Elsevier

The Lancet

Volume 359, Issue 9301, 12 January 2002, Pages 114-117
The Lancet

Articles
Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial

https://doi.org/10.1016/S0140-6736(02)07369-5Get rights and content

Summary

Background

Smokers are at higher risk of cardiopulmonary and wound-related postoperative complications than nonsmokers. Our aim was to investigate the effect of preoperative smoking intervention on the frequency of postoperative complications in patients undergoing hip and knee replacement.

Methods

We did a randomised trial in three hospitals in Denmark. 120 patients were randomly assigned 6–8 weeks before scheduled surgery to either the control (n=60) or smoking intervention (60) group. Smoking intervention was counselling and nicotine replacement therapy, and either smoking cessation or at least 50% smoking reduction. An assessor, who was masked to the intervention, registered the occurrence of cardiopulmonary, renal, neurological, or surgical complications and duration of hospital admittance. The main analysis was by intention to treat.

Findings

Eight controls and four patients from the intervention group were excluded from the final analysis because their operations were either postponed or cancelled. Thus, 52 and 56 patients, respectively, were analysed for outcome. The overall complication rate was 18% in the smoking intervention group and 52% in controls (p=0·0003). The most significant effects of intervention were seen for wound-related complications (5% vs 31%, p=0·001), cardiovascular complications (0% vs 10%, p=0·08), and secondary surgery (4% vs 15%, p=0·07). The median length of stay was 11 days (range 7–55) in the intervention group and 13 days (8–65) in the control group.

Interpretation

An effective smoking intervention programme 6–8 weeks before surgery reduces postoperative morbidity, and we recommend, on the basis of our results, this programme be adopted.

Introduction

About a third of all patients who undergo surgery are smokers. Smoking has repeatedly proved an important risk factor for intraoperative and postoperative complications.1, 2, 3, 4 Smokers have an increased frequency of pulmonary, circulatory, and infectious complications, impaired wound healing,5, 6 and postoperative admittance to the intensive-care unit.7

The mechanism leading to this increased risk could include smoking-induced chronic pulmonary changes—such as increased closing capacity, reduced clearance of pulmonary secretions, and chronic obstructive lung disease8—and impaired cardiovascular function,9 immune function,10, 11 and collagen production.6 Findings of physiological studies have shown that most of the smoking-induced changes are reversible to some degree, and that the period needed for a substantial improvement is about 6–8 weeks.12, 13, 14, 15 Warner and colleagues16, 17 showed that patients who stopped smoking 8 weeks before cardiac surgery had fewer pulmonary complications than smokers. The effect of preoperative smoking intervention on the postoperative complication rate, however, needs to be established. We postulated that smoking intervention from 6–8 weeks before surgery could reduce the frequency of postoperative complications after elective surgery. Our objective was to investigate postoperative morbidity and mortality in patients undergoing elective knee and hip replacement.

Section snippets

Patients

Patients scheduled for primary elective hip or knee alloplasty at three university-affiliated hospitals in Copenhagen were invited to enter the study. All daily smokers were eligible for the study. Exclusion criteria included patients with a weekly alcohol intake greater than 35 units.18 The ethics committee for all hospitals in Copenhagen and Frederiksberg approved the study and patients gave oral and written informed consent. The intervention period was 6–8 weeks before and 10 days after

Results

166 patients were eligible for the study, but 46 refused to participate. Thus, 120 were randomly assigned to intervention or control groups (figure 1). Table 1 shows patient's baseline characteristics. 12 patients dropped out of the study because their operation was cancelled or postponed. More than twice as many patients randomised to the intervention group chose to stop smoking than chose to reduce their tobacco consumption (figure 1).

The overall postoperative complication rate was

Discussion

The results of our trial show that postoperative complications can be substantially reduced by smoking intervention 6–8 weeks before hip or knee replacement. The reduction in postoperative complications was most evident for wound-related complications, and, to a lesser extent, cardiovascular complications. The pathophysiological background for these findings could be the reversibility of the effect of tobacco smoking on the vascular system and delayed wound healing.20, 21, 22

Cessation of

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