The association between established liver cirrhosis and postoperative morbidity and mortality is stark [33]. Whilst chronically elevated alcohol intake resulting in end organ damage will clearly increase surgical risk, heavy drinking has deleterious effects beyond the liver, pancreas and nervous system. These include an impairment of cardiac and immune function and an exaggerated metabolic response to surgical stress. Latent dysfunction of these systems may lead to significant perioperative derangement when subjected to the stress response of major surgery (Table 2.1). In addition, patients with chronic alcohol excess approaching surgery are at risk of the alcohol withdrawal syndrome perioperatively [34].

However, consumption well below the levels traditionally associated with alcohol dependence has implications perioperatively. Evidence suggests that a clear dose–response relationship exists regarding perioperative risk. Postoperative complication rates are 50 % higher with the consumption of 3–4 units daily compared to 0–2 units. When consumption exceeds 5 units daily, rates of complication may be three to five times greater. Relatively low perceived levels of consumption may therefore lead to a significantly increased risk of perioperative complications. [34, 35]

Accurate quantification of alcohol intake is useful preoperatively and may provide insight into a given patient’s associated risk. Traditional screening tools such as the widely used CAGE and AUDIT-C questionnaires are designed to identify severe excess consumption, and in particular, search for features of dependence. Patients can conceivably present for preoperative assessment and intervention, unknowingly consuming excess alcohol at ‘subclinical’ levels sufficient to substantially elevate their surgical risk and without an established ‘label’ of alcohol excess or a manifest associated pathology. This so-called ‘hazardous drinking’ is typically classified as >3 units daily [36]. In the absence of a dedicated perioperative screening tool, we recommend that obtaining an accurate and honest assessment of intake (quantified in alcohol units) at the time of referral may be useful in the surgical setting, with the understanding that patient self-reported consumption is often underestimated but very rarely overestimated. It may be possible to identify patients preoperatively who are drinking at unappreciated ‘hazardous’ levels that may benefit from more informal advice surrounding their consumption in the approach to surgery.

The lead-time required to derive maximum benefit for the recovery of organ systems following preoperative alcohol cessation appears to be greater than for cigarette smoking. Whilst a normalization of immune functioning and the endocrine stress response to surgery may become apparent within 2 weeks of complete cessation, full recovery of coagulation, homeostatic and cardiac functioning may take more than 2 months depending on the initial severity of derangement. Thus effective management is reliant on early preoperative identification of hazardous drinking and prompt intervention [34].

Evidence supporting formal preoperative cessation is sparser than for other lifestyle factors. Nonetheless, a recent Cochrane review evaluated intensive intervention programmes, namely, 4–8 week initiatives aiming to achieve complete cessation through a combination of pharmacological and psychosocial methods [36]. The review identified two randomized controlled trials of pharmacological intervention (disulfiram) in major colorectal surgery and combined pharmacological intervention (disulfiram alongside chlordiazepoxide for withdrawal symptoms) with motivational counseling prior to hip arthroplasty. The authors concluded that an intensive cessation intervention appears to reduce complication rates substantially, without influencing 30-day mortality or hospital length of stay. Questions remain surrounding impact on longer-term alcohol consumption. It should be noted that such interventions are certainly at the ‘extreme’ end of available options to address alcohol intake prior to surgery. Simpler initiatives, including short motivational interviewing are available with an evidence base for reducing intake in both primary care patients and general hospital populations. These techniques may be more applicable to the previously under-recognised group of ‘hazardous drinkers’ presenting for surgery, although they are yet to be scrutinized in the perioperative setting [36].

Excessive alcohol consumption is an important risk factor for postoperative morbidity. Careful questioning and screening in the preoperative assessment clinic to detect those individuals consuming more than the recommended weekly amount is crucial. Research to date only really supports intensive interventions lasting several weeks preoperatively, but the evidence base is certainly sparse. In keeping with the concept of ‘marginal gains’ theory the authors advocate appropriate counselling and advice for those individuals at risk, with complete cessation for a period up to 8 weeks preoperatively being the aim. Where high levels of consumption are identified, investigations seeking evidence of end organ damage are warranted and a treatment plan should be put in place to manage the potential for alcohol withdrawal.

The deleterious effects of cigarette smoke on the surgical patient develop over a wide time course, from the hyperacute effects of the most recent cigarette to more chronic manifestations such as COPD and a wide range of malignancies. Therefore, even younger smokers without demonstrable features of an established smoking related comorbidity are still at increased risk in the perioperative period [38].

Regular cigarette smoke exposure, including secondhand smoke, drives pathological change across a range of organ systems. These effects are mediated by direct cellular injury, disordered coagulation and free radical release in response to toxic smoke contents. The cardiovascular and respiratory systems alongside wound healing are most extensively affected (Table 2.2) leading to an increased risk of multiple perioperative complications and worse surgical outcomes, reflected in a 1.38 fold increase in surgical mortality [37].

Assessment of chronicity and severity of cigarette smoke exposure, often quantified in pack years, has classically been based upon subjective patient reporting, with the associated risk of significant under-reporting of consumption particularly in the heaviest smokers. Leading intervention programmes utilise the Fagerstrom test (Table 2.3) to objectively evaluate nicotine dependence and guide replacement therapies [39, 40].

As with other unhealthy patient behaviours, the preoperative period represents an ideal ‘teachable moment’ for clinicians to provide smoking cessation advice. Clinical concerns regarding the potential rebound deterioration in respiratory function, if an inadequate window of cessation is not permitted prior to surgery, have been the subject of a recent systematic review and meta-analysis. These concerns appear to be entirely unfounded and probably originated from small, observational data from nearly 30 years ago. Whilst there is possibly a greater benefit from longer periods of abstinence, smoking cessation even for short durations prior to surgery may be beneficial and there is certainly no evidence of any significant quality that it is detrimental [41].

In the same fashion that cigarette smoking can exert detrimental physiological effects within minutes to hours, measurable recovery in cardiorespiratory functioning begins equally rapidly following cessation. The short half-lives of nicotine and carbon monoxide allow some detrimental effects to resolve in less than 12 h. However, in terms of an actual measurable effect on complication rates and postoperative outcome, debate continues surrounding the benefit derived from interventions commenced less than 4 weeks before surgery. Systematic reviews have supported these ‘shorter term’ interventions [42], which appear particularly beneficial for wound healing. Evidence suggests that the estimated times from abstinence for measurable recovery of pulmonary capacity may be longer at 4–6 weeks and the ‘ideal’ lead time required to achieve improvements in cardiovascular risk is the least well defined.

In particular, two randomized trials demonstrated a halving of complication rates when the ‘gold standard programme’ (GSP), was commenced at 6–8 weeks and 4 weeks prior to surgery (Table 2.4), in the context of elective orthopaedic and general surgery. The GSP is an entirely outpatient delivered intervention and has been demonstrated to be cost-effective in reducing the economic burden of perioperative complications. Whilst less intensive interventions such as a single short 3-min counselling session from surgeons have been shown to assist in achieving abstinence, best results appear to be obtained in the context of a structured intensive intervention such as the GSP. This approach relies on individual counselling in combination with tailored nicotine replacement therapy. These studies informed a recent Cochrane review concluding that based on available evidence, interventions beginning 4–8 weeks prior to surgery combining nicotine replacement with regular counselling appear to derive the greatest postoperative benefit in terms of overall complications and long term cessation [43]. Effective delivery of programmes such as GSP is reliant upon specifically trained and competent staff. Interestingly, an established barrier to delivery of such programmes is reluctance among staff who themselves smoke to inform patients about the associated risks, a consideration when planning service provision.

Thus, whilst avoiding even a single extra cigarette preoperatively is likely to be beneficial to a small degree, the sooner abstinence from cigarette smoking can be achieved prior to surgery the better [44, 45]. The benefits of achieving preoperative cessation may project well beyond the perioperative period through triggering a permanent lifestyle change with wider benefits for public health. Good quit rates at 1 year postoperatively have been reported following preoperative intervention.

Formal evaluation and optimisation of nutritional status remains an often-neglected element of modern preoperative assessment [46]. This is despite a wealth of data linking malnutrition with poorer postoperative outcome. Surgical patients are at risk of malnutrition in the perioperative period for a range of reasons including: poor access to adequate nutrition whilst hospitalized, alimentary tract dysfunction, unmet calorific demand due to chronic neoplastic and inflammatory processes and disordered handling of nutrients from metabolic disturbance. The surgical insult itself constitutes a significant metabolic stress with documented increases in catabolism, insulin resistance and loss of muscle mass. Hence the optimisation of nutritional status prior to surgery lends itself as a potential means of improving perioperative outcomes [47, 48]. At the other extreme to this ‘undernourished malnourishment’, a rapidly increasing number of patients in the western world are presenting for surgical intervention in the context of obesity.