Egholm Julie Wm, Pedersen Bolette, Møller Ann Merete, Adami Johanna, Juhl Carsten B, Tønnesen Hanne
Orthopaedic Department, Hospital of Southern Jutland, University of Southern Denmark, Aabenraa, Denmark, 6200.
Cochrane Database Syst Rev. 2018 Nov 8;11(11):CD008343. doi: 10.1002/14651858.CD008343.pub3.
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.
To assess the effects of perioperative alcohol cessation interventions on rates of postoperative complications and alcohol consumption.
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.
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.
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.
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.
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.
危险饮酒是一个全球性问题。每年有超过330万人的死亡与危险饮酒有关，而且全球酒精消费量持续上升。大量饮酒的人常常需要接受计划性手术和急诊手术。危险饮酒与术后并发症增加有关，如感染、心肺并发症和出血事件。酒精会导致肝脏、胰腺和神经系统紊乱。停止饮酒可在一定程度上使这些器官系统恢复正常，并可能减少术后并发症的发生。本综述首次发表于2012年，并于2018年更新。
评估围手术期戒酒干预措施对术后并发症发生率和酒精消费量的影响。
截至2018年9月21日，我们检索了以下数据库：Cochrane图书馆中的Cochrane对照试验中心注册库（CENTRAL）；MEDLINE；Embase；通过EBSCOhost检索的CINAHL；以及两个试验注册库。我们浏览了纳入试验的参考文献列表和引用文献，以及任何已识别的相关系统评价，以获取更多试验的参考文献。必要时，我们联系试验作者以获取更多信息。
我们纳入了所有评估围手术期戒酒干预措施对术后并发症和酒精消费量影响的随机对照试验（RCT）。纳入的参与者为有危险饮酒行为且正在接受全身麻醉、区域麻醉或镇静下的各类择期或急性手术的患者，他们被给予围手术期戒酒干预或未接受干预。我们将“危险饮酒”定义为饮酒量相当于每天超过3个酒精单位（AU）或每周超过21个AU（1个AU含12克乙醇），无论有无酒精滥用或依赖症状。这与大多数临床研究中与术后并发症发生率增加相关的酒精量相对应。
我们采用了《Cochrane干预措施系统评价手册》提供的指南。我们在荟萃分析中将主要结局呈现为二分变量。如有数据，我们进行亚组分析和敏感性分析以探讨偏倚风险。主要结局指标为术后并发症以及住院期间和30天死亡率。次要结局为项目结束时成功戒酒、术后酒精使用情况以及住院时间。我们采用GRADE方法评估证据质量。
在本次更新的综述中，我们纳入了一项新研究（70名参与者），共计三项RCT（140名参与者，每日饮酒量为3至40 AU）。所有三项研究质量中等至良好。所有研究均评估了强化戒酒干预措施的效果，包括针对酒精戒断症状的药物策略、患者教育和预防复发措施。我们识别出一项正在进行的研究。总体而言，三项研究中接受手术的122名参与者中有53人发生了任何类型需要治疗的术后并发症。干预组的61名参与者中有20人出现并发症，而对照组的61名参与者中有33人出现并发症（风险比（RR）0.62，95%置信区间（CI）0.40至0.96）。结果显示三项临床研究在结局测量和干预强度方面存在差异。然而，所有戒酒项目均为强化项目且包括药物治疗。该结局的总体证据质量为中等。三项研究中住院期间和术后30天的死亡率较低。研究人员报告干预组的61名参与者中有1人死亡，对照组的61名参与者中有3人死亡（RR 0.47，95% CI 0.07至2.96）。该结局的证据质量较低。研究人员描述干预项目结束时成功戒酒的参与者比对照组更多。干预组的70名参与者中有41人成功戒酒，而对照组的70名参与者中只有5人成功戒酒（RR 8.22，95% CI 1.67至40.44）。该结局的证据质量为中等。所有三项研究均报告了项目结束时术后酒精消费量（每周酒精克数）的中位数和范围值；因此无法估计均值和标准差（SD）。我们未进行荟萃分析。所有三项研究均报告了住院时间，且这些研究均未描述住院时间存在显著差异。数据不足，综述作者无法进行荟萃分析。没有研究报告长期无危险饮酒参与者的患病率。
本系统评价评估了围手术期戒酒干预措施对术后并发症和酒精消费量的疗效。所有三项研究均显示干预期间戒酒的参与者数量显著减少。对接受各类手术的参与者提供为期四至八周的强化戒酒干预措施，以在手术前实现完全戒酒，可能会减少术后并发症的数量。数据不足，综述作者无法评估其对术后死亡率的影响。没有研究报告对住院时间的影响，也没有研究探讨长期危险饮酒的患病率。纳入的研究较少且样本量小；因此，基于这些研究结果得出确切结论时应谨慎。所有三项研究均在丹麦进行，且大多数参与者为男性。纳入的参与者可能代表一个选择性群体，因为他们可能更有积极性和/或对参与临床研究更感兴趣，或者在其他方面有所不同，并且这些研究中干预组和对照组的效果可能都被高估了。试验结果表明这些研究实施困难，未来研究需要强大的研究能力，并且需要在高质量随机对照试验中对围手术期戒酒干预措施进行进一步评估。一旦已识别的一项“正在进行”的研究发表并得到评估，可能会改变本综述的结论。
