Drug- and alcohol-related mortality risk after bariatric surgery: evidence from a 7-year prospective multicenter cohort study

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.

Combined liver transplantation and sleeve gastrectomy: Report of a brief-interval staged approach

Pretransplantation bariatric surgery in patients with high Model for End-Stage Liver Disease (MELD) score is fraught with risks. Bariatric surgery after liver transplantation (LT) may be complicated by surgical adhesions but could have advantages if performed at the time of transplantation. We investigated a method of brief-interval staging combining LT and sleeve gastrectomy (SG). LT recipients with a body mass index (BMI) > 40 kg/m 2 received an SG during the same hospitalization as the LT (LT/SG), at the same time as a planned brief-interval return to the operating room for biliary anastomosis. Differences in intraoperative attributes of the LT (Stage 1) versus SG (Stage 2) procedures were analyzed using Wilcoxon signed-rank test with significance p  < 0.05 and compared with patients with obesity having a two-stage LT without SG. A total of 14 cases {median MELD score 33 (interquartile range [IQR], 18-40)} were compared with 28 controls; 60% were critically ill prior to surgery with mechanical ventilation, vasopressors, or continuous renal replacement therapy. Median interval between procedures was 16.1 (IQR, 12.5-22.7) hours for cases and 12.2 (IQR, 11.1-16.6) hours for controls, p  = 0.27. Median BMI at LT/SG was 47.0 (IQR, 41.7-51.3) kg/m 2 versus 38.1 (IQR, 35.7-39.8) kg/m 2 for controls, p  < 0.001. At 1 year, median excess body weight loss was 74.0% (IQR, 46.2%-78.7%) in cases and 15.8% (IQR, -5.4% to 62.6%) in controls, p  = 0.13; total weight loss was 38.1% (IQR, 23.9-42.9) in cases versus 7.7% (IQR, -2.4% to 27.6%) for controls, p  = 0.03. Graft survival at 1 year was 92.9% for cases and 89.3% for controls with similar early postoperative outcomes. This proof-of-concept study revealed that a brief-interval SG during LT is feasible in patients with high MELD and resulted in sustained weight loss at 1 year with similar graft survival. Further studies are needed to determine an optimal strategy.

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.

Lower survival and higher rates of cirrhosis in patients with ROUX-EN-Y gastric bypass hospitalised with alcohol-associated hepatitis

OBJECTIVE

The incidence of alcohol-associated liver disease (ALD) is increasing, and weight loss surgery is more common due to the obesity epidemic. Roux-en-Y gastric bypass (RYGB) is associated with alcohol use disorder and ALD; however, its impact on outcomes in patients hospitalised for alcohol-associated hepatitis (AH) is unclear.

DESIGN

We performed a single-centre, retrospective study of patients with AH from June 2011 to December 2019. Primary exposure was the presence of RYGB. The primary outcome was inpatient mortality. Secondary outcomes included overall mortality, readmissions and cirrhosis progression.

RESULTS

2634 patients with AH met the inclusion criteria; 153 patients had RYGB. Median age of the entire cohort was 47.3 years; median Model for End Stage Liver Disease - Sodium (MELD-Na) was 15.1 in the study group versus 10.9 in the control group. There was no difference in inpatient mortality between the two groups. On logistic regression, increased age, elevated body mass index, MELD-Na >20 and haemodialysis were all associated with higher inpatient mortality. RYGB status was associated with increased 30-day readmission (20.3% vs 11.7%, p<0.01), development of cirrhosis (37.5% vs 20.9%, p<0.01) and overall mortality (31.4% vs 24%, p=0.03).

CONCLUSIONS

Patients with RYGB have higher rates of readmissions, cirrhosis and overall mortality after discharge from hospital for AH. Allocation of additional resources on discharge may improve clinical outcomes and reduce healthcare expenditure in this unique patient population.

The rewarding effects of alcohol after bariatric surgery: do they change and are they associated with pharmacokinetic changes?

BACKGROUND

Research shows that surgery patients who have undergone Roux-en-Y gastric bypass (RYGB) are at increased risk for an alcohol use disorder (AUD). However, the mechanisms through which this increased risk is incurred are poorly understood. A host of variables have been proposed as potentially causal in developing AUDs, but empirical examination of many of these variables in human samples is lacking.

OBJECTIVES

Our objective was to examine the extent to which alcohol pharmacokinetics (PK), the rewarding effects of alcohol, and the relationship between these variables change from before to after weight loss surgery.

SETTING

Large healthcare facility in the Midwest United States METHODS: Thirty-four participants completed assessments before and 1 year after RYGB. They completed laboratory sessions and provided data on the PK of alcohol and the extent to which alcohol was reinforcing to them at each timepoint.

RESULTS

Findings show that the PK effects of alcohol (P < .01) and how rewarding alcohol was reported to be (P < .01) changed from before to 1 year after weight loss surgery. Further, statistically significant increases in the association between these variables were witnessed from before to 1 year after surgery (P < .01).

CONCLUSION

These results implicate changes (from before surgery to one year after) in the reinforcing and PK effects of alcohol as possible mechanisms for increased risk of alcohol use disorder following Roux-en-Y gastric bypass surgery.

Sex-Specific Differences in Mortality of Patients with a History of Bariatric Surgery: a Nation-Wide Population-Based Study

Purpose

Bariatric surgery reduces mortality in patients with severe obesity and is predominantly performed in women. Therefore, an analysis of sex-specific differences after bariatric surgery in a population-based dataset from Austria was performed. The focus was on deceased patients after bariatric surgery.

Materials and Methods

The Austrian health insurance funds cover about 98% of the Austrian population. Medical health claims data of all Austrians who underwent bariatric surgery from 01/2010 to 12/2018 were analyzed. In total, 19,901 patients with 107,806 observed years postoperative were eligible for this analysis. Comorbidities based on International Classification of Diseases (ICD)-codes and drug intake documented by Anatomical Therapeutical Chemical (ATC)-codes were analyzed in patients deceased and grouped according to clinically relevant obesity-associated comorbidities: diabetes mellitus (DM), cardiovascular disease (CV), psychiatric disorder (PSY), and malignancy (M).

Results

In total, 367 deaths were observed (1.8%) within the observation period from 01/2010 to 04/2020. The overall mortality rate was 0.34% per year of observation and significantly higher in men compared to women (0.64 vs. 0.24%; p < 0.001(Chi-squared)). Moreover, the 30-day mortality was 0.19% and sixfold higher in men compared to women (0.48 vs. 0.08%; p < 0.001). CV (82%) and PSY (55%) were the most common comorbidities in deceased patients with no sex-specific differences. Diabetes (38%) was more common in men (43 vs. 33%; p = 0.034), whereas malignant diseases (36%) were more frequent in women (30 vs. 41%; p = 0.025).

Conclusion

After bariatric surgery, short-term mortality as well as long-term mortality was higher in men compared to women. In deceased patients, diabetes was more common in men, whereas malignant diseases were more common in women.

Graphical abstract

Emergency department encounters, hospital admissions, course of treatment, and follow-up care for behavioral health concerns in patients after Roux-en-Y gastric bypass surgery

BACKGROUND

The benefits of bariatric surgery are well-established, however, concerns surrounding postoperative psychiatric destabilization and alcohol misuse remain. Research has initiated the process of identifying risks associated with bariatric surgery, although less is known regarding when or why psychiatric hospitalizations occur postoperatively.

OBJECTIVES

The goal of the current study was to examine the incidence of, and contributing factors to, behavioral health-related emergency room (ER) encounters and hospitalization after bariatric surgery.

SETTING

Integrated multispecialty health system with an accredited bariatric surgery program.

METHODS

Retrospective review of patients who underwent Roux-en-Y gastric bypass (RYGB) surgery and had been readmitted to the hospital or presented to the ER after bariatric surgery at least once for a behavioral-health related reason.

RESULTS

Of 1449 patients, 93 had at least 1 psychiatric or substance use-related ER visit/hospitalization post-surgery and were included in the study; 53% had 1 ER/hospital encounter after bariatric surgery; 24% had 2 encounters, 11% had 3-4 encounters, and 10% of patients had ≥5 encounters. Across 267 postbariatric surgery encounters, 42.4% were due to alcohol-related problems. The index presentation for alcohol-related reasons occurred at a mean of 1942 days (approximately 5.3 yr; SD = 1217 d). Patients' index presentation for a psychiatric concern (41.3%) occurred at a mean of 1278 days (3.5 yr; SD = 1056 d) post-surgery.

CONCLUSION

A significant percentage of patients who present to the ER or hospital for behavioral health reasons after RYGB surgery had alcohol-related problems, long after their surgery. Psychologists working with bariatric surgery teams should prioritize ongoing assessment of and education on alcohol misuse in those seeking RYGB and in the long-term postoperative period.

Addiction Transfer and Other Behavioral Changes Following Bariatric Surgery

Despite its important treatment implications for obesity and related comorbidities, bariatric surgery requires several behavioral changes that warrant comprehensive evaluation and support before and after surgery. This article outlines emerging scientific and anecdotal evidence for addiction transfer after bariatric surgery. Other common behavioral changes that impact adherence, weight loss, and psychiatric risk after surgery are also reviewed. Last, recommendations for presurgical psychological evaluation and postoperative support are provided.

Suicidal thoughts and behaviors in adolescents who underwent bariatric surgery

BACKGROUND

Extant literature warns of elevated suicide risks in adults postbariatric surgery, making understanding risks for adolescent patients imperative.

OBJECTIVES

To examine prevalence and predictors/correlates of suicidal thoughts and behaviors (STBs) in adolescents with severe obesity who did/did not undergo bariatric surgery from presurgery/baseline to 4 years postsurgery.

SETTING

Five academic medical centers.

METHODS

Using a prospective observational design, surgical adolescents (n = 153; 79% female, 65% white, mean [M]_age = 17 yr, M_{body mass index[BMI]} = 52 kg/m²) and nonsurgical comparators (n = 70; 80% female, 54% white, M_age = 16 yr, M_BMI = 47 kg/m²) completed psychometrically sound assessments at presurgery/baseline and postsurgery years 2 and 4 (year 4: n = 117 surgical [M_BMI = 38 kg/m²], n = 56 nonsurgical [M_BMI = 48 kg/m²]).

RESULTS

For the surgical group, rates of STBs were low (year 2 [1.3%-4.6%]; year 4 [2.6%-7.9%], similar to national base rates. Groups did not differ on a year 4 postsurgical STBs (post-STBs) composite (post-STBs: ideation/plan/attempt; n = 18 surgical [16%], n = 10 nonsurgical [18%]; odds ratio = .95, P = .90). For the surgical group, predictors/correlates identified within the broader suicide literature (e.g., psychopathology [P < .01], victimization [P < .05], dysregulation [P < .001], drug use [P < .05], and knowing an attemptor/completer [P < .001]) were significantly associated with post-STBs. Surgery-specific factors (e.g., percent weight loss, weight satisfaction) were nonsignificant. Of those reporting a lifetime attempt history at year 4, only a minority (4/13 surgical, 3/9 nonsurgical) reported a first attempt during the study period. Of 3 decedents (2 surgical, 1 nonsurgical), none were confirmed suicides.

CONCLUSIONS

The present study indicates that undergoing bariatric surgery in adolescence does not heighten (or lower) risk of STB engagement across the initial 4 years after surgery. Suicide risks present before surgery persisted, and also newly emerged in a subgroup with poorer psychosocial health.