Substance use after bariatric surgery: A review

Perioperative Cannabis Use in Bariatric Patients: A Review of Outcomes and Proposed Clinical Pathway for Management

Legalization of marijuana has led to increased prevalence of medical and recreational cannabis use, underscoring the importance for anesthesiologists, surgeons, and perioperative physicians to understand the effects of this drug in patient care. Bariatric surgical patients represent a unique target population to understand peri-operative cannabis use and its effects as these patients undergo an extensive preoperative psychological and nutritional evaluation. Standardized guidelines on cannabis use in bariatric surgery are lacking and many clinicians remain uncertain on how to handle cannabis use in the peri-operative period. Here, we summarize the data on cannabis use in bariatric patients, specifically exploring anesthetic considerations, weight loss, complications, mortality, and psychiatric outcomes. We propose a clinical pathway to assist clinicians with perioperative decision making in bariatric patients who use marijuana.

Bariatric surgeons' views on pre-operative factors associated with improved health-related quality of life following surgery

Bariatric surgery is an effective treatment for severe obesity, affording significant improvements in weight loss and health-related quality of life. However, bariatric surgeons' views on whether certain pre-operative factors predict improvements in post-operative health-related quality of life, and if so, which ones, are largely unknown. This cross-sectional survey study examined the views of 58 bariatric surgeons from Australia and New Zealand. A total of 18 factors were selected for exploration based on their mention in the literature. Participants rated the extent to which they thought these pre-operative factors would improve post-operative health-related quality of life. Responses showed that bariatric surgeons held diverse perspectives and revealed a lack of consensus regarding "predictive" factors. Generally, respondents agreed that better than average health literacy, higher socioeconomic status, good physical and psychological health, and positive social support were predictors of improved health-related quality of life following surgery. However, poor eating behaviours, smoking, and the use of alcohol or other substances were deemed negative predictors. Interestingly, aside from higher socioeconomic status, good psychological health, and positive social support, none of the aforementioned views aligned with existing literature. This study offers an initial insight into bariatric surgeons' views on the influence of different pre-operative factors on post-operative health-related quality of life. The array of views identified suggests that there may be an opportunity for medical education, but the findings warrant caution due to the sample size. Replication with a larger survey may be useful, especially as predicted health-related quality of life outcomes could guide decisions regarding surgical (non)progression.

The forgotten patient: A psychological perspective on the implementation of bariatric surgery guidelines

There is strong evidence demonstrating the impact of bariatric surgery on weight-loss and comorbidity improvement. In the UK, there is specific guidance to facilitate the assessment of a person's suitability for bariatric surgery. This paper highlights the clinical reality of routinely implementing this guidance, supported by literature and the perspectives of practicing psychologists. The consequences of the implementation of clinical guidelines within the context of the typical biopsychosocial profile of those referred for bariatric surgery are discussed. The ramifications of a screening approach rather than a clinical formulation-based approach to assessment, impact of a possible unconscious bias in commissioning and an overemphasis on a biomedical model approach to treatment are also presented. These contextual factors are argued to contribute to a population of "forgotten patients" that is, patients who have been assessed as not suitable for bariatric surgery, and thus "stuck" in their journey toward better health. For these individuals the only option left are energy balance only approaches, which are the very same approaches to weight-loss and comorbidity improvement that have been attempted, often for many years. Not only have these approaches not resulted in weight-loss and health improvement, they also fail to address the underlying psychological causes of obesity. Consequently, this lack of support means that patients continue to suffer from poor quality of life, with no clear pathway to improved health and wellbeing. This paper illuminates the clear gaps in weight management service provision, the implementation of guidelines in practice, and offers practical suggestions to reduce the unintended consequences of clinical guidelines for bariatric surgery.

The effect of marijuana use on short-term outcomes with bariatric surgery

BACKGROUND

Despite increasing marijuana use nationwide, there are limited data on implications of marijuana use on bariatric surgery outcomes.

OBJECTIVE

We investigated associations between marijuana use and bariatric surgery outcomes.

SETTING

Multicenter statewide study utilizing data from the Michigan Bariatric Surgery Collaborative, a payor-funded consortium including over 40 hospitals and 80 surgeons performing bariatric surgery statewide.

METHODS

We analyzed data from the Michigan Bariatric Surgery Collaborative clinical registry on patients who underwent a laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between June 2019 and June 2020. Patients were surveyed at baseline and annually on medication use, depression symptoms, and substance use. Regression analysis was performed to compare 30-day and 1-year outcomes between marijuana users and nonusers.

RESULTS

Of 6879 patients, 574 reported baseline marijuana use and 139 reported use at baseline and 1 year. Marijuana users were more likely to be current smokers (14% versus 8%, P < .0001), screen positive for alcohol use disorder (20.0% versus 8.4%, P < .0001), and score higher on the Patient Health Questionnaire-8 (6.1 versus 3.0, P < .0001). There were no statistically significant differences in 30-day outcomes or co-morbidity remission at 1 year. Marijuana users had higher adjusted total mean weight loss (47.6 versus 38.1 kg, P < .0001) and body mass index reduction (17 versus 14 kg/m2, P < .0001).

CONCLUSIONS

Marijuana use is not associated with worse 30-day outcomes or 1-year weight loss outcomes and should not be a barrier to bariatric surgery. However, marijuana use is associated with higher rates of smoking, substance use, and depression. These patients may benefit from additional mental health and substance abuse counseling.

Bariatric surgery and its influence on alcohol consumption: Differences before and after surgery - A systematic review and meta-analysis

BACKGROUND

Through new publications on the subject, the main goal of this article is to seek a change in the pattern of alcohol use before and after bariatric surgery.

METHODS

We searched the National Library of Medicine, CINAHL, and PsycINFO databases. We included original articles regarding alcohol consumption before and after bariatric surgery to conduct the systematic review.

RESULTS

Our systematic review, which included 18 articles, yielded mixed results. Meta-analysis of six articles did not reveal statistically significant differences in alcohol use behaviours before and one year after bariatric surgery. However, throughout the perspective of follow-up after bariatric surgery, nine out of the twelve articles showed improvement in the pattern of alcohol consumption when evaluated up to two years after the end of the surgical period, and four out of the five articles with monitoring beyond two years showed worsening in consumption, compared to pre-surgery alcohol use behaviours.

CONCLUSIONS

Conclusions about the relationship between alcohol consumption and bariatric surgery are challenging primarily because of the variety of the methods used and the alcohol consumption measures. Despite that, our research pointed to an increased risk of alcohol use disorders two years after bariatric surgery.

Opioid Analgesics after Bariatric Surgery: A Scoping Review to Evaluate Physiological Risk Factors for Opioid-Related Harm

The persisting use of opioids following bariatric surgery has emerged as a prevalent complication, heightening the probability of opioid-related harm (ORM), such as opioid-related fatalities and prescription opioid use disorder (OUD). A comprehensive review of PubMed literature from 1990 to 2023 was conducted to pinpoint physiological influences on postoperative ORM. As a result, we found that patients undertaking bariatric operations often exhibit an inherently higher risk for substance use disorders, likely attributable to genetic predisposition and related neurobiological changes that engender obesity and addiction-like tendencies. Furthermore, chronic pain is a common post-bariatric surgery complaint, and the surgical type impacts opioid needs, with increased long-term opioid use after surgeries. Additionally, the subjective nature of pain perception in patients with obesity can distort pain reporting and the corresponding opioid prescription both before and after surgery. Furthermore, the postoperative alterations to the gastrointestinal structure can affect the microbiome and opioid absorption rates, resulting in fluctuating systemic exposure to orally ingested opioids. The prospect of ORM development post-bariatric surgery appears amplified due to a preexisting susceptibility to addictive habits, surgically induced pain, modified gut-brain interaction and pain management and the changed pharmacokinetics post-surgery. Further research is warranted to clarify these potential risk variables for ORM, specifically OUD, in the bariatric population.

Pre-Operative Substance Use Disorder is Associated with Higher Risk of Long-Term Mortality Following Bariatric Surgery

PURPOSE

Metabolic and bariatric surgery (MBS) has been associated with reduced all-cause mortality. While the number of subjects with substance use disorders (SUD) before MBS has been documented, the impact of pre-operative SUD on long-term mortality following MBS is unknown. This study assessed long-term mortality of patients with and without pre-operative SUD who underwent MBS.

MATERIALS AND METHODS

Two statewide databases were used for this study: Utah Bariatric Surgery Registry (UBSR) and the Utah Population Database. Subjects who underwent MBS between 1997 and 2018 were linked to death records (1997-2021) to identify any death and cause for death following MBS. All deaths (internal, external, and unknown reasons), internal deaths, and external deaths were the primary outcomes of the study. External causes of death included death from injury, poisoning, and suicide. Internal causes of death included deaths that were associated with natural causes such as heart disease, cancer, and infections. A total of 17,215 patients were included in the analysis. Cox regression was used to estimate hazard ratios (HR) of controlled covariates, including the pre-operative SUD.

RESULTS

The subjects with pre-operative SUD had a 2.47 times higher risk of death as compared to those without SUD (HR = 2.47, p < 0.01). Those with pre-operative SUD had a higher internal cause of death than those without SUD by 129% (HR = 2.29, p < 0.01) and 216% higher external mortality risk than those without pre-operative SUD (HR = 3.16, p < 0.01).

CONCLUSION

Pre-operative SUD was associated with higher hazards of all-cause, internal cause, and external cause mortality in patients who undergo bariatric surgery.

Substance abuse screening prior to bariatric surgery: an MBSAQIP cohort study evaluating frequency and factors associated with screening

INTRODUCTION

Patients undergoing bariatric surgery experience substantial risk of pre- and postoperative substance use. Identifying patients at risk for substance use using validated screening tools remains crucial to risk mitigation and operative planning. We aimed to evaluate proportion of bariatric surgery patients undergoing specific substance abuse screening, factors associated with screening and the relationship between screening and postoperative complications.

METHODS

The 2021 MBSAQIP database was analyzed. Bivariate analysis was performed to compare factors between groups who were screened for substance abuse versus non-screened, and to compare frequency of outcomes. Multivariate logistic regression analysis was performed to assess the independent effect of substance screening on serious complications and mortality, and to assess factors associated with substance abuse screening.

RESULTS

A total of 210, 804 patients were included, with 133,313 (63.2%) undergoing screening and 77,491 (36.8%) who did not. Those who underwent screening were more likely to be white, non-smoker, and have more comorbidities. The frequency of complications was not significant (e.g., reintervention, reoperation, leak) or similar (readmission rates 3.3% vs. 3.5%) between screened and not screened groups. On multivariate analysis, lower substance abuse screening was not associated with 30-day death or 30-day serious complication. Factors that significantly affected likelihood of being screened for substance abuse included being black (aOR 0.87, p < 0.001) or other race (aOR 0.82, p < 0.001) compared to white, being a smoker (aOR 0.93, p < 0.001), having a conversion or revision procedure (aOR 0.78, p < 0.001; aOR 0.64, p < 0.001, respectively), having more comorbidities and undergoing Roux-en-y gastric bypass (aOR 1.13, p < 0.001).

CONCLUSION

There remains significant inequities in substance abuse screening in bariatric surgery patients regarding demographic, clinical, and operative factors. These factors include race, smoking status, presence of preoperative comorbidities, and procedure type. Further awareness and initiatives highlighting the importance of identifying at risk patients is critical for ongoing outcome improvement.

Severe Cannabis use is Associated with Complications and Prolonged Length of Stay in Bariatric Surgery

PURPOSE

In the United States, recreational and medicinal cannabis use has continually increased in recent years, including in patients undergoing bariatric surgery. However, the effects of cannabis use on morbidity and mortality after bariatric surgery are uncertain, and the literature is limited by a paucity of studies. This study intends to evaluate the effects of cannabis use disorder on outcomes in patients undergoing bariatric surgery.

MATERIALS AND METHODS

The National Inpatient Sample 2016-2019 was queried for patients ≥ 18 years who underwent roux-en-y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), or adjustable gastric band (AGB) surgery. Cannabis use disorder was identified using ICD-10 coding. Three outcomes were evaluated: medical complications, in-hospital mortality, and length of stay. Logistic regression was used to evaluate effects of cannabis use disorder on medical complications and in-hospital mortality, and linear regression for length of stay. All models controlled for race, age, sex, income, procedure type, and various medical comorbidities.

RESULTS

A total of 713,290 patients were included in this study, with 1,870 (0.26%) having cannabis use disorder. Cannabis use disorder was associated with medical complications (OR: 2.24; 95% CI: 1.31-3.82; P = 0.003) and longer lengths of stay (β: 1.3; SE: 0.297; P < 0.001), but not in-hospital mortality (OR: 3.29; CI: 0.94-11.5); P = 0.062).

CONCLUSIONS

Severe cannabis use was associated with higher risk for complications and extended length of stay. Future investigations are needed to better elucidate the relationship between cannabis use and bariatric surgery, including effects of dosage, chronicity, and method of ingestion.

Incidence of Substance Use Disorder Following Bariatric Surgery: A Retrospective Cohort Study

BACKGROUND

New-onset substance use disorder (SUD) following bariatric surgery is a significant concern that is likely multi-factorial, although the etiologies are unclear. Previous studies have identified variable rates of SUD along with utilizing different methods and measures. The objective of this study is to evaluate new-onset SUD diagnoses among adults following bariatric surgery and compare these rates to those in the general population as well as those diagnosed with overweight or obesity.

METHODS

Data was extracted from TriNetX Research Platform and used to build three cohorts of adults: those who had bariatric surgery (bariatric surgery cohort), those diagnosed with obesity or overweight, and a general population cohort. Rates of incident SUD were compared among these three groups. Initial encounters for all individuals were from January 1, 2018, to June 30, 2019.

RESULTS

The incidence rate of SUD in patients with a history of bariatric surgery was 6.55% (n = 2523). When compared to the general population, persons who had any type of bariatric procedure had a decreased risk of new-onset SUD with an overall odds ratio (OR) [95% confidence limits (CL)] of 0.89 [0.86, 0.93]. When compared to persons with overweight or obesity, bariatric patients were less likely to develop any form of SUD (OR: 0.65 [0.62, 0.67]).

CONCLUSION

While overall rates of new-onset SUD are lower among those who had bariatric surgery, they also vary by surgery and substance type. Efforts should still be made to address new-onset SUD in order to optimize the post-surgical care of patients.

Treatments for obesity in the context of nonalcoholic steatohepatitis and mental health

Content available: Audio Recording.

Emergence of bariatric psychiatry as a new subspecialty

Bariatric surgery is the branch of surgery aimed at helping a person with obesity lose weight. The implementation of surgical treatment of obesity is growing at an impressive rate. As expected, the expanding implementation of bariatric procedures has progressively revealed critical issues that were not evident when the number of obese patients treated with surgery was relatively small. One critical issue is the importance of mental health assessment and care of bariatric patients. The aim of this review is to provide readers with an up-to-date summary of the goals, methods, and clinical strategies of bariatric psychiatry. The aims can be grouped into three distinct categories. First, to ascertain that there are no psychiatric contraindications to safe bariatric surgery. Second, to diagnose and treat pre-surgery mental conditions that could predict poor weight loss. Third, to diagnose and treat post-surgery mental conditions associated with poor quality of life. Although bariatric psychiatry has gained the status of a new subspecialty within the field of mental health and psychopathology, many clinical questions remain unsolved. We need more long-term data on outcome measures such as quality of life, adherence to behavioral guidelines, risk of suicide, and post-surgery prevalence of psychological disturbances and mental disorders.

Acute and chronic ethanol administration: A potential model of behavioral sensitization using wheel-running in male CD1 mice

RATIONALE

We define behavioral sensitization as an augmented response to subsequent dosing after chronic intermittent administration of a drug. However, the biphasic effects of ethanol (EtOH), first stimulatory followed by depressive, make animal models of behavioral sensitization rare.

OBJECTIVES

This study aimed to determine a dose of EtOH that did not depress wheel-running (WR) in CD1 mice and then to develop a model of EtOH-induced behavioral sensitization.

METHODS

For the first part of this study, male CD1 mice (n = 24, 6/group) were administered either phosphate buffer saline (PBS), 0.5 g/kg, 1 g/kg, or 2 g/kg EtOH at a volume of 3 ml/kg, intraperitoneally (IP). Mice were divided into equal groups and received the weight-based dose once daily on Days 1, 2, 3, 4, and 5. All mice received a challenge dose of 0.5 g/kg on Day 10. In both parts of the study, mice were habituated to the running wheel for 5 min prior to dosing and wheel running was measured for 10 min after each dose.

RESULTS

The acute dose-response of EtOH effects on wheel running determined a significant difference between doses in wheel running (p < 0.05), with a post-hoc analysis establishing that 0.5 g/kg EtOH resulted in significantly more WR compared to 2 g/kg EtOH (p < 0.05). The chronic study demonstrated a significant main effect of Day (1 vs. 5 vs. Challenge, p < 0.001) and an interaction between Day and Treatment, with post-hoc analysis determining the effect to be between PBS and EtOH WR on Day 5 (p < 0.05). In addition, Bonferroni post-hoc analysis determined no differences between Days in the PBS condition, but a significant difference in the EtOH condition between Day 1 and Day 5 (p < 0.001) and that difference from Day 1 persisted when comparing to the Challenge Day (p < 0.01).

CONCLUSION

After chronic, intermittent, low dose administration of EtOH, male mice showed an increase in activity as measured by wheel running. Therefore, we laid the groundwork for a potentially useful rodent model for EtOH-induced behavioral sensitization.

Changes in Smoking Behavior Before and After Gastric Bypass: A 7-year Study

OBJECTIVE

To evaluate smoking history and change in smoking behavior, from 1 year before through 7 years after Roux-en-Y gastric bypass (RYGB) surgery, and to identify risk factors for post-surgery smoking.

BACKGROUND

Smoking behavior in the context of bariatric surgery is poorly described.

METHODS

Adults undergoing RYGB surgery entered a prospective cohort study between 2006 and 2009 and were followed up to 7 years until ≤2015. Participants (N = 1770; 80% female, median age 45 years, median body mass index 47 kg/m2) self-reported smoking history pre-surgery, and current smoking behavior annually.

RESULTS

Almost half of participants (45.2%) reported a pre-surgery history of smoking. Modeled prevalence of current smoking decreased in the year before surgery from 13.7% [95% confidence interval (CI) = 12.1-15.4] to 2.2% (95% CI = 1.5-2.9) at surgery, then increased to 9.6% (95% CI = 8.1-11.2) 1-year post-surgery and continued to increase to 14.0% (95% CI = 11.8-16.0) 7-years post-surgery. Among smokers, mean packs/day was 0.60 (95% CI = 0.44-0.77) at surgery, 0.70 (95% CI = 0.62-0.78) 1-year post-surgery and 0.77 (95% CI = 0.68-0.88) 7-years post-surgery. At 7-years, smoking was reported by 61.7% (95% CI = 51.9-70.8) of participants who smoked 1-year pre-surgery (n = 221), 12.3% (95% CI = 8.5-15.7) of participants who formerly smoked but quit >1 year pre-surgery (n = 507), and 3.8% (95% CI = 2.1-4.9) of participants who reported no smoking history (n = 887). Along with smoking history (ie, less time since smoked), younger age, household income <$25,000, being married or living as married, and illicit drug use were independently associated with increased risk of post-surgery smoking.

CONCLUSION

Although most adults who smoked 1-year before RYGB quit pre-surgery, smoking prevalence rebounded across 7-years, primarily due to relapse.

Bariatric surgery and alcohol and substance abuse disorder: A systematic review

INTRODUCTION

Bariatric surgery is a relatively safe surgical procedure with a high success rate. However, recent reports indicate a higher prevalence of alcohol or substance abuse disorder in this patient group. The purpose of this study was to review the related evidence to serve as a reference for multidisciplinary teams who treat these patients.

METHODS

We searched the PubMed and CENTRAL databases. The odds ratios were extracted from the different articles, comparing the prevalence of the abuse of alcohol or other substances in the postoperative period versus preoperative levels. We also compared the prevalence of alcohol use disorder after different types of bariatric surgery.

RESULTS

A total of 49 121 bariatric patients (80.8% female) were evaluated for alcohol use disorder. In general, bariatric surgery was found to be associated with an increase in the prevalence of alcohol abuse (4.58 ± 5.3 vs. 1.58 ± 10.7% in the preoperative period). We also found that the population of patients who underwent RYGB procedures had a higher prevalence of alcohol use disorder than patients who underwent another type of surgery (OR: 1.83; 95% CI: 1.51-2.21). The prevalence of substance abuse disorder (other than alcohol) after this procedure is less studied, although there appears to be an increased risk of abuse of certain substances.

CONCLUSIONS

Bariatric surgery is the best treatment for obesity and its complications. The evidence reviewed suggests that it correlates with a modest but consistent increase in the prevalence of abuse of alcohol and other substances. Medical teams who treat bariatric patients must be informed about this eventuality for its timely prevention, diagnosis and treatment.

Potential gut-brain mechanisms behind adverse mental health outcomes of bariatric surgery

Bariatric surgery induces sustained weight loss and metabolic benefits via notable effects on the gut-brain axis that lead to alterations in the neuroendocrine regulation of appetite and glycaemia. However, in a subset of patients, bariatric surgery is associated with adverse effects on mental health, including increased risk of suicide or self-harm as well as the emergence of depression and substance use disorders. The contributing factors behind these adverse effects are not well understood. Accumulating evidence indicates that there are important links between gut-derived hormones, microbial and bile acid profiles, and disorders of mood and substance use, which warrant further exploration in the context of changes in gut-brain signalling after bariatric surgery. Understanding the basis of these adverse effects is essential in order to optimize the health and well-being of people undergoing treatment for obesity.

Differential Response in Ethanol Behaviors of Female Rats Given Various Weight Loss Surgeries

AIMS

Currently, the only effective treatment for morbid obesity and its comorbidities is weight loss surgery (WLS). Growing evidence suggests that different types of WLS, such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), have differential effects on alcohol consumption in humans and rats. Thus, we aimed to directly compare the effects of these two surgical procedures, for the first time in female rats, and to determine whether presence or absence of the ghrelin-producing stomach tissue has critical influence on postoperative alcohol intake.

METHODS

We performed two experiments using an identical behavioral protocol, a continuous-access two-bottle choice protocol for various concentrations of ethanol (EtOH). In Experiment 1, 23 high fat diet (HFD) obese, female rats were randomized to three groups: RYGB, SG or sham-operated food-restricted (Sham) controls. In Experiment 2, HFD obese female rats received either sham (n = 11) or a modified RYGB surgery where the remnant stomach was removed (RYGB-X; n = 12).

RESULTS

SG rats drank significantly less than RYGB for 4, 6 and 8% and significantly less than Sham for 6, 8 and 8% reinstatement. RYGB-X consumed significantly less EtOH than Sham across all concentrations, reaching significance for 6 and 8% reinstatement.

CONCLUSION

These findings confirm reduced EtOH consumption by female SG rats as opposed to increased intake following RYGB, and provide the first experimental evidence that the remnant stomach in the RYGB procedure is contributory. Future studies in rats and humans are warranted to confirm that ghrelin plays a critical role in susceptibility to AUD development following WLS.

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.

Food addiction among morbidly obese patients: prevalence and links with obesity complications

BACKGROUND

In the context of obesity, little is known about the prevalence of food addiction nor about the phenotype of obese patients with food addiction. Objectives: To assess: (i) the prevalence of food addiction among obese patients eligible for obesity surgery; (ii) the relationship between clinical features and the complications of obesity. Methods: Consecutive patients consulting for the first time were included. The Yale Food Addiction Scale (YFAS) 2.0 questionnaire was used to diagnose food addiction and its severity. Demographics, clinical features, and obesity complications were systematically collected. Statistics: Student's test was used for numerical variables and Chi-square test or Fisher's exact test for categorical variables. Results: A total of 292 patients were included: 79% female, age (mean ± SD) 42.6 ± 13.0 yrs., body mass index (BMI) 43.2 ± 6.8 kg/m². One hundred and eight patients (37%) had food addiction: 58% severe, 33% moderate, 9% mild. Food addiction prevalence was 39% (n = 61/156) among patients eligible for obesity surgery. Food addiction was more frequent among the unemployed, compared to professionally active patients (41.0% vs. 33.5%, p = 0.046). Clinical and metabolic phenotypes and obesity complications were similar between patients with and without food addiction. Conclusion: Food addiction was present in 37% of obese patients, but was not associated with clinical features or obesity complications. Therefore, it should be systemically assessed for appropriate management.

Smoking in bariatric surgery: a systematic review

BACKGROUND

The prevalence of smoking among patients undergoing bariatric surgery has been reported to be as high as 40%. The effect of smoking in the perioperative period has been extensively studied for various surgical procedures, but limited data are available for bariatric surgery. The objective of this study is to review the existing literature to assess: (1) the impact of smoking on postoperative morbidity and mortality after bariatric surgery, (2) the relationship between smoking and weight loss after bariatric surgery, and (3) the efficacy of smoking cessation in the perioperative period among bariatric surgery patients.

METHODS

A comprehensive search of electronic databases including MEDLINE, EMBASE and the Cochrane Library from 1946 to February 2020 was performed to identify relevant articles. Following an initial screen of 940 titles and abstracts, 540 full articles were reviewed.

RESULTS

Forty-eight studies met criteria for analysis: five structured interviews, three longitudinal studies, thirty-two retrospective studies and eight prospective studies. Smoking within 1 year prior to bariatric surgery was found to be an independent risk factor for increased 30-day mortality and major postoperative complications, particularly wound and pulmonary complications. Smoking was significantly associated with long-term complications including marginal ulceration and bone fracture. Smoking has little to no effect on weight loss following bariatric surgery, with studies reporting at most a 3% increased percentage excess weight loss. Rates of smoking recidivism are high with studies reporting that up to 17% of patients continue to smoke postoperatively.

CONCLUSIONS

Although current best practice guidelines recommend only a minimum of 6 weeks of abstinence from smoking prior to bariatric surgery, the findings of this review suggest that smoking within 1 year prior to bariatric surgery is associated with significant postoperative morbidity. More investigation is needed on strategies to improve smoking cessation compliance among bariatric surgery patients in the perioperative period.

Substance Use, Mental Health, and Weight-Related Behaviors During the COVID-19 Pandemic Among Metabolic and Bariatric Surgery Patients

Purpose

The impact of the COVID-19 pandemic on behavioral issues among those who have completed bariatric surgery (BS) is not well described in ethnically diverse populations. The aim of this study was to compare the impact of COVID-19 lockdown orders and after lockdown orders were lifted on substance use, mental health, and weight-related behaviors among a sample of post-BS adults.

Materials and Methods

A retrospective medical chart review identified BS patients from one university-based obesity medicine clinic and two BS practices. An online non-anonymous survey was implemented in two phases: during lockdown (April 1–May 31, 2020) and after lockdown orders were lifted (June 1, 2020–September 30, 2020) to obtain information about the COVID-19 pandemic’s impact on BS patients.

Results

A total of 189 (during lockdown=39, post-lockdown=150) participants (90.4% female, mean age 52.4 years, SD 11.1, 49.8% non-Hispanic White, 30.6% non-Hispanic Black, 16.1% Hispanic) participated. Lockdown participants were more likely to have sleep problems (74.3% vs. 56.1%, P=.039) and feel anxious (82.0% vs. 63.0%, P=.024) versus post-lockdown participants. A majority (83.4%) reported depression in both lockdown/post-lockdown. Post-lockdown participants were more than 20 times more likely to report substance use compared those in lockdown (aOR 20.56, 95% CI 2.66–158.4).

Conclusions and Relevance

The COVID-19 pandemic is having a substantial negative impact on substance use, mental health, and weight-related health behaviors in diverse BS patients. These findings have important implications for post-BS patient care teams and may suggest the integration of screening tools to identify those at high risk for behavioral health issues.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05488-6.

Liver Transplantation After Bariatric Surgery: a Clinical Cohort Study

PURPOSE

Individuals that undergo bariatric surgery are at higher risk for problematic alcohol use via pharmacokinetic changes in alcohol metabolism and cross addictions. Little data exists regarding post-bariatric surgery patients with alcohol-related liver disease (ALD) who ultimately require liver transplantation. The aim of this project was to better understand demographic, medical, and psychological characteristics of post-bariatric surgery patients who undergo liver transplantation due to ALD.

METHODS

This retrospective clinical cohort identified 1416 patients who underwent ALD liver transplantation over a 10-year timespan at three academic medical centers. Electronic medical records were reviewed for patient characteristics, including sex, age, body mass index, surgery dates, Model for End Stage Liver Disease (MELD) scores, medical history, psychiatric history, and mortality rates.

RESULTS

Within the sample of liver transplantation patients, 1.3% had undergone bariatric surgery prior to transplantation. Fifty percent of the post-bariatric surgery sample was female. The MELD score was higher and the median age at transplantation was younger in the post-bariatric surgery subgroup in comparison to that in the non-bariatric surgery patients. Mood and anxiety disorders were more common among those with a history of having bariatric surgery, with major depressive disorder having the largest difference between subgroups.

CONCLUSIONS

Among patients who require a liver transplantation due to ALD, those with a history of bariatric surgery are more likely to be female, younger, and diagnosed with mood disorders. Further studies with larger and more diverse samples are necessary to better understand how to prevent development of alcohol use disorder in the bariatric surgery population.

Bariatric surgery and alcohol and substance abuse disorder: A systematic review

INTRODUCTION

Bariatric surgery is a relatively safe surgical procedure with a high success rate. However, recent reports indicate a higher prevalence of alcohol or substance abuse disorder in this patient group. The purpose of this study was to review the related evidence to serve as a reference for multidisciplinary teams who treat these patients.

METHODS

We searched the PubMed and CENTRAL databases. The odds ratios were extracted from the different articles, comparing the prevalence of the abuse of alcohol or other substances in the postoperative period versus preoperative levels. We also compared the prevalence of alcohol use disorder after different types of bariatric surgery.

RESULTS

A total of 49 121 bariatric patients (80.8% female) were evaluated for alcohol use disorder. In general, bariatric surgery was found to be associated with an increase in the prevalence of alcohol abuse (4.58±5.3 vs. 1.58±10.7% in the preoperative period). We also found that the population of patients who underwent RYGB procedures had a higher prevalence of alcohol use disorder than patients who underwent another type of surgery (OR: 1.83; 95% CI: 1.51-2.21). The prevalence of substance abuse disorder (other than alcohol) after this procedure is less studied, although there appears to be an increased risk of abuse of certain substances.

CONCLUSIONS

Bariatric surgery is the best treatment for obesity and its complications. The evidence reviewed suggests that it correlates with a modest but consistent increase in the prevalence of abuse of alcohol and other substances. Medical teams who treat bariatric patients must be informed about this eventuality for its timely prevention, diagnosis and treatment.

Cannabis use and bariatric surgery psychology practice: survey and insights

BACKGROUND

Cannabis is second only to alcohol as a substance of abuse and dependence in the United States. While there is extensive research examining alcohol use and bariatric surgery, there is currently little research and there are no published guidelines specific to cannabis use and bariatric surgery.

OBJECTIVES

To identify major themes and general guidelines applied by bariatric surgery psychology clinicians.

SETTING

This practice survey was disseminated to bariatric surgery psychologists at various U.S. academic medical centers, hospitals, and private practices.

METHODS

An electronic, 35-question survey was sent to 47 bariatric surgery psychologists to collect information on current clinical practice guidelines regarding cannabis use before and after bariatric surgery.

RESULTS

The survey questionnaire was completed by 34 (72.34%) bariatric surgery psychologists. The major identified themes included: (1) the lack of a standardized assessment of cannabis use; (2) a requirement for 3 months of abstinence from cannabis before bariatric surgery; (3) recommended lifetime abstinence from cannabis after bariatric surgery; and (4) discussion of cannabis use risks following bariatric surgery, including appetite stimulation, addiction potential, and possible negative impacts on judgment.

CONCLUSION

Cannabis use will likely further increase in the United States. This survey highlighted common bariatric surgery psychology practices in the absence of extensive research and published guidelines. These findings suggest a preliminary framework with which to address cannabis use in patients seeking bariatric surgery. It is recommended that professional organizations and societies build on these initial survey findings to develop guidelines for more consistent, evidence-based practice regarding cannabis use and bariatric surgery.

Meeting of Minds around Food Addiction: Insights from Addiction Medicine, Nutrition, Psychology, and Neurosciences

This review, focused on food addiction (FA), considers opinions from specialists with different expertise in addiction medicine, nutrition, health psychology, and behavioral neurosciences. The concept of FA is a recurring issue in the clinical description of abnormal eating. Even though some tools have been developed to diagnose FA, such as the Yale Food Addiction Scale (YFAS) questionnaire, the FA concept is not recognized as an eating disorder (ED) so far and is even not mentioned in the Diagnostic and Statistical Manuel of Mental Disorders version 5 (DSM-5) or the International Classification of Disease (ICD-11). Its triggering mechanisms and relationships with other substance use disorders (SUD) need to be further explored. Food addiction (FA) is frequent in the overweight or obese population, but it remains unclear whether it could articulate with obesity-related comorbidities. As there is currently no validated therapy against FA in obese patients, FA is often underdiagnosed and untreated, so that FA may partly explain failure of obesity treatment, addiction transfer, and weight regain after obesity surgery. Future studies should assess whether a dedicated management of FA is associated with better outcomes, especially after obesity surgery. For prevention and treatment purposes, it is necessary to promote a comprehensive psychological approach to FA. Understanding the developmental process of FA and identifying precociously some high-risk profiles can be achieved via the exploration of the environmental, emotional, and cognitive components of eating, as well as their relationships with emotion management, some personality traits, and internalized weight stigma. Under the light of behavioral neurosciences and neuroimaging, FA reveals a specific brain phenotype that is characterized by anomalies in the reward and inhibitory control processes. These anomalies are likely to disrupt the emotional, cognitive, and attentional spheres, but further research is needed to disentangle their complex relationship and overlap with obesity and other forms of SUD. Prevention, diagnosis, and treatment must rely on a multidisciplinary coherence to adapt existing strategies to FA management and to provide social and emotional support to these patients suffering from highly stigmatized medical conditions, namely overweight and addiction. Multi-level interventions could combine motivational interviews, cognitive behavioral therapies, and self-help groups, while benefiting from modern exploratory and interventional tools to target specific neurocognitive processes.

Increased Prevalence of Obesity and Metabolic Syndrome in Patients with Alcoholic Fatty Liver Disease

BACKGROUND AND AIMS

Obesity and diabetes are risk factors for advanced alcoholic liver disease, and both are components of the metabolic syndrome. We aimed to assess the prevalence of metabolic syndrome and its components in a contemporary US cohort of adults with alcoholic liver disease and compare it to a historic cohort to assess changes over time.

METHOD

Individuals 18 years or older who participated in the National Health and Nutrition Examination Survey during 2009-2014 and 1999-2001 were used as the contemporary and historic cohort, respectively. Alcoholic liver disease was defined as excessive alcohol consumption (men: ≥ 3 drinks/day; women: ≥ 2 drinks/day) and elevated alanine aminotransferase. Metabolic syndrome definition was based on the updated International Diabetes Federation criteria. Data are presented as mean ± standard error or unweighted frequency. A logistic regression analysis was performed to assess differences in metabolic syndrome components between the two period cohorts while adjusting for central obesity.

RESULTS

The mean age for our contemporary cohort was 41.9, 66.1% being male. Central obesity was present in 66.3%, type 2 diabetes in 18.7%, low high-density lipoprotein in 28.3%, hypertriglyceridemia in 44.8%, and hypertension in 54.7%. 36.9% met the criteria for metabolic syndrome. Compared to the historic cohort, patients in the contemporary cohort were more likely to have central obesity (50% vs. 66%, p = 0.002), metabolic syndrome (26% vs. 37%, p = 0.044), and type 2 diabetes (12% vs. 19%, p = 0.099).

CONCLUSIONS

Prevalence of both obesity and metabolic syndrome is increasing in alcoholic liver disease patients. Further studies are required to investigate effective interventions to avoid disease progression in these high-risk patients.

Food Addiction and Binge Eating During One Year Following Sleeve Gastrectomy: Prevalence and Implications for Postoperative Outcomes

BACKGROUND

Food addiction and binge eating are common among individuals with obesity. However, a paucity of studies prospectively examined the prevalence and implications of food addiction before and post-bariatric surgery. We aimed to examine the prevalence of food addiction and binge eating before and after sleeve gastrectomy (SG) and to assess their associations with behavioral and weight loss outcomes.

METHODS

We followed at 3 (M3), 6 (M6), and 12 (M12) months postoperative, 54 women who underwent SG. Data collected including anthropometrics, nutritional intake, food tolerance, and physical activity measures. The Yale Food Addiction Scale and the Binge Eating Scale were used to characterize food addiction and binge eating, respectively.

RESULTS

The mean baseline age and BMI were 32.1 ± 11.1 years and 44.9 ± 4.9 kg/m², respectively. Pre-surgery, food addiction, and binge eating were identified in 40.7% and 48.1% of patients, respectively. The prevalence of food addiction decreased significantly up to M6, but increased to 29.3% at M12. The prevalence of binge eating decreased significantly through the follow-up up to 17.4% at M12. Those who met criteria for food addiction at M12 achieved significantly lower excess weight loss at M12 compared with those not meeting this criterion (P = 0.005). Food addiction scores at M12 negatively correlated with weekly physical activity (r = - 0.559; P < 0.001) and food tolerance scores (r = - 0.428; P = 0.005).

CONCLUSIONS

The reduction in food addiction observed at M6 was not maintained at M12. Food addiction at M12 was associated with poorer weight loss, eating, and lifestyle behaviors. Clinical practice should focus on the psychological aspects associated with obesity.

A Preliminary Study on the Influence of Cannabis and Opioid Use on Weight Loss and Mental Health Biomarkers Post-weight Loss Surgery

PURPOSE

A subpopulation of weight loss surgery (WLS) patients endorse cannabis and/or opioid use; however, impact on post-WLS anxiety and depression is unclear. This study examined the influence of the independent and combined use of cannabis and opioids on (1) depression and anxiety, (2) duodenum serotonin and cortisol, and (3) total percent weight loss.

MATERIALS AND METHODS

A cross-sectional analysis was conducted among patients (N = 18) who had biomarkers of serotonin and cortisol collected from the duodenum during WLS. Cannabis and opioid use was determined by self-reported lifetime, past-year, and past 30-day use. The Beck Anxiety Inventory and Depression Inventory-II assessed depression and anxiety symptoms. Total percent weight loss was calculated from pre-WLS and post-WLS weight (kg). Chi-squared analyses and t tests were conducted.

RESULTS

Over a quarter (27.8%) were cannabis-only users and 16.7% used a combination of cannabis and opioids. None reported using only opioids in this sample. Combination users presented with greater depressive symptoms (22.7%, p = 0.01) and greater total percent weight loss (34.1%, p = 0.04) than cannabis users (7.8, 23.2%, respectively). Cannabis users had greater serotonin (p = 0.02) and cortisol (p = 0.01) levels than combination users and never users.

CONCLUSIONS

Cannabis users had greater cortisol levels than never users and combination users. Combination users had greater weight loss and depression symptoms than cannabis users. Future studies should consider a larger sample size, utilization of a cohort design to address causality, and examination of the type, dose, and route of cannabis and opioid administration to further understand the impact of the combined use of cannabis and opioids post-WLS.

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

BACKGROUND

While general population studies have demonstrated a relationship between cigarette smoking and weight loss, this association is not well established among the bariatric patient population. Given that bariatric patients are inherently weight-concerned, understanding the effects of smoking on postoperative weight loss is essential. We examined the association of preoperative smoking, postoperative smoking and changes in smoking status with weight loss after bariatric surgery. In addition, we examined the association of changes in smoking status with subjective indices of patient satisfaction while controlling for weight loss.

METHODS

Retrospective chart review of patients who underwent Sleeve Gastrectomy or Roux-en-Y Gastric Bypass for weight loss at a single institution between August 2000 and November 2017. Additional follow up was obtained by telephone survey. Statistical analysis utilized multivariate logistical regressions.

RESULTS

Our study included 512 patients. Majority were female (n = 390, 76.2%) and underwent laparoscopic Roux-en-Y gastric bypass (n = 362, 70.7%). Average age was 46.8 years and average follow up was 6.99 years. Preoperative, postoperative and changes in smoking status were not significantly associated with weight loss. Former smokers were significantly more likely to report postoperative satisfaction with self-overall OR 10.62 (p < 0.01), satisfaction with postoperative outcomes OR 4.18 (p = 0.02), and improvement in quality of life OR 4.05 (p = 0.04) compared to continued smokers independent of weight loss. No difference in rates of satisfaction were found between former smokers and never smokers. Smoking cessation and weight loss were independently predictive of positive responses to these satisfaction indices.

CONCLUSIONS

We found no association between preoperative smoking, postoperative smoking or changes in smoking status with postoperative weight loss. Smoking cessation was associated with patient satisfaction and improvement in quality of life compared to continued smokers. Smoking cessation and postoperative weight loss were independently predictive of increased patient satisfaction.

Risk of Alcohol Use Disorder After Sleeve Gastrectomy

Aim: Several studies demonstrated increased alcohol intake after gastric bypass but not for laparoscopic sleeve gastrectomy (LSG). The purpose of this study is to determine whether there is an increased risk of developing alcohol use disorder after LSG. Materials and Methods: LSG patients with at least 1-year follow-up who completed the alcohol use disorder identification test (AUDIT) preoperatively, and at their control visit, were the subjects. AUDIT was applied to the patients who were followed up from 1 to 6 years postoperatively. Patients were divided into two groups as those who were followed for 1-3 years and 4-6 years. AUDIT scores and risk categories were compared. According to the AUDIT results, score intervals between 0-7, 8-15, 16-19 and 20-40 identified patients with low, moderate, high risk, and alcoholism, respectively. Results: There were 183 LSG patients eligible for inclusion. An AUDIT score of 2.79 before LSG showed prominent reduction in alcohol use in the first 3 years after LSG with a score of 2.27 (P = .033). At 4-6 years follow-up, AUDIT scores showed significant increase from 3.06 to 4.04, suggesting an increase in alcohol use in the long term (P = .042). In addition, the increase of risk after surgery in pre-LSG moderate-risk category (n = 21) turned out to be higher than pre-LSG low-risk category (n = 162). Conclusions: This study showed reduction in AUDIT scores in the first 3-year follow-up after LSG and increase in the 4-6 years follow-up. High pre-LSG AUDIT score, a potential risk for future alcohol use disorder, was one of the key findings of our study. Screening of LSG candidates before and after surgery by AUDIT scoring according to risk categories with larger samples will provide useful input for relevant guidelines.

Psychosocial Outcomes Following Adolescent Metabolic and Bariatric Surgery: a Systematic Review and Meta-Analysis

BACKGROUND

Metabolic and bariatric surgery is an effective strategy to curb the natural history of obesity progression and improve psychosocial status in the short term for adolescents with severe obesity. The medium- and long-term psychosocial impact of bariatric surgery in this population is not established.

METHODS

We searched MEDLINE (Ovid), EMBASE, Web of Science, PsycInfo, and the Cochrane Libraries through October 2017 for reports of weight loss surgery (roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding) on adolescents with severe obesity (age ≤ 21 years) having ≥ 6 months of follow-up. The primary outcome for inclusion in systematic review was use of a validated quality of life (QoL) or other psychosocial instrument at baseline and postoperatively. We used standardized mean difference (SMD) and random-effects modeling to provide summary estimates across different instruments.

RESULTS

We reviewed 5155 studies, of which 20 studies met inclusion criteria for qualitative synthesis. There were 14 studies and 9 unique cohorts encompassing 573 patients which were eligible for meta-analysis regarding postoperative change in QoL. Across surgical procedures, there was significant improvement in QoL of 1.40 SMD (95% confidence interval 0.95 to 1.86; I² = 89%; p < 0.001) at last follow-up (range 9-94 months). Trends in QoL improvement demonstrated the greatest improvement at 12 months; however, significant improvement was sustained at longest follow-up of 60+ months.

CONCLUSIONS

Weight loss surgery is associated with sustained improvement in QoL for adolescents with severe obesity across surgical procedures. Long-term data for psychosocial outcomes reflecting other mental health domains is lacking.

The Clinical Obesity Maintenance Model: A Theoretical Framework for Bariatric Psychology

Ranked highly in its association with serious medical comorbidities, obesity, a rapidly growing epidemic worldwide, poses a significant socio-economic burden. While bariatric procedures offer the most efficacious treatment for weight loss, a subset of patients risk weight recidivism. Due to the heterogeneity of obesity, it is likely that there are phenotypes or sub-groups of patients that require evidence-based psychological support to produce more sustainable outcomes. So far, however, characteristics of patients have not led to a personalized treatment algorithm for bariatric surgery. Maintenance of weight loss following bariatric surgery requires long-term modification of eating behaviors and physical activity. A recent Clinical Obesity Maintenance Model (COMM) proposed a conceptual framework of salient constructs, including the role of habit, behavioral clusters, emotion dysregulation, mood, health literacy, and executive function as interconnected drivers of obesity maintaining behaviors relevant to the field of bariatric psychology. The primary aim of this concise review is to bring together emerging findings from experimental and epidemiological studies relating to the COMM constructs that may inform the assessment and follow up of bariatric surgery. We also aim to explain the phenotypes that need to be understood and screened prior to bariatric surgery to enable better pre-surgery intervention and optimum post-surgery response.

The Neuroendocrine and Metabolic Outcomes of Bariatric Surgery Depend on Presurgical Control over Eating

BACKGROUND

The outcomes of bariatric surgery are very irregular and mostly unpredictable. The search for variables of predictive value is encouraged to help preventing therapeutic failures.

OBJECTIVE

We aimed to confirm the hypothesis that preexisting eating behaviors could predict neuroendocrine and metabolic outcomes of gastric bypass surgery in morbidly obese subjects.

METHODS

Twenty-one morbidly obese patients from the Bariatric Surgery Program of our hospital were selected according to the specific inclusion and exclusion criteria for this study. The subjects filled out a validated questionnaire to quantify the "loss-of-control" (LC) dimension of food craving and provided serum samples at the onset of the study and 1 year after gastric bypass surgery. Hematological, metabolic, and hormonal variables were studied by conventional clinical tests and enzyme immunoassays and checked for correlations with LC both before and after surgery.

RESULTS

Those patients that had exhibited worse eating control at the beginning of the study experienced a better metabolic response 1 year after surgery in terms of reduction of serum insulin, HOMA1-IR, HOMA2-IR, and vitamin D1; all these variables were inversely correlated with presurgical LC. Serum brain-derived neurotrophic factor (BDNF) levels showed the same tendency; in fact, BDNF significantly decreased only in those patients with worse eating control.

CONCLUSIONS

Problematic eating behaviors may predict a better response of insulin resistance and a specific reduction of serum BDNF in morbidly obese patients after gastric bypass surgery.

Incidence and Risk Factors Associated With 30-Day Readmission for Alcoholic Hepatitis

BACKGROUND

Alcohol abuse and liver disease are associated with high rates of 30-day hospital readmission, but factors linking alcoholic hepatitis (AH) to readmission are not well understood. We aimed to determine the incidence rate of 30-day readmission for patients with AH and to evaluate potential predictors of readmission.

METHODS

We used the Nationwide Readmissions Database to determine the 30-day readmission rate for recurrent AH between 2010 and 2014 and examined trends in readmissions during the study period. We also identified the 20 most frequent reasons for readmission. Multivariate survey logistic regression analysis was used to identify factors associated with 30-day readmission.

RESULTS

Of the 61,750 index admissions for AH, 23.9% were readmitted within 30-days. The rate of readmission did not change significantly during the study period. AH, alcoholic cirrhosis, and hepatic encephalopathy were the most frequent reasons for readmission. In multivariate analysis female sex, leaving against medical advice, higher Charlson comorbidity index, ascites, and history of bariatric surgery were associated with earlier readmissions, whereas older age, payer type (private or self-pay/other), and discharge to skilled nursing-facility reduced this risk.

CONCLUSIONS

The 30-day readmission rate in patients with AH was high and stable during the study period. Factors associated with readmission may be helpful for development of consensus-based expert guidelines, treatment algorithms, and policy changes to help decrease readmission in AH.

Problematic Alcohol Use and Associated Characteristics Following Bariatric Surgery

PURPOSE

Evidence suggests that a significant minority of individuals who undergo Roux-en-Y gastric bypass (RYGB) experience problematic alcohol and substance use following surgery. However, little research has examined characteristics, drinking patterns, and possible risk factors within this population. To provide descriptive information of a sample of adults with self-identified alcohol use problems following bariatric surgery, this study examined (1) alcohol and substance use symptoms using standardized assessments, (2) current and past psychiatric comorbidity, (3) subjective changes in alcohol sensitivity following surgery, and (4) specific patterns of alcohol use prior to and following bariatric surgery.

MATERIALS AND METHODS

Adult participants (N = 26) completed a series of structured diagnostic interviews and self-report assessments (e.g., Alcohol Use Disorders Identification Test [AUDIT], Michigan Alcohol Screening Test [MAST], Drug Abuse Screening Test [DAST]) by telephone 1 to 4 years following a RYGB or sleeve gastrectomy.

RESULTS

All participants met objective criteria for current problematic alcohol use based on AUDIT and MAST cutoff scores, reported increased subjective sensitivity to alcohol following surgery, and evidenced significant current and past psychiatric comorbidities, most notably previous major depression (45.5%). Approximately one third of participants evidenced new-onset Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) alcohol use or dependence following surgery. Preoperative drinking frequencies and quantities were similar to those reported during the period of the heaviest postoperative alcohol use.

CONCLUSIONS

Findings have implications for pre- and postoperative prevention and intervention efforts. Additional research is needed to further elucidate risk factors for problematic alcohol use following bariatric surgery.

Is weight regain after bariatric surgery associated with psychiatric comorbidity? A systematic review and meta-analysis

Bariatric surgery has been recognized as the gold standard treatment for severe obesity. Although postbariatric surgery patients usually achieve and maintain substantial weight loss, a group of individuals may exhibit weight regain. Several factors are proposed to weight regain, including psychiatric comorbidity. The objective of the study is to conduct a systematic review and meta-analysis of studies investigating the relationship between psychiatric comorbidity and weight regain. A systematic review through PubMed, Web of Science, Cochrane Library, Scopus, and PsycINFO was performed, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After a stepwise selection, 13 articles were included in the qualitative analysis and 5 were included for a meta-analysis. Women was majority in most of the studies (87.6%), and a bypass procedure was the bariatric intervention most evaluated (66.8%), followed by gastric banding (32.1%) and sleeve (1.1%). Higher rates of postbariatric surgery eating psychopathology were reported in patients with weight regain. However, the association between general psychopathology and weight regain was not consistent across the studies. In the meta-analysis, the odds of eating psychopathology in the weight regain group was higher compared with the nonweight regain group (OR = 2.2, 95% CI 1.54-3.15). Postbariatric surgery eating psychopathology seems to play an important role in weight regain.

Enhanced Recovery Protocol for Laparoscopic Sleeve Gastrectomy: Are Narcotics Necessary?

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have improved patient experience and outcomes in a variety of fields, including bariatric surgery. Given the increasing opioid epidemic in the USA, we sought to determine the impact of our own ERAS protocol on narcotic usage following laparoscopic sleeve gastrectomy.

METHODS

Retrospective chart review was performed on patients undergoing primary laparoscopic sleeve gastrectomy for 6 months before and after implementation of an ERAS protocol. Our protocol strongly discouraged the use of narcotics in the postoperative period. Specific outcomes of interest were postoperative narcotic usage, length of stay, complications, and readmissions.

RESULTS

Patient characteristics were similar in the two groups. ERAS implementation did not correlate with changes in length of stay, complications, or readmissions. However, ERAS implementation was associated with dramatic reductions in the use of intravenous narcotics (100% vs 47%, p < 0.01) and oral schedule 2 narcotics (56% vs 6%, p < 0.01), with an increase in the usage of tramadol (0% vs 36%, p < 0.01). After ERAS implementation, 52% of patients were managed without the use of schedule 2 narcotics (0% pre-ERAS, p < 0.01) and 33% received no narcotics of any kind (0% pre-ERAS, p < 0.01).

CONCLUSION

Implementation of an ERAS protocol for laparoscopic sleeve gastrectomy is associated with a dramatic reduction in the use of narcotics in the postoperative period. This has implementation for the usage of narcotics for laparoscopic surgery and potential elimination of narcotics for certain patients and procedures.

Proteomic Identification of Biomarkers Associated with Eating Control and Bariatric Surgery Outcomes in Patients with Morbid Obesity

BACKGROUND

The current therapeutics of morbid obesity could be significantly improved after the identification of novel biomarkers associated with the food addiction endophenotype of obesity and with bariatric surgery outcomes.

METHODS

We applied differential expression proteomics and enzyme-linked immunosorbent confirmatory assays to identify (a) proteins that varied according to loss of control over eating in morbidly obese patients and (b) proteins that varied between normoweight controls and patients before and 1 year after bariatric surgery.

RESULTS

Clusterin was the only protein that consistently varied according to eating control in patients. Patients showed increased levels of serum amyloid P protein, apolipoprotein A4, serotransferrin, complement factors B and C3 and haptoglobin with respect to controls; the levels of all these proteins tended to return to control values 1 year after surgery. In contrast, apolipoprotein A1 and transthyretin were initially downregulated in patients and were scarcely changed by surgery. Leucine-rich alpha-2-glycoprotein was markedly increased in patients only after surgery.

CONCLUSIONS

Clusterin could be of interest as a putative biomarker for food addiction diagnosis in people with morbid obesity. In addition, postsurgical normalization of the proteins initially dysregulated in obese subjects might help monitor clinical improvements after surgery, while lasting or newly detected alterations (i.e., those affecting transthyretin and leucine-rich alpha-2-glycoprotein) could reflect partial refractoriness and/or contribute to the early prediction of clinical problems.

Exploring pre-surgery and post-surgery substance use disorder and alcohol use disorder in bariatric surgery: a qualitative scoping review

INTRODUCTION

Bariatric surgery (BS) produces superior weight loss compared to non-surgical interventions. However, studies suggest bariatric patients who have undergone gastric-bypass surgery have an increased risk of developing new onset substance use disorder (SUD) or suffer negative outcomes after surgery. As such, many bariatric programs consider alcohol/ illicit drug misuse a contraindication to BS. The purpose of this systematic review was to investigate weight loss outcomes, post-surgery substance use patterns and other morbidity/mortality in BS patients with a history of substance use/SUD.

METHODS

Studies were identified by searching Ovid Medline(R), Embase, and PsychInfo. We included all study types investigating humans of any age/sex who had undergone any BS procedure with data regarding substance use before and/or after surgery. Outcome measures included metabolic outcomes and psychiatric outcomes after bariatric surgery in patients reporting substance use prior to bariatric surgery and substance use patterns after bariatric surgery.

RESULTS

Fifty-eight studies were included in the review. Studies reporting weight loss after BS did not demonstrate an association between substance use and negative weight loss outcomes. Several studies reported a significant portion of participants having new onset or increased substance use after BS. Factors associated with new onset or increased substance use/SUD after BS included the type of surgery, a history of SUD, a family history of SUD, coping skills/life stressors, age, male sex and alcohol sensitization after surgery.

CONCLUSION

Substance use history does not appear to influence weight loss after BS, however it may contribute to increased substance use after BS. Clinicians should ensure valid screening tools when assessing BS candidates for substance use history and ensure long term follow-up care post-operatively.

Polysubstance Use Disorder After Sleeve Gastrectomy

We describe a case of polysubstance use disorder that occurred after sleeve gastrectomy. Alcohol, cannabis, and stimulant use disorder was diagnosed a few years after the bariatric surgery when the patient developed a substance-induced psychotic disorder. Treatments included psychotropic medications to treat his psychosis and involvement in a drug rehabilitation and relapse prevention program. This case highlights the importance of a preoperative assessment of substance use risk in patients undergoing bariatric surgeries as well as the need for close follow-up postoperatively.

Psychosocial Concerns Following Bariatric Surgery: Current Status

PURPOSE OF REVIEW

The purpose of this paper is to review the current status of research on psychosocial concerns following bariatric surgery.

RECENT FINDINGS

Bariatric surgery has a positive overall impact on weight and obesity-related comorbidities, as well as a positive short-term impact on mental health and psychosocial functioning. Nonetheless, research has documented a number of different psychosocial concerns that may emerge following surgery including maladaptive eating, substance use disorders, suicide, lack of social support, and excess skin. Moreover, special populations of patients may have distinctive psychosocial concerns based on sociodemographic factors such as age or severity of obesity. Available studies suggest that psychosocial interventions have a positive impact on post-surgery outcomes, particularly maladaptive eating. However, research is limited, and long-term data are lacking. Monitoring patients after bariatric surgery for negative psychosocial outcomes is warranted. Research is needed to develop and evaluate personalized approaches to optimize long-term weight loss and psychosocial adjustment.

Psychosomatic and Psychosocial Questions Regarding Bariatric Surgery: What Do We Know, or What Do We Think We Know?

SUBJECT

In view of the epidemic increase in severe obesity and the ineffectiveness of conservative weight-loss interventions, bariatric surgery delivers compelling results for patients with class II (BMI ≥ 35 kg/m²) and class III obesity (BMI ≥ 40 kg/m²), not only in reducing weight over the long term, but also in reducing obesity-related somatic comorbidity and improving psychosocial functioning and quality of life. Investigations into the psychosocial aspects of obesity surgery have proliferated over the last 15 years, providing a huge amount of essential research data. Yet the results are partly contradictory and highly dependent on the duration of follow-up.

METHODS

Based of a narrative review, this article provides an overview of the current status and recent developments of the reciprocal effects between bariatric surgery and psychosocial functioning. The review focused on eight domains representing important psychosomatic and psychosocial aspects of bariatric surgery.

RESULTS

Especially in cases of class II and III obesity, bariatric surgery is the only means to reduce bodyweight significantly and permanently, though they carry with them the associated risk factors of metabolic, cardiovascular, and oncological diseases.With regard to psychosocial and psychosomatic aspects, studies with a short-term catamnesis (approx. 3 years) speak in favor of an improvement in the quality of life including mental disorders. If we consider studies with longer follow-ups, however, the results are not as uniform. In particular, we observe an increase in harmful alcohol consumption, self-harm behavior, and suicide risk.

CONCLUSIONS

In light of mental well-being and thus also quality of life, bariatric surgery would appear to convey an elevated risk for a minority of patients.Yet identifying these patients before surgery has so far been insufficient.

Prevalence and Factors Associated With Psychiatric Medication Use in Bariatric Surgery Candidates

OBJECTIVE

We aimed to describe the rates of psychiatric medication use in bariatric surgery candidates and factors associated with psychiatric medication use.

METHODS

Patients from the Toronto Western Hospital Bariatric Surgery Program were recruited from 2011 to 2014. Data extracted included demographics, clinical factors (e.g., mood disorder, anxiety disorder, eating disorder, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7), and psychiatric medication use. Logistic regression analyses were used to examine the relationship between demographic variables, clinical factors, and psychiatric medication use. Multiple logistic regression was conducted to determine the predictors of clinical factors from demographic variables with psychiatric medication use.

RESULTS

A total of 262 (35.1%) patients were taking at least 1 psychiatric medication and 105 patients (14.1%) were taking more than 1 psychiatric medication. Antidepressants were the most common psychiatric medication reported. The majority of patients taking a psychiatric medication had a psychiatric illness, with 16.0% not having a lifetime diagnosis of a mental illness. Being male and being employed significantly predicted lower odds of being on a psychiatric medication. Older age significantly predicted higher odds of being on a psychiatric medication. Psychiatric disorders were significantly associated with psychiatric medication use independent of demographic variables.

CONCLUSION

Our study provides insights into clinical and demographic factors related to psychiatric medication use in bariatric surgery patients. The findings support careful screening and clarification of psychiatric medications, especially in patients without a formal psychiatric diagnosis.

Food Addiction, High-Glycemic-Index Carbohydrates, and Obesity

BACKGROUND

Treatment success in obesity remains low, and recently food addiction has been delineated as an underlying etiologic factor with therapeutic relevance. Specifically, current treatment focuses on reduced food intake and increase of physical activity, whereas interventions for addiction encompass behavioral therapy, abstinence, and environmental interventions such as taxation, restrictions on advertising, and regulation of school menus.

CONTENT

Here, we reviewed the pertinent literature on food addiction with a specific focus on the role of high-glycemic-index carbohydrates in triggering addictive symptoms. Three lines of evidence support the concept of food addiction: (a) behavioral responses to certain foods are similar to substances of abuse; (b) food intake regulation and addiction rely on similar neurobiological circuits; (c) individuals suffering from obesity or addiction show similar neurochemical- and brain activation patterns.High-glycemic-index carbohydrates elicit a rapid shift in blood glucose and insulin levels, akin to the pharmacokinetics of addictive substances. Similar to drugs of abuse, glucose and insulin signal to the mesolimbic system to modify dopamine concentration. Sugar elicits addiction-like craving, and self-reported problem foods are rich in high-glycemic-index carbohydrates. These properties make high-glycemic-index carbohydrates plausible triggers for food addiction.

SUMMARY

We argue that food addiction is a plausible etiological factor contributing to the heterogeneous condition and phenotype of obesity. In at least a subset of vulnerable individuals, high-glycemic-index carbohydrates trigger addiction-like neurochemical and behavioral responses.