Effects of smoking on bariatric surgery postoperative weight loss and patient satisfaction

Weight loss therapy and addiction: Increased risk after bariatric surgery but reduced risk with GLP-1 receptor agonists

BACKGROUND

Obesity is an increasing public health problem because of its high prevalence and associated morbidity and mortality. Two weight-loss strategies are currently used, either bariatric surgery or pharmacological therapy with glucagon-like peptide-1 receptor agonists (GLP-1RAs). Preclinical studies in rodents suggested an increased risk of additive disorders after bariatric surgery contrasting with a reduced risk with GLP-1RAs.

METHODS

An extensive literature search to detect clinical studies that investigated the prevalence of addictive disorders (food addiction, alcohol abuse, smoking, cannabis, cocaine, opioid use) following bariatric surgery or GLP-1RA therapy in obese patients.

RESULTS

In observational cohort studies, the prevalence of alcohol use disorder was twofold higher after > 2 years following surgery (eleven studies, mainly with gastric bypass) whereas it was reduced roughly by half with GLP-1RA therapy (five studies, mainly with semaglutide). Similar findings were reported with other addictive disorders. An addiction transfer from food addiction to other addictive disorders is hypothesized to explain the increased risk after bariatric surgery. Several mechanisms are proposed to explain the favorable findings reported with GLP-1RAs, i.e. effects on the dopamine reward pathway, central GABA (gamma-aminobutyric acid) release, negative emotional stress associated with food/drug restriction and/or neuronal inflammation.

CONCLUSION

Available data from observational cohort studies confirm an increased risk of addictive disorders following bariatric surgery, contrasting with a reduced risk with GLP-1RA therapy. Both physicians and patients should be informed of the higher risk post-surgery whereas available promising results with GLP-1RAs should be confirmed in ongoing dedicated randomized controlled trials before any official indication.

Management of Alcohol and Tobacco Use Disorders in a 39-Year-Old Hispanic Male With a Complex Medical Background: A Case Report

Substance use disorders affect the mental activities of an individual's brain and behavior, leading to a loss of control over their substance use, such as drugs, alcohol, and medication. However, these disorders are treatable. This case report presents and discusses the management of a 39-year-old Hispanic male with a complex medical background and a history of substance use. The patient, who resided with his mother in the Bronx, was admitted to the Outpatient Program (OPD) at the Life Recovery Center (LRC) Addiction Treatment Center for concurrent alcohol and tobacco use disorders. The patient had a history of anemia after bariatric surgery 10 years ago and no significant psychiatric history. Therefore, a comprehensive approach was required for the patient's treatment. The case further highlights the patient's presentation, treatment options, medication, and outcomes, which are essential for managing substance use disorders in individuals with complex medical backgrounds.

Smoking Is Correlated to Internal Hernia After Gastric Bypass Surgery: a Post hoc Analysis of Data from a Randomized Clinical Trial

PURPOSE

Internal herniation is a well-known complication of laparoscopic Roux-en-Y gastric bypass (L-RYGB). The aim of this study was to evaluate smoking as an independent risk factor for internal herniation after L-RYGB.

MATERIALS AND METHODS

This study was performed as an exploratory post hoc analysis of data from a previous published randomized controlled trial (RCT) designed to compare closure and non-closure of mesenteric defects in patients undergoing L-RYGB. The primary outcome of this study was to assess the significance of smoking as a risk factor for internal herniation after L-RYGB. Secondary outcome was early postoperative complications defined as Clavien-Dindo grade ≥ 2.

RESULTS

Four hundred one patients were available for post hoc analysis. The risk of internal herniation was significantly higher among patients who were smoking preoperatively (hazard ratio (HR) 2.4, 95% confidence interval (c.i.) 1.3 to 4.5; p = 0.005). This result persisted after adjusting for other patient characteristics (HR 2.2, 1.2 to 4.2; p = 0.016). 6.0% of the patients had postoperative complications within the first 30 days. 4.9% of these patients were smoking and 6.3% were not smoking, p = 0.657. 11.0% of the patients underwent surgery due to internal herniation by 5 years after the primary procedure.

CONCLUSION

Smoking is a significant risk factor for internal herniation but did not increase risk for 30 days postoperative complications.

Assessing the effects of smoking status on outcomes of elective minimally invasive paraesophageal hernia repair

BACKGROUND

Patients are often advised on smoking cessation prior to elective surgical interventions, but the impact of active smoking on paraesophageal hernia repair (PEHR) outcomes is unclear. The objective of this cohort study was to evaluate the impact of active smoking on short-term outcomes following PEHR.

METHODS

Patients who underwent elective PEHR at an academic institution between 2011 and 2022 were retrospectively reviewed. The National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2021 was queried for PEHR. Patient demographics, comorbidities, and 30-day post-operative data were collected and maintained in an IRB-approved database. Cohorts were stratified by active smoking status. Primary outcomes included rates of death or serious morbidity (DSM) and radiographically identified recurrence. Bivariate and multivariable regressions were performed, and p value < 0.05 was considered statistically significant.

RESULTS

538 patients underwent elective PEHR in the single-institution cohort, of whom 5.8% (n = 31) were smokers. 77.7% (n = 394) were female, median age was 67 [IQR 59, 74] years, and median follow-up was 25.3 [IQR 3.2, 53.6] months. Rates of DSM (non-smoker 4.5% vs smoker 6.5%, p = 0.62) and hernia recurrence (33.3% vs 48.4%, p = 0.09) did not differ significantly. On multivariable analysis, smoking status was not associated with any outcome (p > 0.2). On NSQIP analysis, 38,284 PEHRs were identified, of whom 8.6% (n = 3584) were smokers. Increased DSM was observed among smokers (non-smoker 5.1%, smoker 6.2%, p = 0.004). Smoking status was independently associated with increased risk of DSM (OR 1.36, p < 0.001), respiratory complications (OR 1.94, p < 0.001), 30-day readmission (OR 1.21, p = 0.01), and discharge to higher level of care (OR 1.59, p = 0.01). No difference was seen in 30-day mortality or wound complications.

CONCLUSION

Smoking status confers a small increased risk of short-term morbidity following elective PEHR without increased risk of mortality or hernia recurrence. While smoking cessation should be encouraged for all active smokers, minimally invasive PEHR in symptomatic patients should not be delayed on account of patient smoking status.

The role of preoperative toxicology screening in patients undergoing bariatric surgery

BACKGROUND

Some programs and insurers may require patients to undergo toxicology screening despite lack of evidence that this practice affects postoperative outcomes.

OBJECTIVES

To understand the prevalence of screening positive on toxicology testing in the bariatric surgical population and to examine the association between testing positive and important surgical outcomes.

METHODS

We performed a retrospective review of patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from an academic health system from 2017-2020. We described the rate of preoperative toxicology positivity as determined by serum and urine testing. We examined the association between toxicology positivity and outcomes of preoperative length, 30-day complications (bleeding, venous thromboembolism, leak, wound infection, pneumonia, urinary tract infection, and myocardial infarction), readmissions, and 1-year weight loss using chi-square and t-test analysis.

RESULTS

Of 1057 patients, there were 134 patients (12.7%) who had positive toxicology testing. Of these, 37 (28%) were positive for opiates and 21 (16%) were positive for cotinine. Mean preoperative length was 381.8 days (standard deviation [SD], 222.5) for patients with positive testing versus 287.8 days (SD, 151.5; P = 1.00) for negative testing. Toxicology positivity was not associated with readmissions (5.2% versus 4.3%, X² = 0.22; P = .64). The loss to follow-up at 1 year was 32.5%. There was no association with 1-year mean change in body mass index (mean of loss 12.23kg/m² [SD, 5.61]) versus mean of loss 12.74 (SD, 6.44; P = .20)].

CONCLUSIONS

Our study is the first to describe preoperative toxicology positivity rates. We found no association between toxicology positivity and preoperative length, readmissions, or weight loss. Given its lack of impact on outcomes, toxicology testing prior to bariatric surgery may be an unnecessary burden on patients and healthcare, with regard to cost and wait times.

Association of Postoperative Dieting, Exercise, Dietitian, and Surgeon Follow up With Bariatric Surgery Outcomes

Although postoperative diet modification, exercise, and regular dietitian and surgeon follow-up are often recommended after bariatric surgery (BS), their impact on weight loss is unclear. A Retrospective chart review was conducted for patients who received sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) between August 2000 and November 2017 with telephone follow-up. Multivariable logistic regression models were used for analyses. There were 514 patients included in our study. Most were female (76.3%), mean age was 46.9 years (Standard Deviation [SD] = 11.8), and mean weight loss was 11.6 (SD = 6.5) BMI points at a mean follow-up of 7 years (SD = 4.3). Current surgeon follow-up OR = 2.08 (P < .01) was positively associated with postoperative weight loss, while current dietitian follow-up=OR .41 (P < .01) was negatively associated. Current weight loss supplement use OR = .45 (P = .03) was associated with reduced willingness to undergo surgery again. Increasing preoperative BMI OR = 1.06 (P = .04) and increasing age OR = 1.04 (P = .02) were associated with improved quality of life (QoL) due to BS. Lack of surgeon follow-up and regular dietician consultation was associated with suboptimal weight loss after BS. Older age was positively associated with improved QoL, while current weight loss supplement use was associated with lower likelihood of undergoing surgery again, both independent of weight loss.

Impact of smoking on weight loss outcomes after bariatric surgery: a literature review

BACKGROUND

The association between smoking and surgical complications after bariatric surgery has been well-established. However, given that this patient population is inherently weight-concerned, understanding the effects of tobacco use on postoperative weight loss is essential to guiding clinicians in counseling patients. We aimed to summarize the current literature examining the effects of preoperative and postoperative smoking, as well as changes in smoking status, on bariatric surgery weight loss outcomes.

METHODS

Ovid MEDLINE, PubMed, and SCOPUS databases were queried to identify relevant published studies.

RESULTS

Overall, 20 studies were included. Preoperative and postoperative smoking rates varied widely across studies, as did requirements for smoking cessation prior to bariatric surgery. Reported preoperative smoking prevalence ranged from 1 to 62%, and postoperative smoking prevalence ranged from 6 to 43%. The majority of studies which examined preoperative and/or postoperative smoking habits found no association between smoking habits and postoperative weight loss outcomes. A minority of studies found relatively small differences in postoperative weight loss between smokers and nonsmokers; these often became nonsignificant with longer follow-up. No studies found significant associations between changes in smoking status and weight loss outcomes.

CONCLUSION

While smoking has been associated with weight loss in the general population, most current evidence demonstrates that smoking habits are not associated with weight loss outcomes after bariatric surgery. However, due to the heterogeneity in study design and analysis, no definitive conclusions can be made, and more robust studies are needed to investigate any relationship between smoking and long-term weight loss outcomes. Given the established increased risk of surgical complications and mortality in smokers, smoking cessation should be encouraged.