Smoking increases risk of anastomotic leak after left colectomy

Last Updated: 2015-04-23

By Rita Buckley

NEW YORK (Reuters Health) - Smokers are at increased risk of anastomotic leak after left colectomy, and surgeons should consider postponing elective cases until the patient stops smoking, researchers say.

Dr. Rebeccah B. Baucom and colleagues at Vanderbilt University Medical Center in Nashville, Tennessee, evaluated smoking as an independent risk factor for anastomotic leak in 246 adults who had left colon resections between 2008 and 2012.

The 29 current smokers accounted for 12% of the cohort.

"Notably, the nonsmoking group tended to be older, female, and with higher American Society of Anesthesiologists (ASA) classification," the researchers wrote in their report online March 28 in the American Journal of Surgery.

Most of the operations were done for diverticulitis (53%), cancer (37%), or polyps that couldn't be resected endoscopically (8%).

Within 30 days of surgery, 16 patients developed leaks requiring return to the operating room or percutaneous drainage. Leaks were significantly more common in smokers (17% vs 5%, p=0.01).

On multivariate analysis, odds ratios for a clinical anastomotic leak were 4.2 in smokers vs nonsmokers (p=0.02) and 3.5 in patients with a low anterior anastomosis vs a sigmoid anastomosis (p=0.02).

The rate of organ space infection, a secondary outcome, was higher in smokers (17% vs 8%), but the difference did not reach statistical significance.

In light of these outcomes and other data showing negative effects of smoking on wound healing, physical function, and emotional and social well-being, the researchers suggest that smoking cessation prior to elective colectomy should be seriously considered.

Attempts to help patients stop smoking vary widely by practice and individual surgeons, Dr. Baucom told Reuters Health by email. "Wound complications after certain procedures in some specialties, such as plastic surgery, have been well described, making smoking cessation easier to discuss," she said.

In other areas of surgery, specific risks are less clearly defined. "This makes conversations with patients about the risks that smoking adds to their operations more challenging," she said.

In elective cases, Dr. Baucom said, some surgeons simply tell patients that the risks of the operation are too high until they stop smoking, and leave the way of doing so up to the patients.

Other clinicians use several approaches to help patients stop smoking. "Coaching is probably the most widely used method," Dr. Baucom said, noting that this involves advice to quit smoking with a clear, strong message about the health risks associated with it.

The next step, she said, is to assess readiness to quit. If a patient expresses an interest in doing so, he or she receives counseling about triggers, withdrawal symptoms, and other aspects of stopping. "These can help them develop strategies for coping with such situations," she said.

She said referral to smoking-cessation programs, online or through a telephone hotline, can also help.

Dr. Deborah A. Nagle, chief of colon and rectal surgery at Beth Israel Deaconess Medical Center in Boston, who was not involved in the study, told Reuters Health by email that urgent or semi-urgent surgery can preclude smoking cessation. "In those cases, physicians may address the need to stop smoking and suggest the use of surgical intervention as a starting point," she said.

A 2003 paper in Colorectal Disease reported that cessation of smoking for two to three weeks before colorectal surgery did not reduce the risk of tissue and wound healing problems or other complications. (The paper is here: http://bit.ly/1EhyGCt.)

Both Drs. Baucom and Nagle agree that smoking cessation for four weeks prior to surgery is optimal.

"We should recommend smoking cessation for patients before colorectal surgery, support efforts to quit, and even delay surgery for four weeks or more after patients stop smoking," said Dr. Nagle.

SOURCE: http://bit.ly/1Jxhwk8

Am J Surg 2015.