Meeting NewsPerspective

Bariatric Surgery Patients at Risk for Alcohol Abuse

Praneet Wander, MD
Praneet Wander

ORLANDO — Patients who undergo bariatric surgery show a significantly increased risk for alcohol abuse, highlighting the need for better patient selection and interventions to reduce these risks, according to the results of a medical literature review presented at the World Congress of Gastroenterology at ACG 2017.

“We found that bariatric surgery is associated with an increase in moderate- to high-risk alcohol use, with a new-onset incidence of 8% and increased odds of alcohol abuse after surgery,” Praneet Wander, MD, a gastroenterology fellow at Hofstra Northwell School of Medicine in New York, said during her presentation. “Nineteen percent of patients overall reported drinking problems prior to surgery, and these patients still underwent the procedure.”

While data on the risk for alcohol abuse among bariatric patients are inconsistent, it is known that alcohol is metabolized differently in these patients after surgery, “especially Roux-en-Y gastric bypass,” Wander explained. Alcohol absorption is accelerated in these patients, they show higher maximum blood alcohol concentrations, and require a longer time to eliminate alcohol.

“The reasoning behind this is that there is rapid emptying of liquids from the gastric pouch, which may accelerate absorption of alcohol in the small intestine,” she said. “Also, the stomach, which is the main source of alcohol dehydrogenase is bypassed during these procedures and thus it facilitates rapid absorption of alcohol. There is also undiagnosed depression and substance abuse among patients who undergo bariatric surgery.”

To evaluate the effect of bariatric surgery on alcohol abuse, Wander and colleagues reviewed medical literature published through September 2016, and included 12 prospective and 16 retrospective or cross-sectional cohort studies in their analysis. These studies included a total of 15,714 patients (76.8% women) with an average age ranging from 26.5-50.1 years, and an average follow-up of 2.6 years. Most were Roux-en-Y gastric bypass patients, but some also had laparoscopic gastric banding or other restrictive procedures.

Overall, 8% of patients had new-onset significant alcohol use after undergoing bariatric surgery (pooled event rate, 0.08; 95% CI, 0.07-0.09), and 19% reported significant alcohol use before surgery (pooled event rate, 0.19, 95% CI; 0.12-0.28). Further, 23% of patients had significant alcohol abuse after undergoing bariatric surgery (event rate, 0.23, 95% CI; 0.14-0.34).

The meta-analysis showed that patients had a higher risk for significant alcohol use after bariatric surgery than before (OR = 1.5, 95% CI; 1.07-2.11).

Considering these findings, Wander concluded that better screening is needed for high-risk behaviors and selection of patients for bariatric surgery.

“Also, these patients require close follow-up evaluation for psychiatric illnesses and substance abuse after surgery,” she told Healio Gastroenterology and Liver Disease. – by Adam Leitenberger

Reference:

Wander P, et al. Abstract 10. Presented at: World Congress of Gastroenterology at American College of Gastroenterology Annual Scientific Meeting; Oct. 13-18, 2017; Orlando, FL.

Disclosures: The researchers report no relevant financial disclosures.

Editor's note: This article was updated on October 30 with clarifications from the study author.
Praneet Wander, MD
Praneet Wander

ORLANDO — Patients who undergo bariatric surgery show a significantly increased risk for alcohol abuse, highlighting the need for better patient selection and interventions to reduce these risks, according to the results of a medical literature review presented at the World Congress of Gastroenterology at ACG 2017.

“We found that bariatric surgery is associated with an increase in moderate- to high-risk alcohol use, with a new-onset incidence of 8% and increased odds of alcohol abuse after surgery,” Praneet Wander, MD, a gastroenterology fellow at Hofstra Northwell School of Medicine in New York, said during her presentation. “Nineteen percent of patients overall reported drinking problems prior to surgery, and these patients still underwent the procedure.”

While data on the risk for alcohol abuse among bariatric patients are inconsistent, it is known that alcohol is metabolized differently in these patients after surgery, “especially Roux-en-Y gastric bypass,” Wander explained. Alcohol absorption is accelerated in these patients, they show higher maximum blood alcohol concentrations, and require a longer time to eliminate alcohol.

“The reasoning behind this is that there is rapid emptying of liquids from the gastric pouch, which may accelerate absorption of alcohol in the small intestine,” she said. “Also, the stomach, which is the main source of alcohol dehydrogenase is bypassed during these procedures and thus it facilitates rapid absorption of alcohol. There is also undiagnosed depression and substance abuse among patients who undergo bariatric surgery.”

To evaluate the effect of bariatric surgery on alcohol abuse, Wander and colleagues reviewed medical literature published through September 2016, and included 12 prospective and 16 retrospective or cross-sectional cohort studies in their analysis. These studies included a total of 15,714 patients (76.8% women) with an average age ranging from 26.5-50.1 years, and an average follow-up of 2.6 years. Most were Roux-en-Y gastric bypass patients, but some also had laparoscopic gastric banding or other restrictive procedures.

Overall, 8% of patients had new-onset significant alcohol use after undergoing bariatric surgery (pooled event rate, 0.08; 95% CI, 0.07-0.09), and 19% reported significant alcohol use before surgery (pooled event rate, 0.19, 95% CI; 0.12-0.28). Further, 23% of patients had significant alcohol abuse after undergoing bariatric surgery (event rate, 0.23, 95% CI; 0.14-0.34).

The meta-analysis showed that patients had a higher risk for significant alcohol use after bariatric surgery than before (OR = 1.5, 95% CI; 1.07-2.11).

Considering these findings, Wander concluded that better screening is needed for high-risk behaviors and selection of patients for bariatric surgery.

“Also, these patients require close follow-up evaluation for psychiatric illnesses and substance abuse after surgery,” she told Healio Gastroenterology and Liver Disease. – by Adam Leitenberger

Reference:

Wander P, et al. Abstract 10. Presented at: World Congress of Gastroenterology at American College of Gastroenterology Annual Scientific Meeting; Oct. 13-18, 2017; Orlando, FL.

Disclosures: The researchers report no relevant financial disclosures.

Editor's note: This article was updated on October 30 with clarifications from the study author.

    Perspective
    Shelby Sullivan, MD

    Shelby Sullivan

    Bariatric surgery is not without behavioral risks, and development of binge drinking and alcoholism is one of them.

    Prior research has shown a 2% increase in the risk for alcohol use disorders after gastric bypass surgery, from 7.6% to 9.6%, so it has often been argued that bariatric surgery may increase the risk slightly, but it’s still a small number. This abstract presented at WCOG at ACG 2017 shows a significantly higher number (19% pre-surgery to 23% post-surgery).

    These results mimic prospective data from a U.S. multicenter cohort study recently published in Surgery for Obesity and Related Diseases (King WC, et al), which showed a 20.8% cumulative incidence of post-surgery alcohol use disorder symptoms, but not necessarily disease. Actual substance use disorder treatment was 3.5% — still pretty low — but undergoing Roux-en-Y gastric bypass (RYGB) vs. laparoscopic adjustable gastric banding (LAGB) was associated with a higher risk for alcohol use disorders, so essentially one-fifth of the participants reported incident alcohol use disorder symptoms within 5 years post-RYGB.

    Additionally, a study published in 2015 in JAMA Surgery (Pepino M, et al), appears to support the fact that there are physiologic reasons why a patient who’s had RYGB may be at higher risk for developing an alcohol use disorder. This study showed that the surgery increases the rate of alcohol absorption, resulting in higher peak blood alcohol concentrations, which is associated with the risk for developing an alcohol use disorder.

    This data supports the issue of AUD as something we need to be aware of, and we need to screen patients for it. I’ve seen this in practice, especially in patients who have weight regain after surgery; alcohol can be a significant contributor to excess calories, and therefore contribute to weight regain after surgery. As gastroenterologists who are treating complications of bariatric surgery, we should consider this a complication that we need to discuss with our patients given the long-term ramifications of AUD.

    • Shelby Sullivan, MD
    • Division of Gastroenterology
      University of Colorado Denver

    Disclosures: Sullivan reports financial relationships with Allurion, Aspire Bariatrics, Baranova, GI Dynamics, Elira Therapeutics, Spatz, Reshape, USGI Medical, Obalon and Takeda.

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