Blog

A patient with vulval cancer, smoker, needed surgery like many patients we see every day. Of course, we spoke of smoking and the possibility that her smoking habits contributed to her cancer. We went through the consenting process and we talked about the enormous risk of seroma formation in the groins with wound breakdown and I also told her that her oncological prognosis might be affected if she would continue to smoke. Being an ex-smoker myself we talked about smoking cessation and how hard it is.

The husband enquired as to what the benefits  of smoking cessation was or whether there is a role for nicotine patches. I didn’t know straight away and I asked one of my fellows (who normally knows everything) and he didn’t know either. Hence, this blog post (to fill my knowledge gap).

First, I came across this recently published paper on postoperative outcomes after colorectal surgery (Sharma et al., Annals of Surgery 2012). The U.S. NSQIP (a large representative database with data collected from hundreds of hospitals across the United States) identified more than 47,000 patients who had colorectal surgery from their database, half of who had surgery for cancer. Twenty per cent of patients were current smokers, 20% were ex-smokers and 60% never smoked.

This paper suggests that major surgical complications were a lot lower in never-smokers (11.5%) compared to ex-smokers (15.0%) or current smokers (15.4%). Infectious complications dominated and were 30% higher in smokers, regardless whether they were ex- or current smokers, suggesting that smoking cessation only had a limited effect. Current smokers also had a 50% increased risk of dying as a consequence of surgery.

There are three mechanisms by which smoking could have an effect: It limits tissue oxygenation through carbon monoxide; secondly, nicotine acts as a vasoconstrictor and limits blood flow to visceral organs; thirdly, smokers develop a number of comorbidities and at our QLD centre we recently have shown that medical co-morbidities (expressed as the Charlson score predicts surgical complications in open but also laparoscopic gynaecological cancer surgery.
Logic would suggest that we should be able to reverse the immediate adverse effects of smoking (vasoconstriction) through smoking cessation for a few days or even hours because nicotine has a short half live. On the other hand, long term tissue and existing damage to organ systems (cardiopulmonary) will not be reversed by a few days of not smoking.

How about the Nicotine patch? The nicotine dose in nicotine patches is less than in cigarettes and – unlike cigarettes – patches don’t increase the level of carbon monoxide in the blood.

The Cochrane Collaboration systematically evaluated more than 130 trials involving more than 40,000 smokers who smoked more than 15 cigarettes a day. Their conclusion: Nicotine treatment can help 10 % of smokers quit. Ninety per cent of smokers quit the "Quit program". Whether or not Nicotine worked, did not depend on the type of nicotine treatment (gum, patch, spray, etc.) or whether or not there is additional support available.
The Cochrane data also showed that quitting smoking for at least four weeks is required before surgery reduces the number of complications. In two trials participants had weekly counseling sessions and nicotine therapy starting at least 4 to 8 weeks before surgery. For them, the rate of wound complications dropped from 28% down to 9%.

What can we tell your next patient who is going to see you next week?

• If surgery is needed straight away, smoking cessation is unlikely to yield a benefit in terms of surgical complications.
• If surgery can be delayed for a few weeks that would be of advantage provided the trial of smoking cessation is successful.
• However, some patients can view a newly diagnosed medical condition  (or the need for surgery) as a wake up call and a golden opportunity to start with something new.

What are the things that we want to change in our life but we wait for a golden opportunity to get started?