology at Toronto’s University Health Network and Mount Sinai Hospital, says he has heard anecdotes about Ontario physicians refusing to treat smokers, adding he might have been sympathetic to such a policy early in his career.

Now, after years spent watching smokers suffer from their habit, he says denying care “is a pretty harsh line to take.”

Irish specializes in cutting out head and neck cancers – diseases mainly caused by tobacco use.

About 90 per cent of his patients are smokers and Irish is “very adamant” in pushing them to quit. Almost 60 per cent of them do, he says, citing his own study, soon to be published in a medical journal.

But Irish doesn’t deny treatment to patients who don’t butt out. That would amount to punishing them for an addiction over which they have little control, he says. And they’re being punished enough.

“If you have a cancer and I’m going to take out your tongue or take out your lung or take out your bladder, that’s a pretty high price to pay,” Irish says.

“That’s a pretty good incentive to stop smoking. If you continue to smoke, that, to me, signifies addiction.”

2001 commentary from Freedom from Nicotine Board

This thread touches on another aspect of the denial of treatment string. I do realize it is a sensitive issue and I understand the line that it straddles and seems to cross to some people. But often the physician has the best interest of the patient in mind when taking such a hard line approach. I recognize it because it is not all that dissimilar to the hard line approach we take here at Freedom, and for the same reason, we recognize that success or failure in quitting is a life and death issue. Unless viewed that way a smoker is likely to push his or her luck, smoking till the very last moment, sometimes his or her actual last moment. When refusing treatments, physicians and dentists may not only be trying to minimize their liability, improve their statistics or accomplish any other self-serving goal, they are sometimes just trying to save the person’s life in the best way they know how, influencing the smoker to quit and then letting them repair what damage they can.

I think the people who responded to this string months ago recognized this issue. I was at my dentist yesterday who coincidently brought up this same topic. He was saying how periodontists often refuse procedures on smokers, one for the chemical irritation that smoking will do to the surgery and the other reason for the sucking motion on a cigarette causing problems with the sutures needed for procedures. He also brought up some issues specific to women and estrogen and smoking that apparently is playing havoc in some periodontal diseases. I am going to look into the issues when I get a chance.

Also when I was leaving the dental office, one of the office staff stopped me because her daughter had just left her a message on how she was going crazy after two days without smoking. I actually ended up in a 15 or 20 minute phone conversation with the daughter. Ended up missing my lunch but it was worth it if it gets her through that all critical third day mark.

I think it is important for everyone here to recognize that you all have been getting an education and an understanding of the nicotine addiction and its treatment that is helping you to stay nicotine free. But that understanding will not only be beneficial for you but for many around you. Most people don’t know this information, even some of your medical professionals. Share with them your success and your knowledge.

You would be amazed at just how many people you may touch. When you are at your doctor or dentist, let them know you quit and how you did it and how you feel now that you quit. Don’t assume this is uninteresting information, or something they have heard a thousand times before. It may have been told to them by others but they may not have actually heard it or assimilated the material. The most important message you can get across to them is your understanding of nicotine addiction.

Again, being medical professionals they may understand the danger or smoking but they often don’t understand and have never been trained on the issue of the nicotine addiction. Share that information. The most important message you can share with them is your understanding of how you stay smoke free and how all their other patients can accomplish the same goal, if they simply understand the importance of remembering to never take another puff!

Joel

Ann Surg. 2003 Jul;238(1):1-5.

Abstinence from smoking reduces incisional wound infection: a randomized controlled trial.

Sorensen LT, Karlsmark T, Gottrup F.

*Copenhagen Wound Healing Center and the dagger Department of Surgical Gastroenterology, Bispebjerg University Hospital, Copenhagen Hospital Corporation, Denmark.

OBJECTIVE Clinical studies show that the incidence of postoperative wound complications is higher in smokers than nonsmokers. In this study, we evaluated the effect of abstinence from smoking on incisional wound infection.

METHODS Seventy-eight healthy subjects (48 smokers and 30 never-smokers) were included in the study and followed for 15 weeks. In the first week of the study, the smokers smoked 20 cigarettes per day. Subsequently, they were randomized to continuous smoking, abstinence with transdermal nicotine patch (25 mg per day), or abstinence with placebo patch. At the end of the first week and 4, 8, and 12 weeks after randomization, incisional wounds were made lateral to the sacrum to excise punch biopsy wounds. At the same time identical wounds were made in 6 never-smokers. In 24 never-smokers a wound was made once. All wounds were followed for 2 weeks for development of wound complications.

RESULTS A total of 228 wounds were evaluated. In smokers the wound infection rate was 12% (11 of 93 wounds) compared with 2% (1 of 48 wounds) in never-smokers (P <0.05). Wound infections were significantly fewer in abstinent smokers compared with continuous smokers after 4, 8, and 12 weeks after randomization. No difference between transdermal nicotine patch and placebo was found.

CONCLUSIONS Smokers have a higher wound infection rate than never-smokers and 4 weeks of abstinence from smoking reduces the incidence of wound infections.

PMID: 12832959

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12832959&dopt=Abstract

Australian smokers should be denied elective surgery, say doctors

April 5, 2004

New Zealand Herald 

Smokers should be denied joint replacement surgery, breast reconstruction and a wide range of other elective surgery, say doctors.

Nicotine and other chemicals in cigarette smoke slow down circulation and wound healing, and leave smokers more susceptible to post-operative infection and breathing difficulties, thoracic expert Dr Matthew Peters said in the Medical Journal of Australia.

“The risk of adverse outcomes from wound infections alone is clear enough evidence to suggest that aesthetic plastic surgery should not be offered to current smokers.”

Medical ethicist Dr Nicholas Tonti-Filippini said to deny smokers surgery would be to violate human rights.

http://www.nzherald.co.nz/storydisplay.cfm?storyID=3558886&thesection=news&thesubsection=world

©Copyright 2004, New Zealand Herald

Ann Surg. 2003 Jul;238(1):1-5.

Abstinence from smoking reduces incisional wound infection: a randomized controlled trial.

Sorensen LT, Karlsmark T, Gottrup F.

*Copenhagen Wound Healing Center and the dagger Department of Surgical Gastroenterology, Bispebjerg University Hospital, Copenhagen Hospital Corporation, Denmark.

OBJECTIVE Clinical studies show that the incidence of postoperative wound complications is higher in smokers than nonsmokers. In this study, we evaluated the effect of abstinence from smoking on incisional wound infection.

METHODS Seventy-eight healthy subjects (48 smokers and 30 never-smokers) were included in the study and followed for 15 weeks. In the first week of the study, the smokers smoked 20 cigarettes per day. Subsequently, they were randomized to continuous smoking, abstinence with transdermal nicotine patch (25 mg per day), or abstinence with placebo patch. At the end of the first week and 4, 8, and 12 weeks after randomization, incisional wounds were made lateral to the sacrum to excise punch biopsy wounds. At the same time identical wounds were made in 6 never-smokers. In 24 never-smokers a wound was made once. All wounds were followed for 2 weeks for development of wound complications.

RESULTS A total of 228 wounds were evaluated. In smokers the wound infection rate was 12% (11 of 93 wounds) compared with 2% (1 of 48 wounds) in never-smokers (P <0.05). Wound infections were significantly fewer in abstinent smokers compared with continuous smokers after 4, 8, and 12 weeks after randomization. No difference between transdermal nicotine patch and placebo was found.

CONCLUSIONS Smokers have a higher wound infection rate than never-smokers and 4 weeks of abstinence from smoking reduces the incidence of wound infections.

PMID: 12832959

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12832959&dopt=Abstract

Instr Course Lect. 2004;53:325-40.

Lumbar arthrodesis for degenerative conditions.

Glaser JA, Bernhardt M, Found EM, McDowell GS, Wetzel FT.

Medical University of South Carolina, Charleston, South Carolina, USA. 

There is significant disagreement among spine surgeons regarding the optimal technique of arthrodesis for treatment of degenerative disorders of the lumbar spine. Degenerative conditions of the lumbar spine include degenerative disk “disease,” post-decompression degeneration, degenerative spondylolisthesis, junctional degeneration, spondylolis, and low-grade lytic spondylolisthesis. Although it is impossible to develop strict evidence-based criteria for the selection of one surgical approach over another, some generalizations are possible based on empiric process, anecdotal experience, and published surgical series. Patient selection, cessation of nicotine use, and use of autologous bone graft are factors that influence clinical outcome after lumbar arthrodesis. 

PMID: 15116625 [PubMed – in process]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15116625

 

Guardsman’s surgery postponed

August 4, 2006 – The Meridian Star

By Georgia E. Frye / staff writer 

A surgery scheduled for Thursday for Sgt. 1st Class Grayson “Norris” Galatas was postponed until Aug. 24 when lab results showed nicotine in his system. 

Galatas is currently at Walter Reed Army Medical Center in Washington, D.C. 

Galatas has faced several surgeries since he was wounded when an Improvised Explosive Device exploded near his vehicle April 19, 2005, while he was on duty in Iraq with the 150th Combat Engineer Battalion. 

Galatas suffered severe lacerations to his stomach and back and had shrapnel wounds over much of his body. The surgery Galatas was scheduled to undergo Thursday included removing a skin graft that covers a large section of his stomach and then reconnecting his stomach to his intestines. 

Galatas’ wife, Janis, said the doctors at Walter Reed said nicotine constricts the blood vessels and restricts blood flow to tissue, and getting Galatas off nicotine for three weeks will enhance his chance of healing. 

Norris Galatas doesn’t smoke, his wife said, but never thought about mentioning smokeless tobacco when he was filling out medical paperwork. 

“Norris is understandably upset because he has been waiting since July 2005 to get this done,” Janis Galatas said. “However, he has healed nicely with all the other surgeries and this will only make it better. He will get over it, he always does.” 

Janis Galatas will return home to care for the couple’s horses and return to Walter Reed in time for the surgery. 

“This time I’ll wait until we get the final OK before I travel,” she said, “But we had some fun together for a couple of weeks.”

Story source: http://www.meridianstar.com/local/local_story_216011209.html

© 2006, The Meridian Star

Nicotine’s Role in Failed Low Back Surgery

“The role of smoking in causing pseudarthrosis has been well studied in lumbar spine fusions with up to a fourfold increase in nonunion rates from 8% to 40% for lumbar fusions. Nicotine has a direct inhibitory effect on autologous cancellous bone graft revascularization as well as an increased rate of bone graft necrosis in a rabbit model of bone graft implantation. Systemic nicotine has also been linked to nonunion in spinal fusion animal models.” 

Source:  http://www.springerlink.com/content/7r1k253384w92418/

But what neck disc fusion surgery where entry and disc fixation was accomplished was from the rear (posterior) instead of cutting into the front of the neck (anterior)?  The below new study found that although successful fusion rates were similar between smokers and non-smokers that “Smokers were nearly five times more likely to have a fair or poor outcome compared with nonsmokers.

Does Smoking Influence Fusion Rates in Posterior Cervical Arthrodesis With Lateral Mass Instrumentation?

Clin Orthop Relat Res. 2010 Sep 22. [Epub ahead of print]

Eubanks JD, Thorpe SW, Cheruvu VK, Braly BA, Kang JD.

Abstract 

BACKGROUND: Smoking is associated with reduced fusion rates after anterior cervical decompression and arthrodesis procedures. Posterior cervical arthrodesis procedures are believed to have a higher fusion rate than anterior procedures. 

QUESTIONS/PURPOSES: We asked whether smoking (1) would reduce the fusion rate in posterior cervical procedures; and (2) be associated with increased pain, decreased activity level, and a decreased rate of return of work as compared with nonsmokers. 

METHODS: We retrospectively reviewed 158 patients who had a posterior cervical fusion with lateral mass instrumentation and iliac crest bone grafting between 2003 and 2008. Fusion rates and Odom Criteria grades were compared among smokers and nonsmokers. The minimum followup was 3 months (average, 14.5 months; range, 3-72 months). 

RESULTS: Smokers and nonsmokers had similar fusion rates (100%). Although 80% of patients had Odom Criteria Grade I or II, smokers were five times more likely to have Grade III or IV with considerable limitation of physical activity. Age, gender, and diagnosis did not influence fusion rates or the Odom Criteria grade. 

CONCLUSIONS: In contrast to the effect of smoking on anterior cervical fusion, we found smoking did not decrease posterior cervical fusion with lateral mass instrumentation and iliac crest bone grafting. Posterior cervical fusion with lateral mass instrumentation should be considered over anterior procedures in smokers if the abnormality can appropriately be addressed from a posterior approach. 

http://www.springerlink.c…ontent/7r1k253384w92418/

Smokers are likely to experience an Odom Criteria Grade of III or IV?  What does that mean?  This definition was provided in the full text of the study:

“The Odom Criteria have been used for decades to grade clinical outcomes after cervical spine surgery. It takes into account the patient’s daily symptoms, activity level, and ability to return to work and grades them on a scale of I to IV: Grade I (excellent) = no cervical spine symptoms, daily activities not impaired; Grade II (good) = intermittent discomfort, no substantial interference with work activities; Grade III (fair) = subjective improvement but major limitations of physical activities; and Grade IV (poor) = no improvement or worse compared with the preoperative condition.”

Smoking and Perioperative Outcomes

Anesthesiology. 2011 March 2. [Epub ahead of print]

Turan A, Mascha EJ, Roberman D, Turner PL, You J, Kurz A, Sessler DI, Saager L.

Abstract

BACKGROUND: Patients are often concerned about the effects of smoking on perioperative risk. However, effective advice may be limited by the paucity of information about smoking and perioperative risk. Thus, our goal was to determine the effect of smoking on 30-day postoperative outcomes in noncardiac surgical patients.

METHODS: We evaluated 635,265 patients from the American College of Surgeons National Surgical Quality Improvement Program database; 520,242 patients met our inclusion criteria. Of these patients, 103,795 were current smokers; 82,304 of the current smokers were propensity matched with 82,304 never-smoker controls. Matched current smokers and never-smokers were compared on major and minor composite morbidity outcomes and respective individual outcomes.

RESULTS: Current smokers were 1.38 (95% CI, 1.11-1.72) times more likely to die than never smokers. Current smokers also had significantly greater odds of pneumonia (odds ratio [OR], 2.09; 95% CI, 1.80-2.43), unplanned intubation (OR, 1.87; 95% CI, 1.58-2.21), and mechanical ventilation (OR, 1.53; 95% CI, 1.31-1.79). Current smokers were significantly more likely to experience a cardiac arrest (OR, 1.57; 95% CI, 1.10-2.25), myocardial infarction (OR, 1.80; 95% CI, 1.11-2.92), and stroke (OR, 1.73; 95% CI, 1.18-2.53). Current smokers also had significantly higher odds of having superficial (OR, 1.30; 95% CI, 1.20-1.42) and deep (OR, 1.42; 95% CI, 1.21-1.68) incisional infections, sepsis (OR, 1.30; 95% CI, 1.15-1.46), organ space infections (OR, 1.38; 95% CI, 1.20-1.60), and septic shock (OR, 1.55; 95% CI, 1.29-1.87).

CONCLUSION: Our analysis indicates that smoking is associated with a higher likelihood of 30-day mortality and serious postoperative complications. Quantification of increased likelihood of 30-day mortality and a broad range of serious smoking-related complications may enhance the clinician’s ability to motivate smoking cessation in surgical patients.

PubMed Link:  http://www.ncbi.nlm.nih.gov/pubmed/21372682