Elective operations in people who smoke

[blue2000]

Just curious about people's feelings/practice about operating on the actively smoking patient. As a resident, we often had very limited OR time, so tended to defer patients for a million reasons, including smoking. In private practice, I've loosened up on this some, but wonder if I'm within the norm. For instance I saw a guy today with painful but reducible small to moderate bilateral inguinal hernias who smokes. He's a great candidate for a lap inguinal hernia repair, but should I tell him to quit smoking first? What would you do?

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[ESU_MD]

I do a few lung resections from time to time and you can imagine that the vast majority of these folks smoke. I dont turn them down , but use it as an opportunity to send the "quit smoking" message.. Usually these folks are scared to death and most will at least claim they are quitting. Some guys wont operate on lung cancer smokers, but what can you do.

Now a purely elective plastic case, free flap might be different.

As far as hernias, not sure what the data is.. But if you are in private practice beware- if you dont do the case.. The guy down the street will and say goodbye to that referral

 

[Dr.LeoSpaceman]

At our program, the only strict rule is in the bariatrics group. They need to have quit for at least 30 days, and they will test on the day of surgery in patients they don't believe. However, with the tenuous pulmonary status of those patients, and the risk for marginal ulcers (and the headache associated with that), I think it's totally reasonable. Plus, it's another test of willpower. If they can't quit smoking, I doubt they're really going to change their eating habits.

Otherwise, I don't know that I've seen an attending threaten to cancel surgery for smoking.We always counsel about the risks associated with it in surgery, but we don't push. When it's my decision, I suspect I'll be laissez-faire about it as well.

 

[MediCane2006]

We won't operate on smokers for most elective cosmetics cases (although one of my attendings does, after counseling - and documenting - the hell out of increased risk).

For some flaps, skin grafts, etc in big cancer cases sometimes we dont have much of a choice....

 

[dpmd]

In residency we would pretty much ask people to quit but not do anything to check or enforce. There have been a couple of people that I have told we would test on the day of surgery, but that was more as a way of trying to trick them since we don't actually have the ability to run the test (these were generally users of other stuff too and that we can test for so it wasn't a total lie). I do counsel them on the increase in risk and document it well, but unless they have something that make me not want to do the case (for example I won't do a hernia repair in a smoker with a chronic cough) I will do it if there are good indications (if the hernia just bothers them because of how it looks, or causes some mild discomfort with activities they only rarely need to do I would probably not do it. If they are hindered from doing their job or are really symptomatic it is an easier sell). This attitude will change if my bottom line starts to be affected (pay for performance will probably encourage a lot of surgeons to avoid the risky cases).

 

[cpants]

We have a couple of attendings who adamantly insist on smoking cessation before any elective operations. They will test a urine cotinine before even scheduling a patient and the recheck it day of. They also adamantly insist that patients lose weight before proceeding with operations like hernia repairs or ostomy takedowns.

I understand that politically this probably wouldn't fly in private practice...but these guys also have the best outcomes in our department.

Not too surprising when you refuse to operate on smokers and fat people. The definition of selection bias.

In the real world you operate on all comers. Of course, you encourage people to quit smoking and lose weight and you document the additional risks. Most of 'em don't quit or lose weight preop, and they get operations anyway. IMO, while a cancer operation might be 'elective' in the sense that it is scheduled surgery, it's not really elective in the sense that it can wait on a patient who has probably been trying to quit smoking for 40 years to have biochemical evidence of quitting. Cosmetic cases? Sure, refuse to operate on whoever you want. Hernias? I guess, but it's gonna be pretty hard to explain to the jury why the guy didn't get the curative operation he sought out after he incarcerates and dies of sepsis. He was a smoker.....uhhh, so? Smoking is not a contraindication to any surgery, except maybe certain transplants. If the informed patient accepts the added risks associated, who are we to deny them treatment?

 

[SLUser11]

As far as hernias, not sure what the data is.. But if you are in private practice beware- if you dont do the case.. The guy down the street will and say goodbye to that referral

Truer words have never been spoken.

My two cents: smoking cessation has been shown to decrease SSI and pulmonary complications. Obviously if you demand that all your patients lose weight and quit smoking prior to elective surgery, you'll have great outcomes, but you'll have a relatively small cohort.

For me, I almost always counsel patients on smoking cessation and how it will affect their outcomes, which is a really nice checkbox for those using EMRs and focusing on meaningful use, etc. However, I never withold surgery based on the inability or unwillingness to quit. For cancer cases, it's a no-brainer. However, for anorectal cases, it certainly affects my approach, and I'm less likely to do a flap in that situation.

One patient population where I'm relatively strict about smoking cessation is in Crohn's disease. Nothing I can do to them will be too helpful if they keep puffing away.

 

[Winged Scapula]

Like most things, there is a balance of risks and benefits.

As others have noted, if it is truly an elective case with low risk of sequelae if you refuse to operate, then your greatest risk may be loss of referrals. In PP, that may be a significant risk because John Q. Surgeon down the road may not have the same smoking cessation requirements that you do and eventually word gets around that patients are unhappy, the referral coordinator is unhappy and your patient load drops.

Given that my practice is largely oncologic, I don't have the luxury of refusing to operate on smokers. Our EMR makes it easy to document smoking cessation counseling for Meaningful Use criteria and the risks of poor wound healing due to smoking are included in our consent forms. I am clear with patients that they will have higher than average risk of complications in addition to wound problems. The plastic surgeons also warn them and I am pretty graphic about breasts turning black and flaps falling off, implants extruding etc. "Scared Straight!!" Nipple sparing mastectomies don't go straight to implant but rather get tissue expanders and a prolonged reconstruction (ie, "the Angelina Jolie special").

For elective cases, I will defer on a case by case basis. For chronic subareolar abscesses, I refuse to operate until they quit smoking as this is clearly a contributing factor to the problem. Same goes for prophylactic mastectomies in High Risk/BRCA carriers.

Bottom line for cases such as blue presented depends on your and the patient's risk aversion and tolerance for complications.

 

[maxheadroom]

I do a few lung resections from time to time and you can imagine that the vast majority of these folks smoke. I dont turn them down , but use it as an opportunity to send the "quit smoking" message.. Usually these folks are scared to death and most will at least claim they are quitting. Some guys wont operate on lung cancer smokers, but what can you do.

Now a purely elective plastic case, free flap might be different.

As far as hernias, not sure what the data is.. But if you are in private practice beware- if you dont do the case.. The guy down the street will and say goodbye to that referral

Actually, free flaps are relatively nicotine resistant as they have excellent blood supply. The donor site can frequently be a problem, though.

For cosmetic cases and breast reductions the vast majority of Plastic Surgeons will insist upon complete nicotine abstinence for at least four weeks (many closer to six weeks) preop and post op. Skin flap loss on facelift/abdominoplasty/breast reduction is waaaaaay too risky in those cases.

 

[Smurfette]

I don't insist on smoking cessation for most elective procedures. Would like to, but I wouldn't be able to maintain a practice here if I did. Both due to patients who would simply find somebody else (I don't think any general surgeon nearby insists on it, so I'd lose cases left and right), and the inevitable loss of referrals. There is a higher-than-average rate of smokers here so that also makes it more difficult.

Exceptions to the rule: breast patients who want reconstruction, large ventral hernias, patients with history of wound healing issues, etc.

 

[droliver]

The literature is very clear on this for elective hernias, in that you are an IDIOT for operating on smokers. Much higher recurrence rates (up to 3-4x as high) as you get local hypoxia in an unfavorable preexisting anatomic deformity, wound healing is impaired, and a number of protease enzymes are upregulated which serve to weaken the tissues.

There are some operations that you can get away with on smokers without too much of a problem (ie. like liposuction or a breast aug in plastics), but things under tension or that require more undermining of cutaneous flaps are asking for problems.

 

[Pir8DeacDoc]

If pts understand a higher risk of recurrence I don't think it would make one an idiot for doing their surgery. You explain risks and if it recurs it recurs. I agree with you that tissue loss is a more important and potentially disfiguring issue and would require more rigid restriction.

 

[45408]

I would insist that a patient lose weight before I repair a big ventral hernia, and I don't think I'd worry about losing much business, because I think you'd lose business if you're known as the guy whose hernias all recur. Inguinal hernia...I probably wouldn't delay it for weight loss.

For cosmetic cases and breast reductions the vast majority of Plastic Surgeons will insist upon complete nicotine abstinence for at least four weeks (many closer to six weeks) preop and post op. Skin flap loss on facelift/abdominoplasty/breast reduction is waaaaaay too risky in those cases.

Absolutely. You'd think that the risk of your nipple necrosing would be enough to keep patients from puffing away, but I guess not. It's just sad.

Our vascular surgeons will refuse a bypass/angioplasty on patients who are active smokers, as long as the limb isn't acutely threatened, but I don't think anyone else in the general surgery department refuses an operation because someone smokes.

 

[maxheadroom]

The literature is very clear on this for elective hernias, in that you are an IDIOT for operating on smokers. Much higher recurrence rates (up to 3-4x as high) as you get local hypoxia in an unfavorable preexisting anatomic deformity, wound healing is impaired, and a number of protease enzymes are upregulated which serve to weaken the tissues.

There are some operations that you can get away with on smokers without too much of a problem (ie. like liposuction or a breast aug in plastics), but things under tension or that require more undermining of cutaneous flaps are asking for problems.

Yep. I have a partner who does a ton of complex abdominal wall recon in conjunction with General Surgery and they're super fastidious about their patients being nicotine free.

 

[Bostonredsox]

An internist here not a surgeon, but I would assume if you deferred elective cases in people that smoked, based on the #. Of long term smoking COPD'rs I see....you won't have many people to operate on and your local referring PCPs will start using your competition. Not saying its right but that's what I would envision happening. With today's pt population not operating on smokers is like not operating on diabetics or hypertensives.....that's everyone.

 

[dpmd]

An internist here not a surgeon, but I would assume if you deferred elective cases in people that smoked, based on the #. Of long term smoking COPD'rs I see....you won't have many people to operate on and your local referring PCPs will start using your competition. Not saying its right but that's what I would envision happening. With today's pt population not operating on smokers is like not operating on diabetics or hypertensives.....that's everyone.

Depends on your patient population, but you have a point. However, I won't do an elective operation on a diabetic with an A1c more than 6. I think I am probably the strictest of those I work with, but I feel like getting a diabetic down to an acceptable A1c is easier than getting a smoker to quit smoking. Usually it isn't an issue of someone having a 6.5 or so, it is more like a 10 or 12 so giving a goal of 6 for them to go back to their pcp with usually gets me the the results I need (or maybe the patient is going elsewhere, but right now I have a lot of captive patients since they have no funding and typically can't afford to be self pay with someone else).

 

[Chemdocx]

I don't think we every operated on people who smoked on vascular surgery.

 

[Buzz Me]

None of my patients smoke. They all "quit."




1 week ago

 

[Bostonredsox]

Depends on your patient population, but you have a point. However, I won't do an elective operation on a diabetic with an A1c more than 6. I think I am probably the strictest of those I work with, but I feel like getting a diabetic down to an acceptable A1c is easier than getting a smoker to quit smoking. Usually it isn't an issue of someone having a 6.5 or so, it is more like a 10 or 12 so giving a goal of 6 for them to go back to their pcp with usually gets me the the results I need (or maybe the patient is going elsewhere, but right now I have a lot of captive patients since they have no funding and typically can't afford to be self pay with someone else).

Why <6? The goal a1c for diabetics is <7. And if its a type 1 on a pump or pure insulin therapy or an older patient the goal rises to 7.5-8. Diabetics on therapy, especially if its insulin, who have an a1c of 6 are 9 times out of 10 having significant hypoglycemic episodes. I get wanting your elective pts to be at goal with their therapies and be in "tiptop" shape....but to expect them to be well beyond the goal, which in the case of diabetes is quite dangerous, doesn't make sense to me.

 

[dpmd]

Why <6? The goal a1c for diabetics is <7. And if its a type 1 on a pump or pure insulin therapy or an older patient the goal rises to 7.5-8. Diabetics on therapy, especially if its insulin, who have an a1c of 6 are 9 times out of 10 having significant hypoglycemic episodes. I get wanting your elective pts to be at goal with their therapies and be in "tiptop" shape....but to expect them to be well beyond the goal, which in the case of diabetes is quite dangerous, doesn't make sense to me.

I don't mean under 6, I mean I want it to be 6. Since the AACE recommends a level of less than 6.5 if it can be achieved safely, I don't see how that is well beyond the goal. Certainly if there are reasons that a person can't safely get that low I may reconsider, however as I specifically said before I am talking about people who are sitting at 10+ which isn't an appropriate number regardless of what guideline you want to refer to. Oddly enough, plenty of these have come back with numbers that were under 6.5 without suffering from a bunch of hypoglycemic episodes. Now, if the patient met criteria for the higher goal it is possible their comorbidities would make them a subpar candidate for surgery anyway (limited life expectency or advanced vascular complications not being things that make me want to do really elective cases with).

 

[Bostonredsox]

So you mean you want them to be 6.0 or your ok with 6.9? Like I said only reason I was asking is ACP, AAFP and ACC all recommend treating to a goal A1c of less than 7, meaning anything in the 6.9 and under route. But the greater majority of us back off on our insulin dosing if we are seeing an a1c of 6.1 in a 70 year old. An a1c of 6.0 correlates with an avg blood sugar of 130. A diabetic on insulin whose avg blood sugar is 130 is more often than not having spikes of 210-240 and lows in the 70s, thus we back off the insulin to allow the a1c to climb back to 6.7-6.9, decreasing the likelihood they are having hypoglycemic episodes. Now if there a1c is 6.0 on januvia and metformin, they are by definition still making endogenous insulin and we are not worried about hypoglycemia as these medicines cannot in themselves cause it. If Sulfonylureas and insulin are what is being used, an a1c of 6.0 is not advised and is a setup for hypoglycemic episodes which can be life threatening.

So if by "6" you mean 6.5-6.9, were all good in the hood. But if you truly want your patient to be 6.0 and they are on s'urea's and/or insulin, that is asking for trouble and I would not increase my patients treatment regimen to get them to 6.0 for whatever surgery.

 

[KLPM]

http://www.heraldsun.com.au/news/vi...dical-guidelines/story-fni0fit3-1226669753464

SMOKERS will be asked to quit before undergoing surgery and be referred for help while on waiting lists under new medical guidelines.

A strengthened smoking policy from the Australian and New Zealand College of Anaesthetists will require all elective surgery patients to be asked if they smoke, and for tobacco users to be given referrals to help them quit before their operations.

The policy will not give practitioners the power to delay or cancel surgery. But ANZCA president Dr Lindy Roberts said the guidelines would offer smokers the best chance to avoid life-threatening complications by providing them with support.

The hope is to convince and help smokers to quit four to six weeks before surgery, while they are already on the waiting list, which can greatly cut the risks of serious complications during recovery.

"Smokers are at greater risk of complications such as pneumonia, heart attacks and wound infections," Dr Roberts said.

"When you are coming into hospital for something like an operation, it does provide you with an opportunity to think about your health more generally, and the benefits of giving up smoking for your health are in the longer term as well as relating to surgery and anaesthesia.

"It may be that when presented with the risks for a certain procedure that the surgery is delayed to allow somebody to improve their health prior to the surgery.

"From time to time a decision may be made between the anaesthetist, the surgeon and the patient to delay the surgery if there is something that can be improved to make them fitter for surgery."

The move follows the success of a Frankston Hospital program in which all smokers entering the surgery waiting list were sent a quit pack - prompting 13 per cent to act and contact Quitline. Australian Medical Association Victorian president Victoria president Dr Stephen Parnis said the college's quit-smoking stance was a positive move, balancing the need to advise patients without discriminating.

"This is not about banning people, this is about giving them the best chance to benefit," Dr Parnis said. "When you weigh into account the procedure they need and their health, if there is a benefit to delaying the procedure then we would do that."

edit: Irrelevant video.

[YOUTUBE]http://www.youtube.com/watch?v=xByE8CB9cz0[/YOUTUBE]

 

[dpmd]

But they already have a waiting list for surgery it seems. Would be different here where the longest I have to wait to schedule an elective case is typically three weeks for Medi-cal, and with some of the funding sources I can schedule them in 3 days. For someone to quite 4-6 weeks before surgery I would be delaying their surgery quite a bit and would give them a greater chance of going elsewhere. We can't do the same sort of combined effort here because for the most part people are still practicing independently.

 

[KLPM]

But they already have a waiting list for surgery it seems. Would be different here where the longest I have to wait to schedule an elective case is typically three weeks for Medi-cal, and with some of the funding sources I can schedule them in 3 days. For someone to quite 4-6 weeks before surgery I would be delaying their surgery quite a bit and would give them a greater chance of going elsewhere. We can't do the same sort of combined effort here because for the most part people are still practicing independently.

That is true. I just want to put some perspective regarding the hospital the article mentioned. It's a suburb a fair distance from a major metropolitan hospital. Most of the patients cannot really afford to go elsewhere even if they wanted. Thus there isn't much risk in this case for them to go elsewhere.

But I agree with your point. If you delayed a procedure for 4-6 weeks in someone who can easily go elsewhere then you will be giving away a lot of patients. One of the anaesthetist working at that hospital is like the "quit smoking guru" and has focused all his research on perioperative smoking risks and methods of getting people to quit.

 

[dpmd]

Don't get me wrong, I think it is a great idea. Just not practical here so much.