Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Abstinence by alcohol misusers for 1 month before surgery reduced complications in the month after surgery

ACP J Club. 1999 Sept-Oct;131:38. doi:10.7326/ACPJC-1999-131-2-038


Source Citation

Tønnesen H, Rosenberg J, Nielsen HJ, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ. 1999 May 15;318:1311-6. [PubMed ID: 99257222]


Abstract

Question

In adults who misuse alcohol (i.e., consume ≥ 5 drinks or 60 g ethanol/d) and are scheduled for colorectal surgery, can abstinence for 1 month before surgery reduce complications in the month after surgery?

Design

Randomized (concealed), unblinded, controlled trial with follow-up 1 month after surgery.

Setting

3 gastrointestinal surgery centers in Denmark.

Patients

42 adults who misused alcohol (i.e., consumed ≥ 5 drinks/d) and were referred for elective colorectal surgery were enrolled, and 35 (mean age 60 y, 91% men) completed the study. Exclusion criteria were disseminated malignant disease, bowel obstruction, alcohol-related illness, change in surgical status, drug abuse, psychiatric disease other than alcohol abuse, or unfamiliarity with the Danish language.

Intervention

20 adults were allocated to 1-month withdrawal from alcohol and disulfiram, 800 mg twice per week until the week before surgery, and 22 were allocated to usual care. Other procedures and medications were the same for all participants.

Main outcome measures

Major or minor complications within 30 days of surgery that required treatment. Secondary outcomes were mortality and measures of surgical stress.

Main results

The groups did not differ for length of hospital stay (8 d for intervention vs 10 d for usual care). Patients in the abstinence group had fewer complications overall (P = 0.02) (Table) than did patients in the usual care group, who also showed trends toward decreased major complications (12.5% vs 42%, P = 0.07) and minor complications (25% vs 58%, P = 0.09). The groups did not differ for mortality (6% vs 11%, P = 1) and need for secondary intraperitoneal or superficial surgery (P = 0.07 and 1, respectively). The abstinence group had fewer surgical stress responses for 4 of 7 indications (heart rate and levels of plasma interleukin 6, adrenaline, and noradrenaline). On the 2nd day, fewer patients in the abstinence group developed myocardial ischemia (23% vs 85%) or arrhythmias (33% vs 86%) and had fewer nightly hypoxemic events (4 vs 18) (P ≤ 0.05 for all comparisons).

Conclusion

Abstinence for 1 month before elective colorectal surgery reduced the rate of complications requiring treatment in adults who drank ≥ 5 drinks/d or 60 g alcohol/d.

Source of funding: Danish Ministry of Health's fund for Alcohol Research.

For correspondence: Dr. H. Tønnesen, Clinical Unit of Preventive Medicine and Health Promotion, Bispebjerg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark. FAX 45-3531-3999.


Table. Abstinence vs usual care for adults who abused alcohol and received colorectal surgery*

Outcome at 1 month Abstinence Usual care RRR (95% CI) NNT (CI)
Complications 31.3% 73.7% 57.6% 3 (2 to 12)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

Few studies have focused on patients with hazardous or harmful drinking habits who have major surgical procedures. Prospective observational studies have found that patients who drink ≥ 5 drinks/d are at greater risk for complications after surgery (1). In the study by Tønnesen and colleagues, the intervention was not described in detail and patients scheduled for gastrointestinal surgery were highly motivated and did not have previous medical problems associated with alcohol. All intervention patients reported abstinence, a dramatic result that is inconsistent with the literature on brief interventions for alcohol problems. This may be explained by the intensive treatment with disulfiram in hazardous drinkers who were motivated by upcoming surgery. Nonetheless, the study showed that abstinence before surgery can decrease complications after surgery.

Brief interventions for alcohol problems can decrease alcohol intake, improve liver function, decrease health care utilization, and link patients to treatment for alcohol dependence (2, 3). The results of the study suggest that abstinence is a worthy goal before surgery for persons with hazardous drinking habits. But many questions remain: Will abstinence be an achievable goal for less motivated patients with hazardous drinking habits who have other procedures? Is disulfiram necessary? What psychosocial intervention is the necessary ingredient for success? Is this approach suitable for persons dependent on alcohol? Until these questions are answered, it seems reasonable to advise patients with hazardous drinking habits to abstain 1 month before elective surgery. We can wait with cautious optimism to see if these results can be reproduced and extended to other surgical populations and to alcohol-dependent patients.

Richard Saitz, MD, MPH
Boston Medical Center/Boston University School of MedicineBoston, Massachusetts, USA


References

1. Tønnesen H, Peterson KR, Hojgaard L, et al. Postoperative morbidity among symp-tom-free alcohol misusers. Lancet. 1992;340:334-7.

2. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction. 1993;88:315-35.

3. Chafetz ME. A procedure for establishing therapeutic contact with the alcoholic. Q J Stud Alcohol. 1961;22:325-8.