Tobacco and Complications After Bariatric Surgery

Smoking and Obesity: What's the Connection?

Smoking is often cited as a major risk factor in the development of heart disease and atherosclerosis. However, the relationship between obesity and nicotine consumption isn't so straightforward. In the general population, smokers tend to weigh less than non-smokers. However, when they quit smoking, they may gain weight during the first year. This relationship is less clear-cut in individuals with severe obesity.

It's established that among overweight individuals, at least 40% are smokers. Smokers with a high BMI tend to consume more cigarettes per day. These smokers are more prone to a strong dependence on tobacco than their thinner counterparts.

Sleeve Gastrectomy and Tobacco

Sleeve gastrectomy is a weight-loss surgery that involves reducing the size of the stomach, thus limiting food intake. However, in terms of recovery and healing, smoking tobacco before and after this operation can have serious adverse consequences. Tobacco use can impair blood circulation and tissue oxygenation, slowing healing and increasing the risk of postoperative complications. It is therefore strongly recommended that patients considering sleeve gastrectomy quit smoking before the operation and during the recovery period to optimize their chances of success.

How Does Smoking Affect the Body?

Whether active or passive, smoking significantly impairs the body, causing various harmful effects. This is even more concerning for individuals with obesity and diabetes, as they are already prone to chronic inflammation of all tissues. Cigarette smoke directly affects the endothelium, the inner lining of blood vessels, irritating and damaging it, disrupting blood flow and leading to the formation of microangiopathies. Over time, these complications can have serious consequences on various tissues in the body.

What Problems Can Occur with Bariatric Surgery in a Smoker?

Smoking during or after surgery can lead to various problems. For example, obese patients who smoke are at risk of developing thromboembolic complications, i.e., blood clots. Thrombi are small clots inside blood vessels that are risk factors for more serious and unfortunately sometimes fatal problems. This can occur when small fragments of thrombi detach, travel through the bloodstream, and reach an artery so small that it completely closes, preventing blood flow (embolism). If the clot travels to the brain, it can trigger a stroke. Similarly, if it reaches the lungs, it can cause a pulmonary embolism, while blockage in a renal artery can lead to a renal infarction.

Respiratory Problems and Bariatric Surgery in a Smoker

Obese patients who smoke can suffer from respiratory problems, such as pneumonia. These respiratory problems are more serious because they start from an underlying condition of a tired heart. Obese smokers have difficulty breathing. They often sleep poorly precisely because they don't breathe well. These patients have episodes of apnea at night. They also have inflamed trachea and bronchi. During surgery, they may experience respiratory crises. These crises sometimes require re-intubation or even transfer to intensive care to ensure adequate postoperative breathing. It is therefore very important to improve this respiratory function in order to achieve optimal respiratory conditions for bariatric surgery.

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What Can Be the Surgical Complications in a Smoker?

For smokers, it's essential to consider potential surgical complications such as bleeding, ulcerations, or healing problems, closely linked to cigarette consumption. These risks are real and must be taken very seriously.

When surgeons make incisions (anastomoses) in the stomach tissues, poor blood supply can lead to ischemic lesions. This is because blood doesn't circulate well, oxygen is scarce or completely absent, and small groups of cells become ischemic. In this case, patients have a higher risk of ulcers in the stomach. As they heal, these ulcers cause small retractions over time, narrowing that can cause dysphagia in operated patients.

The entire gastric mucosa tends to redden, become more inflamed with cigarette smoke. Chronic smokers will tend to have inflammation. This inflammation causes narrowing in an already narrowed stomach. Thus, the total volume of what the patient can eat may be slightly less. Especially smokers who consume coffee tend to skip snacks. These individuals will tend to eat less protein. Smoking can also indirectly lead to nutritional alterations that need to be managed.

Smoking After Bariatric Surgery

Undergoing bariatric surgery, it's crucial to note that smoking can negatively impact the patient's healing and recovery. Not only does cigarette smoke contain carbon monoxide, which can hinder blood circulation and disrupt tissue repair, but it also increases the risk of postoperative complications such as infections and healing problems. In their best interest, it's strongly recommended that patients undergoing bariatric surgery quit smoking before the procedure.

It's essential for smokers to understand that quitting can be challenging, but it's paramount to persevere to minimize the risk of complications after surgery. If you're struggling to quit, talk to your doctor for help and advice on smoking cessation programs and treatment options.

How Long to Stop Smoking Before Surgery?

We've long known that smoking is a risk factor for major problems. We also know that the longer the smoking history, the higher the risk of complications or, in any case, a more complex evolution. It is precisely for this reason that major scientific societies have developed guidelines with very precise recommendations regarding smoking cessation for bariatric surgery.

It is recommended to stop smoking at least six weeks before the procedure. A very recent review, published in June 2020, suggests advising the patient to stop smoking a year before the intervention. This is to greatly improve the postoperative course, and many teams comply with this.

When it comes to patients' health, it's essential that they don't resume bad habits after surgery. After all, their lifestyle and health status will undergo significant changes, and it's crucial that they take care of themselves.

After the operation, surgeons ask the patient to get involved, to run, to do physical activity. They must therefore be in the best possible condition, including respiratory.

Can Quitting Smoking Make You Gain Weight?

In many cases, quitting smoking can lead to weight gain (approximately 4 to 5 kg/year), visceral obesity, and an increased risk of type 2 diabetes. These factors often discourage smoking cessation. It's essential to counteract this effect, which can be done with pharmacological treatment to help gradually break the smoking habit, such as nicotine patches or varenicline. Other medications used to combat tobacco dependence include bupropion and nicotine substitutes.

Gastric Surgical Procedures

The stomach, a vital organ of the digestive system, acts as a balloon-shaped sac located between the esophagus and the intestine to collect, digest, and liquefy ingested food.

The stomach, located in the center of the upper part of the abdominal cavity, under the diaphragm, can be divided into three parts:

• The upper part starts with the cardia, which is the passage between the esophagus and the stomach and continues with the fundus, which is the highest part of the stomach and forms a kind of dome;
• The body, under the fundus, descends vertically, narrows, and curves to the right;
• The antrum follows the body and ends with the pylorus, a muscular sphincter that is released allowing the passage of gastric contents into the duodenum;

Postoperative Effects of Smoking After Bariatric Surgery

For all smokers, it is essential to stop tobacco use before and after surgery. If you are considering bariatric surgery, you are on the right path to a healthier life. However, smoking can lead to serious illnesses such as diabetes and heart problems, conditions that bariatric surgery aims to treat. It is therefore crucial to quit smoking to optimize the chances of success of your operation and improve your overall health.

Furthermore, bariatric surgery patients who are also smokers should know whether their smoking habit before surgery affects their postoperative life. Let's look at a study to find the answer. According to a study titled "Smoking in bariatric surgery: a systematic review", smoking is strongly associated with long-term postoperative complications, including marginal ulcers and bone fractures, to name a few.

Additionally, smoking has been identified as a risk factor for increased mortality rates and affects the severity of other postoperative complications such as pulmonary and wound complications.

Now that you have an overview, let's look at the most common postoperative complications due to smoking before and after bariatric surgery.

Recommended to Quit Smoking

Smoking cessation is a health investment that cannot be overlooked. There are ways to significantly reduce the risk of contracting multiple diseases. Although quitting smoking on your own is possible, the chances of success increase with the support of professionals, whether your doctor or specialists in cessation. The latest data published by ISTAT reveals that approximately 90% of former smokers succeeded without assistance, but after an average of 6 attempts. In fact, studies show that the more support you receive, the more likely you are to definitively end your tobacco consumption.

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