Everybody knows that smokin’ ain’t allowed (in school) before lung surgery!

In the 1973 classic ‘Smokin’ in the Boys Room’, the Brownsville Station’s singer refrain is—‘don’t want the teacher to fill me up with your rules, but everybody knows that smokin’ ain’t allowed in school!’ [1] Similarly, the universal medical directive including pre-op lung cancer resection is ‘Stop Smoking’. Kadomatsu, Sugiyama and others in the article ‘Relationship of smoking cessation period with the incidence of complications in lung cancer surgery’ [2] re-evaluates the length of smoking cessation and pack-years of smoking on lung cancer resection morbidity and outcomes.

The authors have shown in 911 patients undergoing lung cancer resection from 2014 to 2017 that pulmonary complications including pneumonia, prolonged air-leak and empyema and total complications are 5 times and 2 times higher respectively in smokers as compared to the non-smoker groups. The pre-op smoking cessation intervals included—9.6% patients in the current (<4 weeks) group, 17% patients in recent (4 weeks to 12 months) group, 13% in the distant (12 months to 5 years) group and 30% ex-smokers (>5 years) group. Using this classification, postoperative complications were greater in current versus recent groups but both were less than distant and ex-smoker cohorts. Interestingly, the ex-smoker group had fewer post-op complications than the distant group and the distant cohort had more complications than the current and recent smoking groups.

This flies in the face of school teachers and surgical dogma. Recent smokers fared better than patients who had quit at least 12 months ago. We encourage our patients to “Stop Smoking” at all visits and particularly prior to operation, but all too often this plea falls on deaf ears. My personal experience is that smoking increases prior to operation as the patient’s anxiety ramps up. I have not denied a potentially curative procedure if a patient has continued smoking. In fact, a 2018 abstract by Serna-Gallegos et al. [3] posits that there is increased upstaging as the time from clinical staging to resection increases in patients with Stage I non-small-cell lung cancer who undergo lobar resection and lymph node staging. These data would argue for early intervention and avoiding delay even in patients who continued to smoke awaiting curative lung resection.

The patient usually confabulates how their smoking has decreased prior to operation when checked against ‘honest’ family member accounts. Those smoking up to their operative date have a more morbid postoperative course, but we have not shown an increased mortality related to failure to cease smoking preoperatively. Our pre-op rehabilitation protocol for low FEV1 patients [4] included cessation of smoking. We noted increased morbidity, but no difference in mortality for those receiving pre-op rehabilitation versus those who declined pre-op rehabilitation.

In addition, the authors did not demonstrate a linear relationship of pack-year smoking to post-op pulmonary morbidity. With the recent article by Yamamichi et al. [5] demonstrating an increase in pulmonary complications for thoracoscopic lung cancer surgery, the teacher’s rules have remained constant. This article affirmed that smoking cessation is a valuable adjuvant prior to lung resection. However, Yamamichi et al. [5] noted that pack-years of smoking did not correlate with outcomes as did the authors of the Kadomatsu et al. [2] manuscript being discussed.

An example is an 80-year old who has smoked for 60 years, has excellent pulmonary function tests and sails through the postoperative course. An identical patient with low FEV1/marginal pulmonary function tests will have a difficult postoperative course. The authors’ correlation of pulmonary complications with depressed lung function is probably their best take-home lesson. Ex-smokers or distant smokers with long smoking histories will likely have the worst pulmonary function tests and the highest incidence of pulmonary complications.

Although the authors did not show a linear relationship between pack-years smoking, and cessation period prior to surgery, they did demonstrate that current smokers had increased postop complications compared to recent smokers. They emphasized that non-smokers had improved outcomes compared to any smoking cohort. At least for now, the ‘Smokin’ in the Boys Room’ lyrics—‘teacher’s rule that everyone knows smoking ain’t allowed (in school) before surgery’—is still in effect!

REFERENCES