Bariatric Surgery and the Risk of Alcohol-Related Cirrhosis and Alcohol Misuse

Jessica L. Mellinger; Kerby Shedden; G. Scott Winder; Anne C. Fernandez; Brian P. Lee; Jennifer Waljee; Robert Fontana; Michael L. Volk; Frederic C. Blow; Anna S. F. Lok

Disclosures

Liver International. 2021;41(5):1012-1019. 

In This Article

Abstract and Introduction

Abstract

Background & Aims: Bariatric surgery is common, but alcohol misuse has been reported following these procedures. We aimed to determine if bariatric surgery is associated with increased risk of alcohol-related cirrhosis (AC) and alcohol misuse.

Methods: Retrospective observational analysis of obese adults with employer-sponsored insurance administrative claims from 2008 to 2016. Subjects with diagnosis codes for bariatric surgery were included. Primary outcome was risk of AC. Secondary outcome was risk of alcohol misuse. Bariatric surgery was divided into before 2008 and after 2008 to account for patients who had a procedure during the study period. Cox proportional hazard regression models using age as the time variable were used with interaction analyses for bariatric surgery and gender.

Results: A total of 194 130 had surgery from 2008 to 2016 while 209 090 patients had bariatric surgery prior to 2008. Age was 44.1 years, 61% women and enrolment was 3.7 years. A total of 4774 (0.07%) had AC. Overall risk of AC was lower for those who received sleeve gastrectomy and laparoscopic banding during the study period (HR 0.4, P <.001; HR 0.43, P =.02) and alcohol misuse increased for Roux-en-Y and sleeve gastrectomy recipients (HR 1.86 and 1.35, P <.001, respectively). In those who had surgery before 2008, women had increased risk of AC and alcohol misuse compared to women without bariatric surgery (HR 2.1 [95% CI: 1.79–2.41] for AC; HR 1.98 [95% CI 1.93–2.04]).

Conclusions: Bariatric surgery is associated with a short-term decreased risk of AC but potential long-term increased risk of AC in women. Post-operative alcohol surveillance is necessary to reduce this risk.

Introduction

The obesity epidemic in the United States (US) has increased demand for weight loss solutions. As a result, bariatric surgery has emerged as one of the most common surgical procedures performed for treatment of obesity. In the USA, sleeve gastrectomy and Roux-en-Y gastric bypass are the most common procedures performed, with adjustable gastric banding being less prevalent and declining (1). Long-term outcomes typically indicate durable weight loss and improvement in quality of life as well as many metabolic risk factors, such as diabetes and hypertension.[1] While many patients undergoing bariatric surgery have fatty liver, including non-alcohol–related steatohepatitis (NASH), those who lose 10% or more of their body weight following gastric bypass may see substantial decreases in not only steatosis but also fibrosis which typically would be expected to protect bariatric surgery patients from cirrhosis, at least in the short term.[2]

While obesity-related complications appear to improve over time, hazardous alcohol misuse both before and after bariatric surgery is a growing clinical concern leading to recommendations for preoperative screening for alcohol misuse.[3] Despite these efforts to screen out patients with heavy alcohol misuse prior to surgery, multiple studies document post-operative substance use and alcohol misuse disorder rates ranging from 7% to 33%.[4,5] The effect of bariatric surgery on the subsequent risk of alcohol-related cirrhosis (AC), however, is unclear, as there are few well-characterized, longitudinal prospective cohorts of bariatric surgery with enough follow-up time to allow for cirrhosis development. A key mediating factor may be alterations in alcohol metabolism following both Roux-en-Y gastric bypass and sleeve gastrectomy, whereby equivalent doses of alcohol result in higher peak blood alcohol levels, more prolonged alcohol elimination time, and greater levels of subjective intoxication.[6,7] Bypass of gastric alcohol dehydrogenase has been hypothesized as a potential mechanism for these observed differences.

More women than men undergo bariatric procedures,[8] and gender also plays an important and multifactorial role in the risk of developing AC. Women are more susceptible to liver disease at lower doses of alcohol, a poorly understood phenomenon that is likely related to differential distribution of hepatic alcohol dehydrogenase, differences in body composition, or to hormonal differences between gender.[9] Women also may have some unique aspects to alcohol misuse disorders (AUD), which often facilitate the development of AC, including different AUD symptom presentation and course and suboptimal diagnosis, screening and intervention in women compared to men.[10,11] Owing to this confluence of risk factors, we sought to determine if bariatric surgery increases the risk of AC and whether the effect is more pronounced in women.

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