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Eur J Cardiothorac Surg 2002;22:287-291
© 2002 Elsevier Science NL

Impaired postoperative outcome in chronic alcohol abusers after curative resection for lung cancer

^a Department of Cardiothoracic Surgery, Gentofte Hospital, University of Copenhagen, Niels Andersens Vej 65, DK-2900 Hellerup, Denmark
^b Clinical Unit of Preventive Medicine and Health Promotion, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark

Received 6 December 2001; received in revised form 10 April 2002; accepted 23 April 2002.

* Corresponding author. Tel.: +45-3977-3797; fax: +45-3977-7644
e-mail: jeped{at}gentoftehosp.kbhamt.dk

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objective: It has been demonstrated that chronic alcohol misusers, who drink at least 60 g of ethanol per day, are suffering increased postoperative morbidity after various non-pulmonary surgical procedures. The aim of this study was to evaluate the association between alcohol consumption and postoperative morbidity and mortality after potential curative resection for lung cancer. Methods: The records of all patients who underwent curative resection for lung cancer in a single University Centre in Cardiothoracic surgery during 1997 and 1998 were retrospectively reviewed. One hundred and seven patients, 42 women and 65 men, median age of 64 (33–79) years, were included and subdivided with regard to alcohol consumption. There were 26 pneumonectomies, 68 lobectomies and 13 lesser resections. Clinical complications occurring within 30 days after surgery and requiring therapy, were registered and subdivided into major, potentially lethal complications, and minor complications. Mortality within 30 days after surgery was also registered. Results: Patients drinking at least 5 drinks per day had increased postoperative mortality, 3/13 versus 2/94 (odds ratio (95% confidence limits): 13.80 (2.06–92.68); P=0.007). The rate of major, live threatening complications including septicaemia and cardiopulmonary insufficiency was significantly increased among patients drinking at least 5 drinks per day 6/13 versus 19/94 (odds ratio (95% confidence limits): 3.38 (1.02–11.25); P=0.047) in univariate analysis. However, in multivariate analysis this association was not significant. Conclusion: Postoperative mortality after curative resection for lung cancer was significantly increased among patients drinking at least 5 drinks of alcohol per day.

Key Words: Alcohol abuse • Lung cancer • Lung resection • Morbidity • Mortality • Postoperative complication

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Preoperative prediction of postoperative outcome in patients undergoing lung resection has mainly concerned pulmonary function, stage of disease and cardiac risk. However, lifestyle factors such as smoking seem also to be of relevance [1] and recently evidence has been gathered showing that excessive intake of alcohol leads to a three fold increase of postoperative morbidity after non-pulmonary surgical procedures [2].

The aim of this study was therefore in a retrospective manner to evaluate any possible association between preoperative alcohol consume and postoperative outcome after curative resection for lung cancer.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
The records of all patients undergoing resection for non-small-cell lung carcinoma in 1997 and 1998 in our department were evaluated. One hundred and twenty-two patients, 47 women and 75 men with median age of 64 (range 33–79) years at the time of surgery, underwent potentially curative resection, and the perioperative data of these patients were registered. As a routine in Denmark, all patients are asked about the amount of alcohol they usually drink, and alcohol consume was available in the records of 107/122 (88%) patients. The remaining 15 patients were excluded from the study. The average daily consumption of alcohol is given as the number of drinks no matter of the type of alcoholic beverage; one drink containing 12 g of ethanol. The patients were allocated in two groups according to their daily consumption of alcohol: 0–4 drinks and 5 or more drinks.

The tumor stage was based on the pathologic evaluation of the specimen.

The standard surgical procedure for lung resection was a muscle-sparing posterolateral thoracotomy followed by wedge resection, resection of one or two pulmonary lobes (lobectomy) or a pneumonectomy, depending on the tumor stage and the predicted postoperative pulmonary function of the patient.

Further preoperative and intraoperative characteristics of the patients are given in Table 1.

2.1. Statistics
All data processing was done with the SPSS 8.0 software. The level of significance was 0.05. Data are given as median (range) and odds ratio (OR) (95% confidence interval (CI)).

With major complications and postoperative mortality within 30 days as dependent variables the independent association was tested for sex, age, alcohol consumption, smoking status, pulmonary function, chronic disease including previous cancer, surgical procedure, duration of surgery, intraoperative bleeding, transfusion of blood and stage of disease. Each independent variable was analysed in a univariate model and if the significance level was less than 0.10 the variable was included in a multivariate model. Continuous variables were tested for linearity and, if not linear, categorized.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Considering the preoperative and intraoperative data, the only remarkable difference between the two groups was the absence of women in the group of patients 5 drinks or more (Table 1).

There were 69% with stage I disease in the group drinking 5 or more vs. 58% in the other group; 8% stage II vs. 16% and 23% stage III vs. 26%.

A total of 70 complications occurring among 38 patients were registered within 30 days after surgery (Table 2). In univariate analysis overall morbidity was insignificantly increased among patients drinking at least 5 drinks per day (Fig. 1) . However, the rate of major complications was significantly increased among patients drinking at least 5 drinks per day (6/13 versus 19/94; OR (95% CI): 3.38 (1.02–11.25); P=0.047) (Fig. 1). Among these complications, there were two cases of septicaemia, four cases out of nine suffering cardiopulmonary insufficiency (requiring intensive care) and two cases out of eight developing empyema in the group of patients drinking at least 5 drinks per day.

View larger version (20K): [in this window] [in a new window]   Fig. 1. Morbidity and mortality rates within 30 days after lung resection according to preoperative alcohol consumption. *P=0.047 (major complications); P=0.007 (mortality).

In multivariate analysis including blood transfusion and alcohol consumption, only blood transfusion was significantly associated to major complications (OR (95 CI): 5.33 (2.04–13.94)). However, we find it acceptable to conclude that there is a trend towards major complications among alcoholic patients.

There was a single case of alcohol abstain-symptoms, as was expected in a heavy-drinking patient. No patients suffered from acute myocardial infarction or pulmonary embolism.

There were no significant differences with regard to the number of days until removal of the last drain or the length of hospital stay between the alcohol groups.

There were no intraoperative deaths, but five patients died within 30 days after operation; three of them were drinking at least 5 drinks per day, and alcohol consumption was the only pre- or intraoperative factor that was significantly associated to postoperative mortality (3/13 versus 2/94: OR (95% CI): 13.80 (2.06–92.68); P=0.007) (Fig. 1). Two more patients died within the same hospital stay but beyond 30 days, both drinking less than two drinks per day. The causes of death in the heavy-drinking group were: cardiopulmonary arrest at day one (necropsy revealed no further diagnosis); multiple organ failure (MOF) including adult respiratory distress syndrome (ARDS) at day 4; and MOF including septicaemia at day 18. The causes of death in the group drinking up to 2 drinks per day were empyema, MOF and cardiopulmonary insufficiency (two cases).

All of the patients dying and drinking 5 drinks or more were suffering from chronic diseases: previous hepatitis, previous cancer of the prostate and thrombophlebitis in one patient; coronary disease in one patient; chronic obstructive lung disease (COLD) in one patient. Only one of the other patients dying was suffering from hypertension. However, chronic disease was not associated to postoperative mortality.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
This study shows a significant association between preoperative consumption of at least 60 g of ethanol per day and increased postoperative mortality among patients undergoing curative resection for lung cancer. It also demonstrates a trend towards major complications among alcohol abusers.

Previous studies of the association between preoperative alcohol consumption and postoperative morbidity after non-thoracic surgery have shown similar results [2–4].

Two previous works have concerned preoperative alcohol consume and lung resection. Canver et al. [5] studied a population of 79 veterans in a retrospective chart review, and 23 (29.1%) were drinking more than 2 drinks per day. No conclusion was made on the influence of alcohol intake on outcome, but overall 30-day mortality was 3.7%, and thus within the mortality rates generally reported. In a large study on 3516 patients undergoing major lung resection, Harpole et al. [6] found no influence on outcome among 18.7% of the patients with a preoperative consume of more than 2 drinks per day.

Beneficial effects of moderate alcohol consumption such as protection against coronary heart disease and death from cancer are well known from the literature [7,8], and intake of one bottle of red wine have been shown to increase coronary blood flow significantly [9]. However, some of the underlying mechanisms, i.e. the antithrombotic effect which may be protective in a lifetime-perspective, may be adverse during surgical stress.

The increased postoperative morbidity and mortality in alcoholic patients described in the literature is mainly due to infections, bleeding problems and cardiopulmonary insufficiency [2]. All deaths in the present study are related to severe complications of these kinds, and they occur more often among the alcohol abusers. The pathogenic mechanisms are thought to be immunosuppression, haemostatic imbalance, preclinical cardiac insufficiency and exaggerated response to surgical stress, which has been shown among symptom-free alcohol misusers after colorectal surgery [10].

However, the conclusions of the present study are not very strong due to methodological problems. The main problems are the retrospective design and the small number of cases. Thus death within 30 days is a rather seldom event and though preoperative alcohol consumption is significantly associated with postoperative death, the confidence interval is rather broad indicating the need to do a study in a larger cohort of patients. Multivariately, alcohol consumption is over-ruled by the stronger association with blood transfusion when looking at major complications, and this is well known from the literature [11].

The fact that there were no women in the heavy-drinking group could impact our results, but sex was not associated to postoperative outcome.

In Denmark all patients are asked about the amount of alcohol they usually drink at the routine history taking by the medical doctor at admission. The data are thus non-validated, and compared to other measures of alcohol consumption, some degree of understatement could be expected. The following misclassification would consist of alcohol patients included in the group with lower intake, while the opposite is not probable [12,13].

The mortality among patients drinking 5 drinks or more may partly be due to chronic diseases. On the other hand, this group did not suffer a higher rate of or more serious chronic diseases compared to the other groups (Table 1), and the outcome among all patients suffering from chronic diseases was not impaired. A history of chronic alcohol abuse have been related to increased risk of developing adult respiratory distress syndrome in critically ill patients [14], and it is a possible mechanism whereby chronic alcohol abuse compounds the effects of chronic diseases in our study.

Another methodological problem in this study could be selection of patients for lung resection. This study only considers patients operated upon for cure and the preoperative selection of patients may have excluded patients with a poor performance due to excessive alcohol consumption.

Other lifestyle factors such as smoking may be of importance for the development of postoperative complications [1,6,15–18]. Three out of four patients in the drinking group of the present study were smokers, but the smoking rates are high among both of the groups, and the difference is insignificant (Table 1). Smoking status was not related to postoperative outcome in our study, but the reports of smoking may be insufficient. Probably most of the patients were former smokers, and no data were obtained considering when they stopped smoking.

The outcome in our non-alcoholic patients, showing a 30-day morbidity and mortality of 33 and 2.1%, respectively, did not differ from other studies reporting 30-day morbidity and mortality of 27–60% and 1.3–8.6% in patients with lung cancer [5,15,16,19–24]. However, it should be noted that the definitions of postoperative complications varies among the literature; some reporting only cardiopulmonary complications and some including complications, that did not lead to secondary treatment. As well, the 30-day mortality in many studies included in-hospital mortality beyond 30 days.

In conclusion, this study indicates that preoperative assessment of perioperative risk among patients undergoing lung resection should include a consideration of the patient's intake of alcohol. The evidence of a negative association between high alcohol consumption and impaired postoperative outcome after lung resection needs to be prospectively evaluated in large-scale trails including intervention. Withdrawal from alcohol 1 month before surgery may reduce postoperative morbidity among alcohol abusers according to a recent study among patients admitted for colorectal surgery [25].

	Acknowledgments

 
The authors thank Jette Vibe Petersen, M.D. for her assistance in the statistical analysis. The study was performed at the Department of Cardiothoracic Surgery, Gentofte Hospital, University of Copenhagen, Denmark.

	Footnotes

 
Part of this report was orally presented at the Nordic Biological Alcohol Research Meeting, Oslo, Norway, September 7–10, 2000 and at the 9th International Conference on Health Promoting Hospitals, Copenhagen, Denmark, May 16–18, 2001.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

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