AUD is characterized by a pattern of alcohol consumption that persists despite negative personal and health consequences[6]. The prevalence of alcohol use has been steadily increasing with some data suggesting over 40% of adults engage in potentially harmful drinking[6]. An expanding body of literature suggests that bariatric surgery increases the risk of alcohol misuse. Estimates suggest that between 2%-33% of adult bariatric surgery patients develop AUD, with the peak incidence occurring in the second post-operative year[3,4,7,8]. This risk may be higher in adolescent bariatric surgery recipients with a recent multi-center study reporting an AUD prevalence of approximately 45% eight years post-surgery[9].
Multiple studies have identified the following as risk factors for harmful alcohol use after bariatric surgery: younger age, tobacco use, pre-surgical alcohol use, and reduced social support[8,10,11]. Additionally, one large prospective study identified higher household income and lower-level education as risk factors for AUD[7]. Patient sex influences risk as well: female sex is a risk factor for AUD in adolescent bariatric surgery recipients[12], while male sex is a risk factor in adult bariatric surgery recipients[10]. Although adult males have a higher risk of AUD, most bariatric surgery recipients with AUD are female, reflecting the overall higher proportion of females in the bariatric surgery population[3]. The risk of post-surgical AUD may also depend on the type of surgery performed. Some studies indicate a higher risk following gastric bypass procedures as compared to restrictive procedures[11,13], although this relationship is not yet fully elucidated[7,11,13].
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Although pre-surgical alcohol use is associated with AUD following bariatric surgery, new onset alcohol use is also common[7,14-16]. In a recently published study, Kim et al[14] utilized a large commercial insurance database to assess alcohol use in patients who underwent bariatric surgery compared to patients who underwent cholecystectomy. They found that 2.8% of the post-bariatric surgery group developed de novo alcohol use or dependence compared to 1.7% of the post-cholecystectomy group. On subgroup analyses, Roux-en-Y gastric bypass (RYGB) was associated with a 150% higher risk of acquiring an alcohol-associated diagnosis (e.g., alcohol use, alcohol use, and alcohol-associated hepatitis) compared to post-cholecystectomy controls (95%CI 1.40-1.62, P < 0.001). In contrast, vertical sleeve gastrectomy (VSG) was associated with a slightly reduced risk of acquiring an alcohol-associated diagnosis. Notably, since this study was conducted using International Classification of Diseases, Tenth Revision (ICD-10) codes, the context of these diagnoses was not available. A multi-center retrospective study within the United States Veterans Affairs Healthcare System used the Alcohol Use Disorder Identification Test (AUDIT-C) to assess for harmful alcohol use among bariatric surgery patients (n = 1539 VSG, n = 854 RYGB) compared to non-surgical controls[15]. Among patients without pre-surgical alcohol use, new unhealthy alcohol use was significantly more common in the surgical groups at post operative years 3, 5, and 8. At the end of the study period, the risk of unhealthy alcohol use was 7.9% in VSG patients, 9.2% in RYGB patients, and 4.4%-4.5% in non-surgical control patients. Similarly, a recent prospective study observed a quadratic relationship between alcohol use and time after bariatric surgery, with annual increases in both quantity and frequency of alcohol consumption from years 1-7 after bariatric surgery[16]. This discrepancy in findings may be due to differing follow-up periods, as Kim et al[14] followed patients for a mean of 2.7 years whereas the latter two studies had an 8 year follow up and noted a significant increase in harmful alcohol use between 3-8 years post-surgery.
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