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Short-Term Preoperative Smoking Cessation and Postoperative Complications: a Systematic Review and Meta-Analysis Arrêt A` Court

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Short-Term Preoperative Smoking Cessation and Postoperative Complications: a Systematic Review and Meta-Analysis Arrêt A` Court Can J Anesth/J Can Anesth (2012) 59:268–279 DOI 10.1007/s12630-011-9652-x REPORTS OF ORIGINAL INVESTIGATIONS Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis Arreˆta` court terme du tabagisme en pre´ope´ratoire et complications postope´ratoires: revue syste´matique de la litte´rature et me´ta-analyse Jean Wong, MD • David Paul Lam, BSc • Amir Abrishami, MD • Matthew T. V. Chan, MBBS • Frances Chung, MBBS Received: 24 August 2011 / Accepted: 1 December 2011 / Published online: 21 December 2011 Ó Canadian Anesthesiologists’ Society 2011 Abstract derive the minimum duration of preoperative abstinence Purpose The literature was reviewed to determine the from smoking required to reduce such complications in risks or benefits of short-term (less than four weeks) adult surgical patients. smoking cessation on postoperative complications and to Source We searched MEDLINE, EMBASE, Cochrane, and other relevant databases for cohort studies and ran- domized controlled trials that reported postoperative complications (i.e., respiratory, cardiovascular, wound- Author contributions Jean Wong was involved in data abstraction, healing) and mortality in patients who quit smoking within interpretation of data, drafting and revising, and final approval of the six months of surgery. Using a random effects model, article. David Paul Lam was involved in data abstraction and drafting meta-analyses were conducted to compare the relative of the article. Amir Abrishami was involved in drafting and revising the article, data analysis, and interpretation of the data. Matthew risks of complications in ex-smokers with varying intervals Chan revised and approved the final version of the article. Frances of smoking cessation vs the risks in current smokers. Chung was involved in the conception and design, revising, and final Principal findings We included 25 studies. Compared approval of the article. with current smokers, the risk of respiratory complica- Electronic supplementary material The online version of this tions was similar in smokers who quit less than two or article (doi:10.1007/s12630-011-9652-x) contains supplementary two to four weeks before surgery (risk ratio [RR] 1.20; material, which is available to authorized users. 95% confidence interval [CI] 0.96 to 1.50 vs RR 1.14; J. Wong, MD (&) CI 0.90 to 1.45, respectively). Smokers who quit more Department of Anesthesia, Toronto Western Hospital, University than four and more than eight weeks before surgery had Health Network, University of Toronto, 2-434 McLaughlin lower risks of respiratory complications than current Wing, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada smokers (RR 0.77; 95% CI 0.61 to 0.96 and RR 0.53; e-mail: [email protected] 95% CI 0.37 to 0.76, respectively). For wound-healing D. P. Lam, BSc Á A. Abrishami, MD complications, the risk was less in smokers who quit Department of Anesthesia, Toronto Western Hospital, University more than three to four weeks before surgery than in Health Network, University of Toronto, 2-405 McLaughlin current smokers (RR 0.69; 95% CI 0.56 to 0.84). Few Wing, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada studies reported cardiovascular complications and there F. Chung, MBBS were few deaths. Department of Anesthesia, Toronto Western Hospital, University Conclusion At least four weeks of abstinence from Health Network, University of Toronto, 2-433A McLaughlin smoking reduces respiratory complications, and abstinence Wing, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada of at least three to four weeks reduces wound-healing M. T. V. Chan, MBBS complications. Short-term (less than four weeks) smoking Department of Anaesthesia and Intensive Care, The Chinese cessation does not appear to increase or reduce the risk of University of Hong Kong, Prince of Wales Hospital, postoperative respiratory complications. Shatin, NT, Hong Kong, SAR 123 Short-term preoperative smoking cessation 269 Re´sume´ perioperative death and a 30-109% increase in the risk of Objectif La litte´rature disponible a e´te´ passe´e en revue serious postoperative complications, depending on the type pour de´terminer les risques ou avantages d’un arreˆtdu of complication.3 However, this study did not examine tabagisme a` court terme (moins de quatre semaines) sur les whether short-term abstinence from smoking before surgery complications postope´ratoires et pour en de´duire la dure´e reduces the risk of postoperative complications. minimum d’abstinence tabagique pre´ope´ratoire qui permet A relatively long period of abstinence from smoking de diminuer la survenue de ces complications chez des before surgery reduces postoperative complications.6,7 Two adultes subissant une chirurgie. systematic reviews showed that preoperative smoking Source Notre e´tude a porte´ sur les bases de donne´es cessation programs increased short-term (up to six months) MEDLINE, EMBASE, Cochrane, et les autres bases de abstinence.8,9 Consequently, both the American Society of donne´es pertinentes a` la recherche d’e´tudes de cohortes ou Anesthesiologists10 and the Canadian Anesthesiologists’ d’e´tudes randomise´es et controˆle´es ayant de´crit les Society11 recommend promoting smoking cessation before complications postope´ratoires (c’est-a`-dire respiratoires, surgery. However, surgery is frequently scheduled within a cardiovasculaires, retard de cicatrisation) et la mortalite´chez few weeks of diagnosis of certain conditions, thus pre- des patients ayant cesse´ de fumer dans les six mois ayant cluding longer periods of preoperative abstinence. As well, pre´ce´de´ l’intervention chirurgicale. Des me´ta-analyses ont anesthesiologists typically see patients within one to four e´te´ effectue´es en utilisant un mode`le a` effets ale´atoires pour weeks of planned surgery. Anesthesiologists may be comparer les risques relatifs de complications chez les reluctant to advocate smoking cessation shortly before anciens fumeurs, avec des de´lais variables d’arreˆtdu surgery because the benefits of a short period of abstinence tabagisme, aux risques chez des fumeurs actifs. (less than four weeks) are uncertain, and there could pos- Constatations principales Nous avons inclus 25 e´tudes. sibly be increased risks of postoperative respiratory12 or Compare´s aux fumeurs actifs, les risques de complications cardiovascular complications, or mortality.13 Interestingly, respiratoires ont e´te´ comparables chez les fumeurs ayant a paradoxical effect of lower mortality and improved out- cesse´ de fumer moins de deux semaines, ou entre deux come was observed in smokers compared with non- et quatre semaines avant une intervention chirurgicale smokers after acute myocardial infarction, heart failure, (rapport de risque [RR]: 1,20; intervalle de confiance [IC] a` and stroke.14-16 These data suggest that it may be inap- 95 %: 0,96-1,50, contre, respectivement, RR: 1,14; IC a` propriate to stop smoking shortly before surgery. 95 %: 0,90-1,45). Les fumeurs ayant cesse´ de fumer A recent meta-analysis found that smoking cessation plus de quatre semaines et plus de huit semaines avant less than eight weeks before surgery did not increase or l’intervention chirurgicale avaient des risques de decrease the rate of overall or respiratory complications.17 complications respiratoires moins e´leve´s que les fumeurs However, the authors pooled studies with varying duration actifs (RR: 0,77; IC a` 95 %: 0,61-0,96 et RR: 0,53; IC a` of smoking cessation (two to eight weeks before surgery) 95 %: 0,37-0,76, respectivement). Concernant les and did not examine wound-healing complications. complications lie´es a` la cicatrisation, le risque a e´te´ plus Therefore, the effect of cessation of smoking shortly before faible chez les fumeurs ayant cesse´ plus de trois a` quatre surgery is still unclear. semaines avant l’intervention que chez les fumeurs actifs It is important to determine the benefits or risks of short- (RR: 0,69; IC a` 95%: 0,56-0,84). Peu d’e´tudes ont de´crit des term abstinence from smoking before surgery in order to guide complications cardiovasculaires et il n’y a eu que peu de anesthesiologists and other clinicians when providing preop- de´ce`s. erative advice to smokers. The objectives of this systematic Conclusion Un minimum de quatre semaines d’abstinence review are to determine the benefits or risks of short-term (less du tabagisme diminue le risque de complications respiratoires than four weeks) abstinence from smoking compared with et un minimum de trois a` quatre semaines re´duit le risque de continued smoking on postoperative complications (respira- complications lie´es a` la cicatrisation. L’arreˆta` court terme tory, cardiovascular, wound-healing) and mortality and to (moins de quatre semaines) du tabagisme ne semble pas determine the minimum duration of preoperative smoking augmenter ou re´duire le risque de complications respiratoires cessation to reduce postoperative complications. postope´ratoires. Methods Smoking is associated with increased postoperative mor- bidity and mortality.1-3 This is a major concern as up to 20% Search strategy of surgical patients are smokers.4,5 A recent large observa- tional study of non-cardiac surgical patients reported that In collaboration with a research librarian, we smoking is associated with a 38% increase in the risk of searched Medline (January 1950 - April 2010 and May 123 270 J. Wong et al. 2010 - January 2011), EMBASE (January 1980 - January needing treatment, atelectasis requiring bronchoscopy 2011), Cochrane Database
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