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Why Is Your Patient With Crohn's Disease Still Smoking? Impact of Smoking on Surgical Outcomes
Adriana Olariu^*1, Caitlin W. Hicks², Lillias Maguire¹, Richard a. Hodin¹, Liliana Bordeianou^1
1General Surgery, Massachusetts General Hospital, Boston, MA; ²General Surgery, Johns Hopkins Hospital, Baltimore, MD

Introduction:
The influence of smoking on the course of Crohn's disease (CD) has been the subject of recent controversy, with several studies suggesting no negative impact from tobacco use. The aim of this study is to assess the effects of smoking on the length of small bowel (SB) resected, postoperative complications, reoperation rate, and disease phenotype in CD patients.

Patients and methods:
A retrospective review of 130 consecutive CD patients who underwent ileocolic resection between 2008-2013 was performed. Patients were classified according to their smoking status at surgery into smokers and non-smokers. Demographics, disease characteristics, preoperative medical treatment, complications and pathology reports were reviewed. Univariable and multivariable analyses were used to compare the two groups.
Results:
23 (18%) smokers and 107 (82%) non-smokers were similar in terms of age, gender, comorbidities, CD behavior and indications for surgery (see Table 1). Although the two groups had similar disease duration (12 vs 11.9 years, p=0.97), smokers were more likely to undergo a reoperation because of symptomatic recurrence (48% vs 26%, p=0.04). Smokers had similar rates of exposure to steroids (64% vs 55%, p=0.44) and anti-TNFs (35% vs. 39%, p=0.69). However, 13% of smokers and 3% of non-smokers were on rescue therapy with Methotrexate (p=0.07).
Ultimately, both groups had similar surgical outcomes but smokers required additional surgical procedures more frequently, including strictureplasties and secondary colonic resections (65% vs 42% p=0.04).
On final pathologic assessment, both groups had similar rates of active (83% vs 83%, p=0.96) and chronic inflammation (78% vs 90%, p=0.13), stricturing disease (39% vs 48%, p=0.46) and fistulization (13% vs 30%, p=0.12). However, inflammation was present at the resection margin in 9 (75%) smokers vs. 29 (39%) non-smokers (p=0.03). The mean length of resected SB was 21.4+/-2.3 cm in smokers vs. 21.8+/-1.8 cm in non-smokers (p=0.89). On multivariable analysis aimed at determining predictors of length of SB resection, reoperation increased the length of SB resected (17.6+/-3.5 cm vs 24.7+/-3.1 cm, p=0.04) and this variable appeared to be collinear with smoking.

Conclusions:
Eighteen percent of CD patients who underwent surgery continued to smoke at the time of the intervention. Smoking may accelerate disease activity, potentiate disease severity, and increase surgical recurrence, as manifested by the more frequent use of rescue therapy and the higher reoperation rate in this group despite similar disease duration. Preoperative smoking cessation should be encouraged and aggressive postoperative smoking cessation should be pursued in all CD patients to minimize lifetime SB loss to disease and at surgery.

Table 1. Characteristics of smoking vs. non-smoking CD patients treated with ileocolic resection

Variable	Smokers (N=23)	Non-Smokers (N=107)	p-value
Age (years)	42 ± 3.3	38.8 ± 1.5	0.36
Duration of disease (years)	12 ±2.6	11.9 ± 1.2	0.97
Males (%)	52.2	47.7	0.69
Comorbidities (%)	34.8	21	0.16
CD Behavior (%)
Non-stricturing, non- penetrating	4.35	6.54	0.69
Stricturing	82.6	76.6	0.53
Penetrating	39.1	42.1	0.80
Perianal disease modifier	13	17.8	0.58
Preoperative Medications (%)
Steroids	63.6	54.7	0.44
5-ASA	21.7	29.3	0.47
Anti-TNF	34.8	39.3	0.69
6MP	4.4	12.3	0.46
Azathioprine	17.4	19.8	0.79
Methotrexate	13	2.83	0.07
Cyclosporine	0	0.94	1.00
Antibiotics	39.1	34.3	0.64
Indications for Surgery (%)
Small Bowel Obstruction	73.9	68.2	0.59
Perforation	8.7	9.35	0.92
Abscess	26.1	18.7	0.40
Fistula	21.7	25.2	0.72
Cancer	8.7	3.74	0.29
Refractory Symptoms	43.5	43	0.97
Bleed	8.7	8.41	0.96
Other	0	5.6	0.59

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