Abstract: Comparative Evaluation of Smoking in Plastic versus General Surgical Postoperative Complications: A Propensity-Matched Analysis

Abstract

INTRODUCTION: Smoking is an established modifiable risk factor for perioperative complications.1 This is especially relevant in elective plastic surgical (PS) than in urgent general surgical (GS) procedures. From 2005–2014, smoking rate among U.S. adults decreased from 20.9% to 16.8%. 2 This study compares smoking prevalence in patients undergoing plastic and general surgical procedures, and the postoperative complication profile when smoking is isolated as an independent risk factor. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to examine smoking and 30-day postoperative complications for plastic and general surgical procedures. Patients were propensity-score matched (PSM) for demographics and comorbidities to isolate smoking and minimize confounders. RESULTS: We examined 294,903 patients from 2005–2014. The smoking rates in GS cohort paralleled national trends (R=-0.85); smoking rates in PS patients were significantly lower for all years studied (p<0.01). After PSM, GS smokers continued to be more comorbid than respective nonsmokers, with greater incidences of diabetes, hypertension, dypsnea, and prior cardiac surgery (p<0.01); PS smokers were not significantly different than respective nonsmokers. Smokers had increased rates of superficial surgical site infections (SSI) (p<0.01), PE (p<0.01), and MI (p<0.02) for GS, but not for PS cohort. Both PS and GS smokers had increased dehiscence (p<0.01), deep SSI (PS: p=0.01, GS: p<0.01), and reoperation (p<0.01). Patients with ≥11 pack-years experienced significant increases in deep SSI (PS: p=0.02, GS: p=0.02) and reoperation (PS: p=0.05, GS: p<0.01). In GS smokers, ≥ 21 pack-years was associated with increased sepsis (p<0.01), MI (p=0.04) and organ/space SSI (p<0.01), and ≥ 31 pack-years was associated with increased dehiscence (p<0.01). PS cohorts had increased rates of wound complications for both smokers and non-smokers when compared to GS cohorts. CONCLUSION: This is the first propensity-matched, large-scale database analysis isolating smoking as a risk factor for postoperative complications in PS and GS procedures. The contrast in smoking rates between GS and PS patients highlights the differences in patient selection for urgent versus elective procedures. Our data indicates that smoking is an independent risk factor for PS and GS procedures. Smoking may also have different risk factor profiles for postoperative complications in PS versus GS patient populations emphasizing the need for caution when generalizing GS evidence for use in the PS population. Reference Citations: 1. Coon Devin, Tuffaha Sami, Christensen Joani, B. S. C. (2013). Plastic Surgery and Smoking. Plastic and Reconstructive Surgery, 132(4), 686e–687e. 2. Jamal, A., Homa, D. M., O’Connor, E., Babb, S. D., Caraballo, R. S., Singh, T., … King, B. A. (2015). Current Cigarette Smoking Among Adults - United States, 2005–2014. MMWR. Morbidity and Mortality Weekly Report, 64(44), 1233–40. http://doi.org/10.15585/mmwr.mm6444a2