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. 2011 Dec 6;14(3):320–323. doi: 10.1093/icvts/ivr093

Table 1:

Best-evidence papers

Author, date, journal and country. Design duration study type (level of evidence) Patient group Outcome(s) Results Comments/Weaknesses
Barrera et al., (2005), Chest, USA, [3] Prospective observational cohort study (level 2b) n = 300 (144 males, 156 females. Average age: 64 ± 12 years)

  1. Current smokers: 13 (4%)

  2. Stopped 1 week-2 months pre-op: 39 (13%)

  3. Stopped >2 months pre-op: 184 (62%)

  4. Non-smokers: 64 (21%)

Exclusions: <18 years, second surgery during admission, undergoing concomitant rib, chest wall, diaphragmatic, pericardial or pleural resections

  1. Respiratory failure requiring ICU admission and/or intubation

  2. Pneumonia

  3. Atelectasis requiring bronchoscopy

  4. Pulmonary embolism

  5. Need for supplemental oxygen therapy at discharge

 Overall complications:

  1. 3 (23%)

  2. 9 (23%)

  3. 34 (19%)

  4. 5 (8%)

Overall more pulmonary complications noted in smokers compared to non-smokers (P = 0.03) but no difference among the subgroup of smokers (P = 0.76)

  • - Single centre, small sample size (especially number of current smokers), relied on questionnaire rather than chemical confirmation for determination of smoking status, results reflect complications which may not be associated with smoking (i.e. pulmonary embolism)
Groth et al. (2009), Lung Cancer, USA, [4], Retrospective cohort study (level 2b) n = 121 (all male patients, mean age: 67.4 years)

  1. Current smokers: 23

  2. Quit smoking <1 month before surgery: 16

  3. Quit smoking >1 month before surgery: 81

Excluded: 1 patient (lifetime non-smoker)

  1. Air leak

  2. Reintubation

  3. Pneumonia

  4. Any complications
    1. 8.0%
    2. 6.3%
    3. 8.5%
    1. 0%
    2. 6.3%
    3. 4.9%
    1. 12.0%
    2. 6.3%
    3. 12.2%
    1. 44%
    2. 18.8%
    3. 42.7%

  • - Rate of PPC incidence not affected significantly by smoking status across three groups

  • - Single centre, retrospective, only male patients, lack of statistical power, small sample size, patients self-reporting of smoking status
Mason et al. (2009), Ann Thorac Surg, USA, [2] Multicentre prospective cohort study (level 2b) n = 7990 (3862 males, 4128 females), Analysed = 7965 (25 died on day of op)

  1. Current smokers: 1595 (23%)

  2. Quit 14 days–1 month pre-op: 404 (6%)

  3. Quit 1–12 month pre-op: 940 (12%)

  4. Quit smoking >1 year pre-op: 4026 (58%)

  5. Never smoked: 1025 (13%)

Exclusions: patients aged <18, emergency operations, or missing data on age, gender, operation date

  1. Hospital mortality—death occurring within hospitalization period

  2. Pulmonary complications—prolonged ventilation (>48 h post-op), reintubation, atelectasis requiring bronchoscopy, tracheostomy, neumonia, and ARDS
    1. 24 (1.5%)
    2. 7 (1.7%)
    3. 12 (1.3%)
    4. 62 (1.5%)
    5. 4 (0.39%)
    1. 110 (6.9%), P = 0.03
    2. 25 (6.2%), P = 0.14
    3. 60 (6.4%), P = 0.2
    4. 234 (5.8%), P = 0.3
    5. 27 (2.6%)

  • - Mortality was lower with longer intervals of smoking cessation before resection

  • - Risk of major pulmonary complications steadily decreased as interval between cessation and operation increased. No sharp transition suggesting optimal timing of cessation

  • - Self-reported and voluntary data collection that lacks formal auditing may predispose to underreporting of outcomes, smoking status based on self-reporting (bias)
Nakagawa et al. (2001), Chest, Japan, [5] Retrospective cohort study (level 2b) n = 288 (167 males, 121 females)

  1. Never smoked: 117

  2. Quit > 4 weeks before operation: 121

  3. Quit 2–4 weeks before operation: 13

  4. Current smoker: 37

  1. Atelectasis prompting bronchoscopy

  2. Pneumonia

  3. PaCO2 > 50 mmHg 24 h post-op

  4. Air leak or effusion requiring intercostals tube drainage for > 7 days

  5. Bronchopleural fistula with large air leak or infection

  6. Empyema

  7. Chylothorax

  8. Hemothorax requiring drainage/reoperation

  9. Tension pneumothorax

  10. Pulmonary embolism

  11. Lobar gangrene

  12. Mechanical ventilation > 72 h

  13. Intercostal tube drainage > 14 days

  14. Required fraction of inspired oxygen > 0.6 post-op

 Total complications in each patient group:

  1. 28 (23.9%)

  2. 42 (34.7%)

  3. 7 (53.8%)

  4. 16 (43.2%)

  • - Incidence of pulmonary complications amongst current/recent smokers was higher than never smokers (P < 0.05)

  • - Risk for developing PPCs declined in patients who stopped smoking 5–8 weeks prior to surgery, and risk for complication in patients whose pre-operative smoke-free period was >10 weeks was similar to that in the never-smokers group

  • - Self-reporting of smoking status, retrospective study, single centre, small sample size
Sawabata et al. (2007), Gen Thorac Cardiovasc Surg, Japan, [6] Multicentre Retrospective cohort study (level 2b) n = 169 (89 males, 80 females)

  1. Never smoked: 66

  2. Ex-smoker (stopped >1 year prior to cancer diagnosis): 36

  3. Current smoker: 67

  1. 5-year survival rate
    1. 91%
    2. 88%
    3. 72%

  • - Current smokers showed a worse survival rate than those in other two groups, although the difference was only statistically significant between the never-smoked group and current smokers (P = 0.02)

  • - Retrospective, small sample size, self-reporting of smoking status
Shimizu et al., (2008), Interact CardioVasc Thorac Surg, Japan, [7] Retrospective cohort study (level 2b) n = 194, (123 males, 71 females, average age: 68.8 ± 10 years)

  1. Non-smokers: 70

  2. Ex-smokers (quit > 12 months before surgery): 40

  3. Current smokers (smoked within 12 months of surgery): 84

  1. Respiratory complications—pneumonia, atelectasis, prolonged air leakage, bronchopleural fistula

  2. Cardiac event
    1. 7 (10%)
    2. 9 (23%)
    3. 16 (19%)

  • - Current smokers/ex-smokers did not show a significant difference in respiratory complications (P = 0.65)

  • - Retrospective, small sample size, self-reporting of smoking status
Vaporciyan et al. (2002), Ann Thorac Surg, USA, [8] Retrospective cohort study (level 2b) n = 261 (179 males, 78 females, average age: 60 ± 10 years)

  1. Never smoked: 34 (13.2%)

  2. Quit >1 month before operation: 163 (63.4%)

  3. Quit <1 month before operation: 60 (23.3%)

Excluded: patients who died within 12 h of op from cardiac or haemorrhagic cause

  1. Major pulmonary event- pneumonia, ARDS

  2. Mortality

  3. Length of stay (LOS) in hospital
    1. 5 (14.7%)
    2. 15 (9.2%)
    3. 13 (21.7%)
    1. 1 (2.9%), b + c 15 (6.7%)
    1. 10.35 ± 11.85 days, b + c 11.87 ± 14.57 days

  • - Timing of smoking cessation increased the incidence of pulmonary complications (P = 0.013)

  • - The mortality rates were significantly higher in non-smokers compared to smokers (P = 0.40), however, the LOS was not (P = 0.57)

  • - Also, mortality and LOS were much higher in those with PPCs compared to those without (P < 0.001)

  • - Retrospective, small sample size, single centre