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. 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. 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.