Mediation of smoking-associated postoperative mortality by perioperative complications in veterans undergoing elective surgery: data from Veterans Affairs Surgical Quality Improvement Program (VASQIP)—a cohort study

Abstract

ObjectiveTo assess the mediation of smoking-associated postoperative mortality by postoperative complications.DesignObservational cohort study.SettingUsing data from the Veterans Affairs (VA) Surgical Quality Improvement Programme, a quality assurance programme for major surgical procedures in the VA healthcare system, we assessed the association of current smoking at the time of the surgery with 6-month and 1-year mortality.Primary and secondary outcome measuresUsing mediation analyses, we calculated the relative contribution of each smoking-associated complication to smoking-associated postoperative mortality, both unadjusted and adjusted for age, race/ethnicity, work relative value unit of the operation, surgeon specialty, American Society of Anesthesiologists class and year of surgery. Smoking-associated complications included surgical site infection (SSI), cardiovascular complications (myocardial infarction, cardiac arrest and/or stroke) and pulmonary complications (pneumonia, failure to wean and/or reintubation).ResultsThere were 186 632 never smokers and 135 741 current smokers. The association of smoking and mortality was mediated by smoking-related complications with varying effects. In unadjusted analyses, the proportions of mediation of smoking to 6-month mortality explained by the complications were as follows: SSIs 22%, cardiovascular complications 12% and pulmonary complications 89%. In adjusted analyses, the per cents mediated by each complication were as follows: SSIs 2%, cardiovascular complications 4% and pulmonary complications 22%. In adjusted analyses for 1-year mortality, respective per cents mediated were 2%, 3% and 16%.ConclusionsPulmonary complications, followed by cardiovascular complications and SSIs were mediators of smoking-associated 6-month and 1-year mortality. Interventions targeting smoking cessation and prevention and early treatment of pulmonary complications has the likelihood of reducing postoperative mortality after elective surgery.

Cardiopulmonary exercise testing screening and pre‐operative pulmonary rehabilitation reduce postoperative complications and improve fast‐track recovery after lung cancer surgery: A study for 342 cases

“…Interventions targeting prevention and early treatment of pulmonary complications have the likelihood of reducing postoperative mortality after elective surgery. 25 Testing the pre-operative prediction of pathogens, which may be involved in airway infection, could guide antibiotics. 26 Of course, the emergence of antimicrobial resistance has been contemporaneous with the intensive use of antibiotics.…”

Peer Review #1 of "E-cigarettes versus nicotine patches for perioperative smoking cessation: a pilot randomized trial (v0.1)"

“…Furthermore, veterans may face unique challenges in smoking cessation, given the perception that smoking was a normalized part of military life (Gierisch et al 2012) and the high rate of coexisting mental health disorders (Duffy et al 2012). An analysis within the Veterans Affairs (VA) healthcare system showed that pulmonary complications, cardiovascular complications, and surgical site infections were mediators of smoking-associated mortality at 6-months and 1-year after elective surgery (Singh et al 2013). A systematic review has shown that preoperative smoking cessation therapy improves both short and long-term smoking cessation (Thomsen et al 2014).…”

Optimize perioperative health and begin with insistence on pre-operative smoking cessation

“…There is no doubt any longer that smoking confers additional risk to surgical patients and that more smoking confers more risk. 3 There have been suggestions that amount of smoking has an association with amount of complications. 4 It seems clear that an incomplete smoking cessation intervention should provide some health benefit but that the large and obvious benefits of intensive interventions and many weeks of effective smoking cessation should be the goal.…”