Should recent smoking be a contraindication for sleeve gastrectomy?

BACKGROUND: One of the ultimate goals of bariatric and metabolic surgery is to decrease cardiovascular morbidity and mortality. Obese individuals who smoke tobacco are at an increased risk of cardiovascular events and may benefit the most by positive effects of bariatric surgery on cardiometabolic risk factors. The safety profile of sleeve gastrectomy in patients who smoke has not yet been characterized.

OBJECTIVES: To investigate the independent effect of smoking on early postoperative morbidity and mortality of laparoscopic sleeve gastrectomy.

SETTING: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

METHODS: All patients undergoing primary laparoscopic sleeve gastrectomy from 2010 to 2014 were identified within the NSQIP database. Thirty-day postoperative outcomes for smokers, defined as patients who smoked within the year before surgery, were compared with nonsmokers.

RESULTS: A total of 33,714 people underwent sleeve gastrectomy; 30,418 (90.2%) patients were nonsmokers, whereas 3296 (9.8%) patients smoked within a year before surgery. Among the 17 examined individual adverse events, patients who smoked were more likely to experience an unplanned reintubation (odds ratio [OR] = 1.88, 95% confidence interval [CI]: 1.01-3.50). Patients in the smoking group were significantly more likely to experience a composite morbidity event (4.3% versus 3.7%, P = .04), serious morbidity event (.9% versus .6%, P = .003), and 30-day mortality (0.2% versus .1%, P = .0004). The length of hospital stay, unplanned readmission, and readmission rates were comparable between the 2 groups. These differences in the composite morbidity event, serious morbidity event, and mortality persisted even when those patients with chronic obstructive pulmonary disease, used as a surrogate for end-stage pulmonary effects of smoking, were excluded from the analysis.

CONCLUSION: Sleeve gastrectomy is a well-tolerated procedure in nonsmokers and smokers. However, patients who have smoked within a year before sleeve gastrectomy are at an increased, albeit still very low, risk for 30-day morbidity and mortality compared with nonsmokers. Additional studies are needed to determine if long-term improvement in co-morbidities can offset this initial modest increased perioperative risk.