Risk of Alcohol Use Disorder After Sleeve Gastrectomy

Abstract

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.

Introduction

Bariatric surgery is the most effective treatment against morbid obesity.¹ Obesity has been rapidly increasing around the world, and accordingly, more patients are operated for weight reduction every year.² Besides efficient weight loss, many comorbidities related to obesity can also be avoided by bariatric procedures.³

However, some adverse effects may arise after bariatric surgical procedures in the long term such as increased alcohol intake. Many studies demonstrated an increased alcohol consumption, especially, after Roux-en-Y gastric bypass (RYGB).^4–7 It is stated that the newly formed anatomy in RYGB modifies the alcohol metabolism and consequently expedites the alcohol absorption and extends the time for elevated blood alcohol level.^8,9 The issue whether alcohol use increases after laparoscopic sleeve gastrectomy (LSG), which almost comprises 60% of all bariatric procedures, is controversial.¹⁰

Currently, the best available method to evaluate excessive alcohol intake is the “alcohol use disorder identification test” (AUDIT), which was proposed by the World Health Organization.¹¹ This is a 10-question test for the purpose of identifying people with alcohol use disorder. It can be completed in 5 minutes and it was tested internationally in first-line health services with high validity and credibility. Ibrahim et al., by using the AUDIT, showed no change in alcohol usage in the first year after LSG and RYGB; however, in the second year, the AUDIT scores showed an increase with an average rate of 7%–8%.¹² The aim of this study is to determine whether there is an increased risk of developing alcohol use disorder after LSG by utilizing AUDIT scores.

Materials and Methods

The study was approved by the institutional ethics committee. This study comprises patients from two private affiliated bariatric centers. All patients were informed about the study in detail, and written informed consents were obtained.

Inclusion criteria

Patients with preoperative body mass index (BMI) >35 kg/m², ages between 18 and 65 years, without chronic liver disease, and who completed 1 year follow-up after LSG were included.

Exclusion criteria

People who had bariatric surgery previously and have current alcoholism and also declined to complete the mentioned screening test were excluded.

AUDIT

The first three questions are on the amount and frequency of alcohol use and the next three questions are about potential symptoms of addiction. The final four questions address the current and life-long alcohol use associated problems. Turkish validation reliability studies were conducted in 2002 by Saatçioğlu et al.¹³ Four risk levels are defined by the AUDIT according to score intervals. A score interval between 0 and 7 suggests low risk, 8 and 15 moderate risk, and 6 and 19 high risk, and a score between 20 and 40 interval is regarded as alcohol addiction. AUDIT results were obtained in two sequential follow-up periods separately: 1–3 years (early follow-up) and 4–6-years (late follow-up).

Alcohol use was assessed by the AUDIT preoperatively, and at their last control visit to the patients who were followed up from 1 to 6 years. 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.

Statistical analysis was performed using SPSS (version 21, SPSS, Inc., Chicago, IL). Standard deviation and mean values were used for the variables with normal distribution and median values were used for the variables that were not normally distributed. Chi-square or Fisher's exact tests were used for categorical variables, whereas for continuous variables, paired-samples t-test, independent samples t-test, or Mann–Whitney U test was performed. P values <.05 were considered statistically significant.

Results

Between January 2012 and December 2019, 183 patients with at least 1-year follow-up who also completed the AUDIT were available for analyses. Preoperative mean BMI was 42.7 ± 6.5 kg/m², and by 2019, the updated mean BMI dropped to 28.25 ± 4.75 kg/m². Mean follow-up duration was 42.32 ± 20.2 months (range: 12–93 months). Patients' demographics for both groups are given in Table 1.

Table 1.

Patients' Characteristics

	1–3-year follow-up (n = 102)	4–6-year follow-up (n = 81)	P
Men/women	37/65	31/50	.4
Age (years)	39.7 ± 11	39.6 ± 10.2	.96
Baseline BMI	40.5 (32–61)	42.5 (33–70)	.09
Baseline EW	44 (16–108)	50.7 (20–118)	.023
Updated BMI by 2019	27.3 ± 4.1	29.4 ± 5.2	.003
Updated EWL by 2019 (%)	90 ± 26	78 ± 26	.002
Follow-up period (month)	26.5 (12–46)	62 (48–93)	<.001

Values are means ± standard deviation, median (min-max) or number of subjects.

BMI, body mass index; EW, excess weight; EWL, excess weight loss.

Risk categories according to AUDIT scores and their distribution among two follow-up groups are presented in Table 2. Preoperatively, 162 (88%) and 21 (12%) patients were ranked in either low- or moderate-risk categories, respectively. Among 21 patients in the preoperative moderate-risk category, 10 were in the 1–3 and 11 were in the 4–6 years follow-up groups. After the entire follow-up (1–6 years), 163 (89%), 11 (6%), 2 (1.09%), and 7 (3.82%) patients were ranked in low-, moderate-, high-risk, or alcoholism categories, respectively. Among 10 patients who were in the 1–3 years follow-up group and in moderate-risk category preoperatively, 4 had shifted downward to the low risk and 2 were shifted/elevated to the alcoholism category during the follow-up (Table 2). Among 11 patients who were in the 4–6 years follow-up group and in moderate-risk category preoperatively, 1 was shifted down to the low, 1 was shifted/elevated to the high, and 4 were shifted/elevated to the alcoholism categories (Table 2).

Table 2.

AUD Risk Categories Between Groups Before and After LSG

	Low risk (0–7) (n)	Moderate risk (8–15) (n)	High risk (16–19) (n)	Alcoholism (20–40) (n)	Total (N)
Preoperative (1–3 years) (n)	92	10	0	0	102
Preoperative (4–6 years) (n)	70	11	0	0	81
Preoperative total (N)	162	21	0	0	183
Postoperative (1–3 years) (n)	96	4	0	2	102
Postoperative (4–6 years) (n)	67	7	2	5	81
Postoperative total (N)	163	11	2	7	183

AUD, alcohol use disorder; LSG, laparoscopic sleeve gastrectomy.

There were 92 participants in the 1–3 years follow-up group in low-risk category, and there was a reduction in AUDIT scores in the first 3 years of monitoring (P = .012). In the 4–6 years of follow-up group, there were 70 people in the low-risk category, and despite an increase in the amount of alcohol consumption according to the AUDIT scores, the difference was not statistically significant (P = .102). When evaluated across all participants, a significant reduction in AUDIT scores was seen in the first 3 years of follow-up (n = 102; P = .033) opposed to a significant increase in the 4–6 years of follow-up (n = 81; P = .042) (Table 3).

Table 3.

Comparative Outcomes at Baseline and 1–3 Years/4–6 Years After LSG Between Different Risk Categories (Low-Risk Category and Total), AUDIT Scores

	Variable	n	Mean	SD	t	P
1–3 years low-risk category	Preoperation	92	1.86	1.95	2.58	.012^*
1–3 years low-risk category	Postoperation	92	1.37	2.08
4–6 years low-risk category	Preoperation	70	1.52	1.62	−1.66	.102
4–6 years low-risk category	Postoperation	70	2.28	4.13
1–3 years group	Preoperation	102	2.79	3.62	2.16	.033^*
1–3 years group	Postoperation	102	2.27	4.07
4–6 years group	Preoperation	81	3.06	4.54	−2.06	.042^*
4–6 years group	Postoperation	81	4.04	6.35
Total	Preoperation	183	2.91	4.05	−0.57	.565
Total	Postoperation	183	3.06	5.28

p < .05; Z = paired sample t-test.

AUDİT, alcohol use disorder identification test; LSG, laparoscopic sleeve gastrectomy.

Discussion

American Society for Bariatric and Metabolic Surgery guidelines, which particularly deal with alcohol use before and after bariatric surgery, emphasize that the risk of alcohol use disorder is increased after RYGB operations.^8–10,14 It was recommended that more studies should be done regarding LSG that has increasing popularity worldwide¹⁰ and the number of reports are limited.

In one study, 12 patients were evaluated for alcohol metabolism after LSG. Although the same amount of alcohol was consumed, blood alcohol concentration was found to be higher after surgery and remained elevated for a longer duration compared with the period before surgery.¹⁵ In another study, no difference was detected in alcohol absorption and time for normalization of blood alcohol levels before and after LSG.¹⁶ In our study, pre-LSG assessment of risk categories by AUDIT scoring in 183 patients revealed that 162 were in the low- and 21 were in the moderate-risk category. Post-LSG and after the entire follow-up (1–6 years), AUDIT scores categorized 163 patients to be in the low-risk, 11 in the moderate-risk, 2 in the high-risk, and 7 in the alcoholism category. Overall, 7 people developed alcoholism during the follow-up. In several studies, increase in AUDIT scoring reflecting higher alcohol consumption was parallel to the duration of follow-up.^12,17 In a study by King et al., the prevalence of alcohol use disorder remained unchanged at first year, but increased at 24 months follow-up.¹⁷ Similarly, Ibrahim et al. showed no change in AUDIT scores in the first year after LSG and RYGB; however, in the second year, AUDIT scores showed an increase of 4–5 for both methods and alcohol use disorder developed on an average rate of 7%–8%.¹² This study also showed a statistically significant increase in the AUDIT scores in the 4–6 years of follow-up group compared with first 3 years of follow-up (Table 3).

Ibrahim et al. have associated preoperative alcohol use rates with future risk of alcohol use disorder.¹² Their study revealed that 25% of those in the preoperative moderate-risk category shifted to a high-risk category postoperatively. Similar association was also confirmed in our study (Table 2). Bearing in mind that alcoholism is a contraindication to bariatric surgery for known reasons,¹⁰ preoperative identification of moderate-risk patients by the implementation of AUDIT scorings, in line with aggressive psychiatric consultation, can be helpful for patient selection.

Although some suggested that alcohol use disorder arises from an increase in alcohol absorption and high levels of alcohol remaining in the blood for longer periods,¹⁸ some indicated that certain sociodemographic characteristics such as premorbid personality and marriage status may have affected these processes and that alcohol absorption alone is not an adequate explanation.¹⁹ It is recommended to pay attention to certain changes in reward mechanisms during the follow-up. In an interview with 541 bariatric surgery patients, Wee et al. detected a regression from 17% to 13% in high-risk patients at 1 year after surgery.²⁰ In contrast, they also showed that after a year, new patients at a rate of 7% entered the high-risk group. Reduced alcohol use in some and increased alcohol use in others are an issue that needs to be elucidated. Besides the studies regarding the similarity of these patterns with weight gain,²¹ there are also studies explaining their relevance with psychological dynamics of obese individuals. Along with the studies showing high prevalence of alcohol and substance use especially in obese men with a decreasing alcohol use disorder prevalence in female obese individuals,^22,23 there are also studies that report no such changes.^24,25 Whether the development of alcohol use disorder in obese individuals is related with premorbid personality or the surgical method administered remains uncertain.

In the 3-year follow-up group of our study, post-LSG alcohol use rate was lower than the preoperative rate. In the early post-LSG stage, the motivation gained from efficient weight loss, metabolic changes (i.e., ghrelin effect, increased sensitivity to alcohol), strict dietary follow-up, and the patients' willingness to be more careful on food and drink choices may be the reasons. However, we detected a prominent increase in alcohol use after the third year. After LSG, in the long term, patients losing track of the follow-up, losing their previous motivation, and regaining weight may be under risk to develop new pathologies that arise due to cross-addiction.

An important finding of our study was that the patients with moderate risk according to the pre-LSG AUDIT scores were at significantly increased risk for alcohol use disorder post-LSG. It seems advisable to address such moderate-risk cases with special care. Informing them properly and providing additional and probably more aggressive psychiatric consultation can be necessary. It may be appropriate for AUDIT to enter the follow-up protocols after bariatric surgery of patients with moderate risk scores at pre-LS6 AUDITS. Thus, patients with alcohol use disorder tendency can be detected earlier to take necessary measures.

This study covers a wide range of time. The wide time intervals in 1–3- and 4–6-year follow-up groups may make it difficult to interpret the results. The data obtained from the patients were evaluated with maximum efficiency. However, examining patients who have similar sociodemographic characteristics and are followed by the same team can add valuable information to the literature.

Conclusion

Our study showed reduction in AUDIT scores in the first 3 years of follow-up after LSG and increase in AUDIT scores in 4–6 years of follow-up. High preoperative AUDIT score in LSG candidates is a potential risk for future alcohol use disorder. 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.

Footnotes

Disclosure Statement

The authors have no commercial associations that might be a conflict of interest in relation to this article.

Funding Information

No funding was received for this article.

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