1. Clearing the Air COPYRIGHT © 2014, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2014 Dear Consult Guys: Need your help in “clearing the air” about a patient who I saw today. Mr. J is 60 years old and is due to have surgical repair of a ventral hernia in 6 weeks. His medical history is unremarkable except for smoking ½ to 1 pack cigarettes which he has done for 40 years and continues to do. He has no history of cardiac, renal, GI, or surprisingly pulmonary disease. He leads an active life and routinely performs more than 4 mets activity. He is taking no medications Physical exam: Bp 120/70, HR 70 Cardiac rhythm regular, S1 S2 normal, no murmur JVP, carotid upstroke normal Abdominal exam reveals large ventral hernia Lungs clear BS normal Distal pulses intact, no edema I’ve estimated his risk of complication relating to ventral hernia repair to be low. The question I have though relates to his smoking. He told me today that he would like to use the upcoming surgery as an opportunity to stop smoking. He says that he is finally motivated and asked for my help and advise to begin as soon as possible. Here’s the conflict: I remember learning that smoking cessation less than 8 weeks before surgery can actually increase the risk of perioperative pulmonary complication. I know that its not intuitive and seems even strange but should I advise him not to stop smoking before surgery and then after surgery attempt to rekindle his enthusiasm to stop. Can you guys clear the air on this one? Sincerely, Concerned Doc Dear Consult Guys: Need your help in “clearing the air” about a patient who I saw today. Mr. J is 60 years old and is due to have surgical repair of a ventral hernia in 6 weeks. His medical history is unremarkable except for smoking ½ to 1 pack cigarettes which he has done for 40 years and continues to do. He has no history of cardiac, renal, GI, or surprisingly pulmonary disease. He leads an active life and routinely performs more than 4 mets activity. He is taking no medications Physical exam: Bp 120/70, HR 70 Cardiac rhythm regular, S1 S2 normal, no murmur JVP, carotid upstroke normal Abdominal exam reveals large ventral hernia Lungs clear BS normal Distal pulses intact, no edema I’ve estimated his risk of complication relating to ventral hernia repair to be low. The question I have though relates to his smoking. He told me today that he would like to use the upcoming surgery as an opportunity to stop smoking. He says that he is finally motivated and asked for my help and advise to begin as soon as possible. Here’s the conflict: I remember learning that smoking cessation less than 8 weeks before surgery can actually increase the risk of perioperative pulmonary complication. I know that its not intuitive and seems even strange but should I advise him not to stop smoking before surgery and then after surgery attempt to rekindle his enthusiasm to stop. Can you guys clear the air on this one? Sincerely, Concerned Doc

4. Can smoking cessation lead to increased risk ? When does smoking cessation lower perioperative risk? Smoking Cessation in the Perioperative Period Copyright © 2014

5. Perioperative Pulmonary Complications *Warner MA, et al. Role of Preoperative Cessation of Smoking and Other Factors in Postoperative Pulmonary Complications: A Blinded Prospective Study of Coronary Artery Bypass Patients. Mayo Clinic Proceedings. 1989; 64: 609-616. Smoking StatusComplications Never smoked12% Stopped > 6 months preop12% Stopped > 8 weeks preop14% Stopped < 8 weeks preop57% Current smoker33%

6. Perioperative Pulmonary Complications Conclusion: Smoking cessation should occur at least 8 weeks prior to surgery. Quitting within 8 weeks does not increase complication rates higher than current smoking. *Warner MA, et al. Role of Preoperative Cessation of Smoking and Other Factors in Postoperative Pulmonary Complications: A Blinded Prospective Study of Coronary Artery Bypass Patients. Mayo Clinic Proceedings. 1989; 64: 609-616. Smoking StatusComplications Never smoked12% Stopped > 6 months preop12% Stopped > 8 weeks preop14% Stopped < 8 weeks preop57% Current smoker33%

7. Copyright © 2014

9. Myers K. Stopping Smoking Shortly Before Surgery and Postoperative Complications. JAMA Internal Medicine. 2011; 171: 983-989.

10. Lindstrom D. Effects of a Perioperative Smoking Cessation Intervention on Postoperative Complications: A Randomized Trial. Annals of Surgery. 2008; 248: 739-745.

11. Clearing the air No evidence that brief preoperative smoking cessation increases pulmonary risk Meta-analysis of available studies does not find an increase in risk The mechanism to explain increased risk – increased sputum production – does not occur following smoking cessation Support the patient to stop smoking now Copyright © 2014

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