Tobacco Cessation Program for Hernia Patients

There are many benefits and often better outcomes for smokers who stop smoking in the weeks leading up to and after a surgical procedure. MUSC Health’s Tobacco Cessation Program supports smokers preparing to undergo hernia surgery. Dr. Hatem Abdallah, a general surgeon and Medical Director for Robotic Surgery MUSC Florence, and Demetress Adams-Luddd, a MUSC Tobacco Treatment Specialist discuss efforts to help patients become smoke-free before surgery.

“Robotic surgery… has been a game-changer for the area in terms of our offering to patients. The smoking cessation program is a compliment to that ability for us to tackle more complex hernias, but also optimizing those outcomes in the best possible manner.”
– Hatem Abdallah, M.D.

Topics covered in this show

• Abdallah specializes in hernia repair. Hernias are holes that occur in the abdominal wall, and about 15 to 20% of patients needing hernia repair are active smokers who are at higher risk for infection during surgery.
• Smoking decreases oxygen perfusion in tissues that are healing in the body by affecting blood vessels delivering that oxygen. This is especially a concern for patients undergoing surgery because smoking can impact the body’s natural ability to heal. Hernia repair is not recommended for those who are active smokers for this reason.
• MUSC Health’s Tobacco Cessation Program is intended to solve this issue by helping patients bridge the gap between smoking and necessary surgeries. This is a unique resource to the region that offers a multidisciplinary approach to these patients.
• Quitting smoking 4 to 6 weeks prior to and after surgeries can decrease surgery complications by 50%. The alternative is having to undergo multiple surgeries to deal with complications from the original surgery impacted by smoking.
• Abdallah and his colleagues use state-of-the art robotic surgery which offers a minimally invasive surgical option. The robot has more nuanced mobility than the human wrist and is highly precise due to higher visibility as well.
• Demetress Adams-Ludd, a social worker and Tobacco Treatment Specialist, works directly with Abdallah to support patients in their efforts to quit smoking. She offers in-patient and out-patient care that includes both mental health and educational support.
• Marion County is a center for tobacco farming in the region. Smoking is therefore deeply embedded in the local culture. Part of Adams-Ludd’s role is to educate patients about the impact of smoking on their health, the underlying root-causes of smoking, as well as behavioral changes and medicinal interventions that can support quitting.
• The goal of the Tobacco Cessation Program is to meet the needs of every patient at MUSC Health who wants support in quitting smoking. Demetress Adams-Ludd offers a list of resources, both local and national, for those who are interested in quitting smoking.

Read the show transcript below

Erin Spain, MS [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. There are many benefits and better outcomes for smokers who quit the habit in the weeks leading up to and after a surgical procedure. Today, we're talking about how MUSC Health's tobacco cessation program is supporting smokers preparing to undergo hernia surgery. Dr. Hatem Abdallah, a general surgeon and medical director for robotic surgery at MUSC Health, Florence and Demetress Adams-Ludd, a MUSC tobacco treatment specialist are our guests today. Welcome first, Dr. Abdallah.

Hatem Abdallah, M.D. [00:00:50] Good morning. Thanks for having me.

Erin Spain, MS [00:00:52] Well, you specialize in hernia repair. Tell me a little bit about the surgeries that you offer at MUSC Health.

Hatem Abdallah, M.D. [00:00:59] So I'm a board-certified general surgeon and I have a special interest in hernia surgery. Hernias are holes that occur in the abdominal wall, and there's a plethora of different approaches that exist in terms of how to approach these hernias and how to fix them. And so that's sort of the area of interest that's kind of sparked this discussion today.

Erin Spain, MS [00:01:19] So how many hernia surgeries are you typically doing? How many of these patients do you see?

Hatem Abdallah, M.D. [00:01:24] I would say they probably compose about 20%, if not higher of the different types of patients that we see within the scope of general surgery. And what we've noticed is that about 15 to 20% will actually be active smokers. It's become an issue in terms of figuring out how do we optimize these patients to get the best result in their surgery.

Erin Spain, MS [00:01:45] Why is it more dangerous to be a smoker who is about to undergo surgery?

Hatem Abdallah, M.D. [00:01:51] Overall, smokers getting any surgery, let alone hernia surgery, are at higher risk for complications. Those complications can include something we call SSIs or surgical site infections that could include something as simple as a wound infection just at the skin level. It can also mean in terms of a hernia patient, you know, an infection in the mesh because mesh is still considered standard of care for the majority of patients. And so we worry about the ability of the body to heal in the setting of ongoing smoking. What people don't realize is that smoking itself actually causes the blood vessels that bring the oxygen to the tissue that you're trying to have heal, meaning, you know, that tissue that you operated on, and it actually causes it to decrease the oxygen perfusion or the amount of tissue that can get that oxygen to help it heal. So you're already kind of handicapping the patient before you've even started by smoking and getting those things to heal after surgery of any kind, let alone a hernia repair.

Erin Spain, MS [00:02:48] Do you see this complication yourself in some of your patients?

Hatem Abdallah, M.D. [00:02:52] Personally, I don't recommend doing hernia surgery on active smokers if possible. That being said, sometimes folks come in with an emergency and your hands are kind of tied and you're trying to get them out of the situation. And so you don't really have much of a choice. But if you have the luxury of time and you have some planning and it's an elective setting, that's the best time to to stop that if it's possible.

Erin Spain, MS [00:03:15] So, now you're partnering with the MUSC Health Tobacco Cessation Program to really get some of these patients ready for surgery. Tell me about this partnership.

Hatem Abdallah, M.D. [00:03:24] So this was kind of born out of, you know, my realization that there's a need here that really wasn't being fulfilled. The literature is quite obvious in terms of what the outcomes look like in people who are actively smoking and undergo either elective or immersion hernia repair. We just know the complications are are higher. Overall, your best chance at a solid hernia repair is your first chance. Meaning if you do it right in the right setting and you've optimized that patient, there's a really big concept in surgery now called pre habilitation, meaning you're essentially working to make that patient the best version of themselves possible at stopping smoking or weight loss or getting their diabetes under control. It’s kind of a, you know, multi-pronged approach to optimizing that patient, to getting them through that surgery with the least amount of morbidity possible, whether that's smoking cessation, meaning wound complications, poor wound healing, we see oftentimes also in diabetics. So that's kind of what was born out of this is that we had a need and we weren't really connecting the dots, if you will. And then the other part of it is we would see a lot of patients, a lot of times would be told, okay, you know, I don't think you're a good candidate for surgery. And that was kind of it. And they were kind of left to their own devices to try to figure out how to quit. And as most people realize, quitting smoking is is quite a an undertaking on their own. And so I saw that there was a need here. And let's put our heads together and figure out let's give these patients a home, so to speak, so they don't feel like we're just, you know, saying good luck and and go ahead and try to quit and then call me when you do, as opposed to saying, you know, here's our team, here's how we get you to quit and I'd like to see you back. And let's follow through with things and let's get you to that elective surgery that you need ultimately. And then with the added benefit of, hey, I was able to quit smoking as well.

Erin Spain, MS [00:05:07] Are there guidelines that you have in place, how long they have to be smoke free before or after surgery for you to proceed?

Hatem Abdallah, M.D. [00:05:14] Yes. So my requirement is four weeks and that's actually born out of the literature from plastic surgery. Plastic surgeons, they obviously deal with large areas of soft tissue that they have to move from one place to another, such as flaps and things that has really been studied rigorously in that literature and that's what they showed is that if you can quit at least four weeks before your chance of complications goes down precipitously, just such as you mentioned. And so that is my requirement. And we will actually test the patient's urine to verify, to make sure that we're not setting them up for failure by getting them to surgery if they actually were, in fact, smoking and we just didn't realize it. Just making sure that we're consistent and just being very transparent with the patient and saying we are generally concerned about your health. I don't want you to have a complication that is potentially avoidable.

Erin Spain, MS [00:06:03] Well, because there is evidence out there, there's studies that've been done showing that quitting smoking just 4 to 6 weeks before surgery and staying smoke-free for several weeks after a procedure can decrease the rate of surgical complications by 50%. That's pretty dramatic. Are you seeing that some success stories in with your patients?

Hatem Abdallah, M.D. [00:06:23] Yeah, I think the nice thing now is that when family doctors send us patients, not only are they getting their hernias fixed, but also we're getting their patients to quit smoking, you know, a benefit. And yes, we have had success for years where as long as we sit down and explain it to the patient, provide the resources, they are willing to use those resources and those tools essentially to get through the process and get their hernias fixed in a safe manner that will optimize their chances of a good, solid repair for life. I tell all my patients, we plan on doing this one time, and obviously patients who get recurrences, meaning the hernia comes back or if they have complications, that can be quite an undertaking and quite a disruption to their lives. And my goal is to try to prevent that before we even get to the operating room from the beginning.

Erin Spain, MS [00:07:05] And you mentioned, this is an elective surgery, but if you have a hernia that needs to be repaired and you aren't able to do it because of possible complications as a smoker, what is that like for that patient and what does it feel like to be walking around with the hernia that, you know, you can't get repaired?

Hatem Abdallah, M.D. [00:07:23] It's quite uncomfortable. I mean, it's quite a disruption to people's lives, you know, whether their job is physical or not or they have a job or whatever their daily life is like, it is quite disruptive, as one could imagine, to have to deal with that. But, you know, I always tell them the flip side is that, you know, if you have a complication from this repair, it can even be worse. You know, it's a risk-benefit, just like every decision we make in surgery is always risk-benefit. So it's kind of just a matter of walking the patient through that process and explaining it to them so that they don't think that we're just trying to dismiss their concern. Obviously, we don't want them to be in pain, but at the same token, we know what can happen if you don't optimize that patient as best that is possible prior to proceeding to surgery.

Erin Spain, MS [00:08:02] Now we're going to talk more with Demetress here in a minute about tobacco cessation programming offered at MUSC Health Florence. But just tell me, what do you think about this program and the type of services that they're offering your patients?

Hatem Abdallah, M.D. [00:08:16] I think it's a fantastic resource that's unique to the region that has not been offered before, and we're proud of it because it now offers patients a comprehensive approach to their care as opposed to just, you know, we have the technical know how to fix the hernia. However, now we actually approach the patient in a holistic manner, and I think that's how medicine should be overall. You have similar programs in bariatric surgery, in other forms of surgery where you have multidisciplinary teams, cancer obviously, another big one. Having a multidisciplinary approach to hernias is an invaluable resource to patients. There's over 400,000 incisional hernias that are done in this country every year. That's almost half a million people that have to go through an operation because they went through another one. And so anything we can do to optimize that event in that patient's life we are excited for.

Erin Spain, MS [00:09:06] And you're doing other things at MUSC Health to make hernia surgery a little bit easier for folks, including using a lot of robotic surgery. Can you tell me about that?

Hatem Abdallah, M.D. [00:09:16] We here at MUSC Florence, we have The Da Vinci XII robot. My partners and I, we all do robotic surgery, specifically robotic hernia surgery, anything from, you know, a simple, straightforward operation all the way to the most complex abdominal wall reconstructions, all with robotic surgery, which is a minimally invasive approach. The robot is a instrument that is under the surgeon's control that helps us better do the operation compared to traditional open or laparoscopy. Ultimately, the patients would benefit because we're using small incisions. The robot itself allows us to use awristed articulation, meaning the tips of the instruments, move even more than the human wrists can. And we can see a lot better compared to traditional modalities such as laprostoptic surgery. So that's been a game changer for the area in terms of our offerings to patients. You know, the smoking cessation program, it just is a complement to that ability for us to kind of tackle, you know, more complex hernias, but also optimizing those outcomes in the best possible manner.

Erin Spain, MS [00:10:17] You as the surgeon, you might be the first person to talk to this patient about their smoking habit and letting them know that, hey, you know, you really need to stop smoking before the surgery. Tell me about those conversations. What are those like and what is it like now that you have a resource for them to go to?

Hatem Abdallah, M.D. [00:10:34] You know, initially patients will come to you and they're expecting an operation because they have symptoms, they have a hernia. And so sometimes it's not always the easiest conversation to have with the patient because they have the expectation that you're going to just go ahead and get them, you know, the surgery that they think they need. However, I think it's just a matter of kind of taking the time and walking them through and showing them that you truly do care about their outcome. And it's not just about doing another operation and moving on with your day. It's actually about getting that patient through the whole process and back to their activities of daily living in a meaningful way to decrease their chance of having a problem ultimately, you know, similar to the one that they came to see within the first place, which is a hernia.

Erin Spain, MS [00:11:14] So how long are you willing to wait or work with the patient to get them to the smoke free status?

Hatem Abdallah, M.D. [00:11:21] As long as the hernia that they have is not one that is going to compromise their health in the immediate future and that is based off of imaging studies. My clinical examination evaluation of the patient. As long as it's safe to wait, I will wait and I will work with them as long as they're willing to work.

Erin Spain, MS [00:11:39] We are now joined by MUSC Health Tobacco Treatment Specialist Demetress Adams-Ludd. She is a social worker who helps patients at the MUSC Health Florence Medical Center and the MUSC Health Marion Medical Center quit smoking through behavioral changes and pharmaceutical therapy. She's been working with Dr. Abdallah to specifically help patients who want to undergo hernia surgery, quit smoking at least four weeks before their procedure. Welcome to the show.

Demetress Adams-Ludd [00:12:08] Thank you for having me.

Erin Spain, MS [00:12:09] Tell me about the tobacco treatment program, MUSC Health Florence Medical Center and MUSC Health Marion Medical Center and what you provide to patients.

Demetress Adams-Ludd [00:12:18] The tobacco treatment program originated through our Hollings Cancer Center in Charleston, South Carolina. So this program has been in existence for 5 to 6 years, and it's led by our director, Dr. Benjamin Toll. And I've been service in this area with helping patients with bedside inpatient counseling just to get them motivated and get them pointed in the direction of using our tobacco services through in MUSC or outside organizations like 1-800-quit -now, not only do I help the Robotics Hernia Clinic, I also help the pulmonology clinic here at MUSC Florence. There is a need in this area for tobacco cessation.

Erin Spain, MS [00:12:55] Tell me about that. How common is it to have patients who are smokers who are coming in for, say, a hernia surgery?

Demetress Adams-Ludd [00:13:02] It is very common, Marion, in the Dillon area, which is in Marion County, this is kind of the heart of where tobacco, farm families, cultures of smoking kind of started in this state. I speak to generations of families who this tobacco smoking cigarettes is what they know. They roll it, they farm it. This is a part of their culture. So it's been interesting learning about the history of tobacco, but I will say the prevalence of it is pretty high in this area. As far as surgeries, a lot of folks that I meet, they definitely have to quit smoking before surgeries and it's becoming more and more common, which they may not appreciate, unfortunately, patients. But as a tobacco treatment specialist, I really appreciate the medical world going in this direction because the implications of having toxins in your body and having a surgery where your percentage of infection just increases, you know, you just want to have a safe surgery. And if cessation is the way to go, even for 4 to 6 weeks, which obviously we would love a lifetime of cessation for folks, we want to be able to support them throughout their service.

Erin Spain, MS [00:14:07] How difficult is it?

Demetress Adams-Ludd [00:14:09] It is very difficult. So I look at this as a challenge, a good challenge, because I am not just pushing people for their health, but I'm guiding them there. I'm listening. I'm being empathetic. Sometimes it's not just about tobacco cessation. There's underlying layers and root causes to folks smoking. And sometimes they just folks just need someone listening to them and pointing them in the direction to make behavioral changes, which is a huge factor in getting folks to move toward cessation, is making behavioral changes.

Erin Spain, MS [00:14:39] Tell me some examples of behavioral changes and then some examples of how you use pharmaceuticals to support people as well.

Demetress Adams-Ludd [00:14:46] With behavioral changes. So one of the first things I do when I'm speaking to patients, whether in an inpatient or outpatient setting, is we talk about triggers. I might ask some specific questions about who in your home uses tobacco products? How long have you used these products? When did you start using these products? Around when do you notice that you're using your tobacco products? And those cues and triggers. So triggers, for example, could be when I wake up in the morning, the first thing I get is a cigarette when I go to the bathroom or after I go to the bathroom when I have a cup of coffee, when I'm stressed after a meal, when I'm riding in the car, when I'm drinking alcohol. So we go through a ton of questions when I'm inpatient and even outpatient. So just get familiar with our triggers. And then we move to ask you a little bit more questions. Have you ever used NRT, which is the nicotine replacement medications, whether that's your products or gum, your lozenges? Some folks even try inhalers. And then I ask another question. Have you ever been prescribed medication from your doctor to help with cessation? And that may be using medications like your varenicline or chantix, as most people are aware of that being a Wellbutrin. And so those conversations kind of help move a direction and create a plan of how we want to attack our patients’ tobacco cessation, along with other health factors as well.

Erin Spain, MS [00:16:00] So everybody responds differently to different combinations of behavioral and pharmaceutical care?

Demetress Adams-Ludd [00:16:07] Absolutely. I have a ton of patients at this particular hospital who prefer not to use pharmacotherapy. So they are against using patches. They are against maybe use a lozenge or gum. And it's not that they haven't tried. Some have tried and may have used the product inappropriately or may have been told this product will help you stop quitting when that's not actually how the product works so they lose faith in it. So I find myself doing a lot of education on how products work and when to use them, and that's why I'm a huge advocate for patients or just general public that want to work on tobacco cessation, having conversations with your pharmacist, your physician, or even a tobacco treatment specialist. Because sometimes what we read on the label, we may need a little bit more elaboration in real life. That is something that I do advocate for. But yeah, they there are patients that don't want to use pharmacotherapy, which is which is fine, is their autonomy. But then I really emphasize to those patients about making behavioral changes. And so is really having a outline of your day almost and looking at those times and those trends in your smoking or figuring out how can I remove smoking from this behavior? But with that being said, I also incorporate teaching patients or clients how to incorporate healthy behaviors, because when you remove one thing, you want to replace it with something healthy.

Erin Spain, MS [00:17:28] Tell me about this partnership with Dr. Abdullah and the hernia patients.

Demetress Adams-Ludd [00:17:32] I was approached by a doctor and he told me about what he's doing. And so we just worked out a plan where as soon as they get a patient that they know is a smoker, they would like assistance. A referral was immediately made to me. If I'm available at the moment, I can go straight to the office and meet their patient face to face so they get to see who I am, ask me questions. Sometimes it lowers anxiety, it also gets rid of initial jitters and we just kind of move forward there or whatever mode the patient would like to meet with me. We do that and we just go through a couple of weeks of just training where we're talking about behavior changes, we're talking about pharmacotherapy. So we're just kind of making sure that we're doing whatever we can to help that patient move forward in their cessation.

Erin Spain, MS [00:18:13] What is follow up like for somebody who they're able to be smoke free, they're able to have their surgery. Do you get to see those folks again and see how they're doing?

Demetress Adams-Ludd [00:18:21] If a patient decides that they want to continue using our services, which some folks feel comfortable with, we are definitely here to support them in any way. And that may even include continuum of pharmacotherapy. Some patients without having nicotine in their body, they're going back into the natural environment. They had their surgery. Life is back to normal. And so it is easy to kind of relapse or relapse. And so behavior patterns that they once didn't have. So just having that support where we want to be there, we want to explore options and we want to continue that maintenance. So yes, we try to make ourselves readily available.

Erin Spain, MS [00:18:54] What advice do you have for people listening who maybe they're a smoker, a loved one is a smoker and they want to quit, but they've struggled in the past. What do you say to them?

Demetress Adams-Ludd [00:19:04] Well, first I would say kudos to them for trying. Even if it's several attempts, it is very difficult to quit using tobacco products. So please don't get down on yourself. I would say first, just recognize that you can do it. Start doing your research about creating a plan. One person's quit is not the same as another person's. We all may take different paths in how we quit looks, and it takes several times to get to a complete cessation.

Erin Spain, MS [00:19:29] Well, thank you so much. Demetress Adams-Ludd for joining me today and telling me about this program in partnership with the hernia patients at MUSC Health Florence.

Demetress Adams-Ludd [00:19:37] Thank you. Erin, for having me.

Erin Spain, MS [00:19:44] For more information on this podcast, check out advance.muschealth.org.