Effects of perioperative alcohol cessation interventions on postoperative complications following surgery

Review question

We assessed the evidence from randomized controlled trials to determine whether not drinking alcohol during the perioperative period reduces postoperative complications for people with risky alcohol consumption. These programmes supported participants in quitting drinking or in reducing their alcohol consumption before, during, and after surgery. 'Risky drinking' was defined as alcohol consumption equivalent to more than 3 alcoholic units (three small glasses of wine) per day or 21 units per week - with or without alcohol abuse or dependency. Most clinical studies report that consuming this amount of alcohol increases postoperative complication rates.

Background

Risky consumption of alcohol is a global problem, and alcohol is an important threat to world health. More than 3.3 million deaths annually are associated with risky use of alcohol, and global alcohol consumption continues to increase. People who have a high level of alcohol consumption often require planned and emergency surgical procedures.

Risky drinking affects surgical outcomes - even when the disease is not alcohol related. Typical surgical complications include infections, heart and breathing problems, and bleeding episodes. Alcohol causes disorders of the liver, pancreas, and nervous system. Stopping drinking of alcohol can normalize these organ systems to some degree and may reduce the occurrence of complications after surgery. Quitting drinking can result in mild to severe alcohol withdrawal symptoms and may lead to a change in lifestyle.

This review was first published in 2012 and was updated in 2018.

Search date

The evidence is current to 21 September 2018.

Study characteristics

We included three randomized controlled trials with a total of 140 participants. All three studies included participants with risky alcohol intake (3 to 40 AU daily) who were in need of surgery. These studies investigated intensive alcohol interventions aimed at complete alcohol cessation at the time of surgery compared with no intervention. Interventions included educational strategies for alcohol withdrawal and relapse prevention. Programmes were started three months before surgery, four weeks before surgery, and from the time of admission to surgery, and continued for six weeks after surgery, respectively.

Quality of the evidence

The quality of the evidence is of moderate to low quality.

Key results

In all three studies, intensive intervention programmes clearly increased the number of participants who quit drinking alcohol. The occurrence of postoperative complications appeared to be reduced as well. Of 61 participants in the intervention groups, 20 had complications requiring treatment, compared with 33 of 61 participants in the control groups (moderate-quality evidence). Of 70 participants in the intervention groups, 41 successfully quit drinking, compared to five of 70 participants in the control groups (moderate-quality evidence). Data were insufficient to show the effect of quitting drinking on the number of deaths (low-quality evidence), and results show no effect on length of hospital stay. None of the included studies reported on the number of participants who continued to avoid risky drinking in the longer term (at three-, six-, nine-, and 12-month follow-up).

Included studies were few and reported small sample sizes; therefore one should be careful about drawing firm conclusions based on these results. All three studies were conducted in Denmark, and most participants were men. The included participants may represent a selective group, as they could be more motivated and/or more interested in participating in clinical research or otherwise different, and effects may therefore have been overestimated for both intervention and control groups in these studies. More research is needed and new strategies are required to improve outcomes after surgery among risky drinkers.

Authors' conclusions: 

This systematic review assessed the efficacy of perioperative alcohol cessation interventions for postoperative complications and alcohol consumption. All three studies showed a significant reduction in the number of participants who quit drinking alcohol during the intervention period. Intensive alcohol cessation interventions offered for four to eight weeks to participants undergoing all types of surgical procedures to achieve complete alcohol cessation before surgery probably reduced the number of postoperative complications. Data were insufficient for review authors to assess their effects on postoperative mortality. No studies reported an effect on length of stay, and no studies addressed the prevalence of risky drinking in the longer term.

Included studies were few and reported small sample sizes; therefore one should be careful about drawing firm conclusions based on these study results. All three studies were conducted in Denmark, and most participants were men. The included participants may represent a selective group, as they could have been more motivated and/or more interested in participating in clinical research or otherwise different, and effects may have been overestimated for both intervention and control groups in these studies. Trial results indicate that these studies are difficult to perform, that strong research competencies are necessary for future studies, and that further evaluation of perioperative alcohol cessation interventions in high-quality randomized controlled trials is needed. Once published and assessed, the one 'ongoing' study identified may alter the conclusions of this review.

Read the full abstract...
Background: 

Risky consumption of alcohol is a global problem. More than 3.3 million deaths annually are associated with risky use of alcohol, and global alcohol consumption continues to increase. People who have high alcohol consumption often require planned and emergency surgical procedures.

Risky drinking is associated with increased postoperative complications such as infections, cardiopulmonary complications, and bleeding episodes. Alcohol causes disorders of the liver, pancreas, and nervous system. Stopping consumption of alcohol can normalize these organ systems to some degree and may reduce the occurrence of complications after surgery.

This review was first published in 2012 and was updated in 2018.

Objectives: 

To assess the effects of perioperative alcohol cessation interventions on rates of postoperative complications and alcohol consumption.

Search strategy: 

We searched the following databases up until 21 September 2018: Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; Embase; CINAHL via EBSCOhost; and two trials registers. We scanned the reference lists and citations of included trials and any identified relevant systematic reviews for further references to additional trials. When necessary, we contacted trial authors to ask for additional information.

Selection criteria: 

We included all randomized controlled trials (RCTs) that evaluated the effects of perioperative alcohol cessation interventions on postoperative complications and alcohol consumption. We included participants with risky consumption of alcohol who were undergoing all types of elective or acute surgical procedures under general or regional anaesthesia or sedation, who were offered a perioperative alcohol cessation intervention or no intervention.

We defined 'risky drinking' as alcohol consumption equivalent to more than 3 alcoholic units (AU)/d or 21 AU/week (with 1 AU containing 12 grams of ethanol) with or without symptoms of alcohol abuse or dependency. This corresponds to the amount of alcohol associated with increased postoperative complication rates in most clinical studies.

Data collection and analysis: 

We used guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions. We presented main outcomes as dichotomous variables in a meta-analysis. When data were available, we conducted subgroup and sensitivity analyses to explore the risk of bias. Primary outcome measures were postoperative complications and in-hospital and 30-day mortality. Secondary outcomes were successful quitting at the end of the programme, postoperative alcohol use, and length of hospital stay. We assessed the quality of evidence using the GRADE approach.

Main results: 

We included in this updated review one new study (70 participants), resulting in a total of three RCTs (140 participants who drank 3 to 40 AU/d). All three studies were of moderate to good quality. All studies evaluated the effects of intensive alcohol cessation interventions, including pharmacological strategies for alcohol withdrawal symptoms, patient education, and relapse prophylaxis. We identified one ongoing study.

Overall, 53 of the 122 participants from three studies who underwent surgery developed any type of postoperative complication that required treatment. Of 61 participants in the intervention groups, 20 had complications, compared with 33 of 61 participants in the control groups (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.40 to 0.96). Results show differences between the three clinical studies regarding outcome measurement and intensity of the interventions. However, all alcohol cessation programmes were intensive and included pharmacological therapy. The overall quality of evidence for this outcome is moderate.

In-hospital and 30-day postoperative mortality rates were low in the three studies. Researchers reported one death among 61 participants in the intervention groups, and three deaths among 61 participants in the control groups (RR 0.47, 95% CI 0.07 to 2.96). The quality of evidence for this outcome is low.

Investigators describe more successful quitters at the end of the intervention programme than among controls. Forty-one out of 70 participants in the intervention groups successfully quit drinking compared with only five out of 70 participants in the control groups (RR 8.22, 95% CI 1.67 to 40.44). The quality of evidence for this outcome is moderate.

All three studies reported postoperative alcohol consumption (grams of alcohol/week) at the end of the programme as median and range values; therefore it was not possible to estimate the mean and the standard deviation (SD). We performed no meta-analysis. All three studies reported length of stay, and none of these studies described a significant difference in length of stay. Data were insufficient for review authors to perform a meta-analysis. No studies reported on the prevalence of participants without risky drinking in the longer term.

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