Link Established Between WLS and Alcohol Use Disoder

Study Supports Link Between Bariatric Surgery And Alcohol Use Disorder

by Kate O'Rourke

Boston—About 17% of patients who undergo Roux-en-Y
gastric bypass (RYGB) have an alcohol use disorder three years after
their surgery, new research shows.

This rate is approximately 10% higher than what is seen in the
general population, as found in data from the National Institutes of
Health (NIH).

The study suggests that all patients undergoing RYGB need to be
cautioned regarding alcohol use, and routinely asked about such problems
during follow-up visits, said James Mitchell, MD, chairman of the
Department of Psychiatry and Behavioral Science at the University of
North Dakota School of Medicine and Health Sciences, in Grand Forks, who
presented the findings at Obesity Week 2014 (abstract 201).

The study included 201 RYGB patients in the Longitudinal Assessment
of Bariatric Surgery (LABS), an NIH-funded consortium of six clinical
centers and a data-coordinating center that works with NIH staff to
conduct research involving bariatric surgery.

Patients were interviewed three years after surgery, using the
Structured Clinical Interview for DSM Disorders (SCID-DSM)-IV, and
accessory impulse control disorders criteria. SCID criteria for alcohol
use disorder require a positive response to ingestion of five or more
drinks on one occasion as a screening question, which based on
pharmacokinetic research in RYGB patients, is excessive. The researchers
also evaluated patients with the Alcohol Use Disorders Identification
Test (AUDIT), which assigns a score based on answers to a series of
questions, such as how often during the past year the respondent failed
to do what was normally expected because of drinking. Alcohol use
disorder symptoms were defined as an AUDIT score greater than 8, or a
positive response to symptoms of alcohol dependence or alcohol-related
harm. The median age of patients in the study was 48 years, and 81% were
women.

The investigators found that 16.9% of patients had an alcohol use
disorder three years after RYGB, with 41.2% of them being a de novo
problem (Table 1). Patients with a history of alcohol abuse were at
highest risk, but some reported that cases were new. Conversely, 26.9%
had a history of alcohol use disorder before surgery by SCID and/or
AUDIT definition, but did not report symptoms of an alcohol use problem
within the three years after surgery. The investigators also identified
fluctuations in other addictive disorders, such as impulsive-compulsive
buying and Internet use (Table 2)

Table 1. Characterization of Patients With an Alcohol Use Disorder After Bariatric Surgery Alcohol Use Category Patients, % Definition Continued alcohol use disorder 20.6 Positive on the AUDIT the year before surgery, and continues to meet SCID-IV and/or AUDIT criteria after surgery Recurrent alcohol use disorder 38.2 Negative on the AUDIT in the year before surgery, but positive for lifetime presurgery (SCID) and postsurgery (SCID and/or AUDIT) New alcohol use disorder 41.2 No history of alcohol use disorder before surgery (SCID or AUDIT) but positive for the disorder after surgery (SCID and/or AUDIT) AUDIT, Alcohol Use Disorders Identification Test; SCID, Structured Clinical Interview for DSM Disorders-IV

Table 2. Prevalence of Non–Drug-Related Compulsive Disorders Pre-Op, % Pre-Op and Post-Op, % Post-Op, % Overall non–drug-related addictive behavior disorders 5 6.5 3 Impulsive-compulsive buying 3 5.5 1.5 Impulsive-compulsive Internet use 0.5 0 2

The study adds to the growing body of evidence showing an association
between weight loss surgery and alcohol abuse. “There is definitely
enough convincing evidence that some patients are at risk for problems
with alcohol after [weight loss] surgery,” said Stephanie Sogg, PhD,
staff psychologist at Massachusetts General Hospital, and assistant
professor at Harvard Medical School, in Boston.

Dr. Sogg, who gave an overview of the evidence at Obesity Week,
pointed out that numerous studies have been published about alcohol use
after bariatric surgery, but many have small sample sizes and/or low
response rates, and almost all are retrospective. The studies also use a
wide range of assessment methods (i.e., questionnaires and interviews)
and different definitions of alcohol use, misuse and abuse, which makes
comparison across studies difficult


“Some studies merely look at alcohol use. Others look at high-risk,
hazardous or problem drinking, and some studies look at whether patients
have symptoms of or meet the criteria for alcohol abuse or dependence,”
Dr. Sogg said


Many studies also don’t make a distinction between three different
subgroups: individuals who have alcohol problems at the time of surgery
and continue to have problems afterward, recovered substance abusers who
relapse after surgery and individuals who develop new-onset alcohol
problems after surgery. “These are three very clinically distinct
subgroups and many studies lump them all together,” she said.

Dr. Sogg pointed out that overall, studies have shown that after
weight loss surgery, there is an increase in alcohol use, with a higher
percentage of patients reporting any alcohol use as well as increased
quantities and/or frequencies of alcohol consumption among those who use
it.

A previous study using data from LABS showed that the risk for
developing an alcohol use disorder was greater in the second year after
surgery than the first (JAMA 2012;307:2516-2525). The Swedish
Obese Subjects Study found that the rate of self-reported alcohol
problems continued to increase for 10 years (Obesity 2013;21:2444-2451)

“Across all of the studies, the prevalence of alcohol problems after
surgery ranges from 4% to 28%, with about 10% meeting criteria for
abuse/dependence; this includes patients who previously had these
problems,” Dr. Sogg said. “What is strikingly consistent is that across
all studies, if you look at all of the people who develop problems with
alcohol after surgery, about 60% of those cases are new-onset cases.

In contrast, some individuals reduce alcohol intake after weight loss
surgery. “Anywhere between 17% and 59% of patients who had problem
drinking before surgery reported being free of such problems when they
were assessed at some point after surgery,” Dr. Sogg noted. Weight loss
surgery may have opposite effects on drinking patterns, depending on an
individual’s genotype or phenotype. Studies in rats have revealed that
RYGB increases alcohol consumption in wild-type rats (who ordinarily do
not like alcohol) and decreases consumption in genetically
“alcohol-preferring” rats (Obes Surg 2013;23:920-930; Biol Psychiatry 2012;72:354-360).

RYGB in particular can change the sensitivity to or the
pharmacodynamics of alcohol after weight loss surgery. After RYGB,
patients who drink alcohol reach a higher peak blood alcohol level more
quickly, and a longer time is required for alcohol to clear out of their
system (Surg Obes Relat Dis 2007;3:543-548; Obes Surg 2010;20:744-748)


“These changes become more pronounced as time goes on after surgery,
not less pronounced,” Dr. Sogg said. These pharmacodynamic changes may
be linked to the onset of alcohol problems after RYGB

“People who have alcohol problems after surgery are much more likely
to have undergone a bypass, and that makes us suspect that there is some
anatomic and metabolic basis for this.”

Research findings on whether similar pharmacodynamic changes occur in
patients who had a sleeve gastrectomy are mixed; such changes were
found in one study but not in others, and no studies have yet examined
the prevalence of alcohol problems among patients who have had a sleeve
gastrectomy, a procedure that only recently has been performed in large
numbers.

Factors common to both the gastric bypass and sleeve gastrectomy that
could lead to higher and more rapid blood alcohol concentrations
include less alcohol dehydrogenase in the stomach, faster gastric
emptying, shorter transit time in the intestines to break down the
alcohol, lower body weight and less food in the stomach when alcohol is
consumed. “We tell our bariatric surgery patients not to eat and drink
at the same time. If you drink on an empty stomach, you are definitely
going to feel more intoxicated,” Dr. Sogg said.

She said it is important for clinicians to ensure that all patients
undergoing weight loss surgery be screened for alcohol use problems
before surgery and be educated about the risk for postoperative
problems. Dr. Sogg counsels patients to be watchful for early warning
signs of increased alcohol consumption, and not to drink at all after
surgery if they are going to drive.

“It is also important for surgery practices to identify the
appropriate referral resources to use when they do encounter patients
who have this kind of problem,” Dr. Sogg said. However, she also noted,
“It is not yet clear whether a patient who has alcohol problems after
surgery will respond to traditional addiction treatment approaches or if
they need specifically tailored care.”

Dr. Mitchell also believes that all patients should be cautioned and
monitored, and that a history of a substance use disorder should not
rule out a patient for bariatric surgery. “The monitoring can be done by
carefully and nonjudgmentally asking about such problems during
follow-up visits,” Dr. Mitchell said. “If there is a suspicion of such
problems, but the patient denies it, I would ask for permission to talk
with another family member.”

Weight-loss surgery helps prevent diabetes: Swedish study | Reuters

Weight-loss surgery helps prevent diabetes: Swedish study | Reuters:

'via Blog this'

Weight-loss surgery helps prevent diabetes: Swedish study

* Obese people who got surgery had lower risk over time

* More study needed, experts say

By Gene Emery

Aug 22 (Reuters Health) - Obese people who undergo weight-loss surgery can dramatically delay, and perhaps prevent, the onset of type 2 diabetes, Swedish researchers said on Wednesday.

Prior studies have shown that weight-loss surgery can reverse type 2 diabetes in patients who already have the condition. The latest findings offer evidence that the procedures can prevent the condition.

"We saw a marked delay (in the development of diabetes) over 15 years," said Dr. Lars Sjostrom of the University of Gothenburg in Sweden, whose study appears in the New England Journal of Medicine.

"Some of those surgical patients will probably develop diabetes later. But over a lifetime, there will be a large difference."

According to the World Health Organization, 346 million people worldwide have diabetes. Most of them, about 90 percent, have type 2 diabetes, the form of the disease linked with obesity and lack of exercise.

The link between obesity and diabetes is well-documented, and making lifestyle changes or taking weight-reducing drugs can cut the risk of diabetes by 40 to 45 percent.

The study, part of the larger Swedish Obese Subject study, was designed to see if the surgical weight loss would have the same effect. None of the patients included in the test had diabetes when the project began in 1987.

Participants chose whether or not to have surgery, and enrollment ended in February 2001. Stomach stapling was the most common procedure (69 percent), followed by gastric banding (19 percent) and gastric bypass (12 percent.)

When they compared the two groups over the course of the 15-year study, the team found that among the 1,658 volunteers who underwent weight-loss surgery, the annual risk of developing diabetes was about 1 in 150.

That compared with an annual risk of 1 in 35 among the 1,771 people in the control group, about four times higher than the treatment group.

The improvement was seen even though the people who underwent surgery initially were a bit heavier and had more risk factors than the control group at the start of the study.

"It's favorable in spite of these differences," Sjostrom said.

The improvements correlated with weight loss seen in the groups. In the surgery group, the average weight loss at the 15-year mark was 20 kilograms, or 44 pounds. The non-surgery group - which received standard care consisting of recommendations for healthier eating and more physical activity - stayed within three kilograms (7 pounds) of their starting weight.

Three patients died within 90 days of their surgery, and between 2 percent and 5 percent of patients had lung complications, vomiting, infections, bleeding or a blood clot.

According to the American Society for Metabolic and Bariatric Surgery, about 220,000 people had bariatric surgery in 2009. Surgery costs range from $11,500 to $26,000.

Dr. Danny Jacobs of Duke University School of Medicine in Durham, North Carolina, said in a commentary in the journal that "it remains impractical and unjustified to contemplate the performance of bariatric surgery in the millions of eligible obese adults."

Sjostrom said more studies are needed and a cost analysis of the pros and cons of surgery, now underway, could be published in a year or so.

SOURCE: bit.ly/PFZtyr New England Journal of Medicine, August 23, 2012. (Reporting by Gene Emery in Providence, Rhode Island; Editing by Ivan Oransky and Stacey Joyce)

HEALTHCARE

Obesity in Middle Age Tied to More Rapid Mental Decline: Study

Obesity in Middle Age Tied to More Rapid Mental Decline: Study

'Fat and fit' concept may not apply to brain function, research suggests

By Steven Reinberg
HealthDay Reporter

MONDAY, Aug. 20 (HealthDay News) -- People who are obese and suffer from high blood pressure and other problems linked to heart disease and diabetes may also see a faster decline in their mental abilities, according to a new study by French researchers.

Yet even obese people without these physical conditions experienced a faster decline in functions such as memory, the researchers noted. This finding belies the concept of being obese and healthy, they added.

"The prevalence of obesity is rising; 400 million adults were obese in 2005 and this number is expected to rise to over 700 million by 2015," said lead researcher Archana Singh-Manoux, research director of the Center for Research in Epidemiology & Population Health at INSERM, in Paris.

Obesity is known to be bad for health, she said. It is associated with a higher risk of early death and chronic illness.

"Our results add to this list of adverse health effects, showing poorer [mental] outcomes among the obese," Singh-Manoux said.

Having high blood pressure, high cholesterol or high blood sugar, or being on medication to control these conditions, are among the signs of metabolic syndrome. This cluster of symptoms is considered a forerunner for heart disease and diabetes.

For the study, participants with at least two of these signs were considered to have metabolic syndrome.

Participants came from the long-running Whitehall II study, which began in 1985 and follows British civil servants from middle age onward.

For the new findings, researchers followed more than 6,400 people aged 39 to 63 for 10 years. At the start of the study, they recorded patients' risk factors, including weight.

During the follow-up decade, participants also took tests on memory, reasoning and overall mental function at three intervals, according to the report published in the Aug. 21 issue of the journal Neurology.

People with metabolic syndrome who were also obese saw a more rapid decline -- 22.5 percent faster -- in their mental function than those who weren't obese and didn't suffer from the syndrome.

Moreover, those who did not have metabolic syndrome but were obese also saw mental function decline more quickly than participants who were not obese.

Obesity is a known risk factor for many adverse health outcomes, including dementia. It typically is accompanied by metabolic syndrome, Singh-Manoux said. This, however, is not always the case, leading to the concept of so-called "metabolically healthy obesity," she said.

"Some research suggests this type of obesity carries less health risk, but the evidence is far from clear," Singh-Manoux said.

"Our results show this not to be the case for mental function," she said. "Obesity, in those who were metabolically healthy and unhealthy, was associated with poor mental function at the start of the study and greater decline over 10 years."

Dr. Richard Lipton, professor and vice chairman of neurology at Albert Einstein College of Medicine in New York City, said that "this study suggests that taking the steps recommended to prevent heart attack and stroke in midlife, including controlling body weight, high blood pressure, diabetes and lipid profiles, may also have a beneficial effect on cognitive function late in life."

Although more studies are needed, people should heed the advice on how to protect their hearts, Lipton said, which will, in turn, protect their brains as well.

"Maintaining normal body weight while preventing or treating abnormalities in blood pressure, glucose regulation and lipids may provide a therapeutic twofer, protecting the heart and brain," he said.

More information

To learn more about obesity, visit the U.S. National Library of Medicine.

SOURCES: Archana Singh-Manoux, Ph.D., research director, Center for Research in Epidemiology & Population Health, INSERM, Paris; Richard Lipton, M.D., professor, vice chairman, neurology, Albert Einstein College of Medicine, New York City; Aug. 21, 2012, Neurology

Last Updated: Aug. 20, 2012

Copyright © 2012 HealthDay. All rights reserved.

Harvard Report - Weight Loss Surgery, the Brain and Addiction

Alcohol abuse after weight loss surgery?

Researchers gather at Radcliffe to investigate gut-brain communication

By Alvin Powell

Harvard Staff Writer

Monday, July 30, 2012

Photos by Thomas Earle/Harvard Staff Photographer

The Radcliffe Institute for Advanced Study brought together scientists, whose research is relevant to obesity and addiction, to investigate an increased incidence of alcohol abuse among those who have had the surgery and, through that, the possible impact of the surgery on the brain circuits that control addiction.

Asmall group of scientists gathered last week at the Radcliffe Institute for Advanced Study to share ideas about a medical mystery: the increasing evidence that some types of weight loss surgery affect not just the stomach, but the brain as well.

The procedures, two types of bariatric surgery known as gastric bypass andsleeve gastrectomy, physically bypass or remove a portion of the stomach. Used only for obese patients whose weight threatens their health, the surgeries have proven dramatically effective, reducing patients’ excess weight in the months and years following surgery by 50, 60, and even 80 percent.

The procedures were initially thought to work through simple physical means: Patients with smaller stomachs wouldn’t be able to eat as much, allowing them to lose weight and also giving them an opportunity to reform eating habits.

James Mitchell, one of the authors of the JAMA study, said research showed that the risk factors for developing alcohol problems post-surgery include pre-surgery smoking, recreational drug use, and regular alcohol use.

But in recent years, scientists have noticed side effects of the surgery that hint at something entirely different: that the surgery somehow affects not just the stomach, but the body’s broader metabolism and even the brain.

The Radcliffe event brought together scientists whose research is relevant toobesity and addiction to investigate an increased incidence of alcohol abuseamong those who have had the surgery and, through that, the possible impact of the surgery on the brain circuits that control addiction.

The effect, reported in a handful of studies in recent years, was highlighted in June, when a large survey of more than 1,900 bariatric surgery patients was published in the Journal of the American Medical Association (JAMA). The survey showed that alcohol abuse increased significantly in the second year following gastric bypass surgery and that, among those reporting post-surgery alcohol problems, 60.5 percent hadn’t had drinking problems before.

The seminar was organized by two assistant professors at Harvard Medical School (HMS), Janey Pratt, co-director of the Weight Center at Harvard-affiliated Massachusetts General Hospital and assistant professor in surgery, and Stephanie Sogg, staff psychologist at the MGH Weight Center and assistant professor in psychology.

The first day was dominated by presentations from the 18 invited scientists on everything from background on the surgical procedures to the use of functional magnetic resonance imaging to monitor brain activity to the latest work on the chemical signals involved in hunger, fullness, the pleasurable aspects of eating, and addiction. The second day focused on future research, with discussion of collaborative projects and potential funding sources.

“It was the first time everybody was in one room together. The intellectual energy, it was amazing, one idea launched into another,” Sogg said. “The whole thing was just remarkable.”

“It was the first time everybody was in one room together. The intellectual energy, it was amazing, one idea launched into another,” said Stephanie Sogg (right), staff psychologist at the MGH Weight Center. Joining Sogg was Nicole Avena (left), a research neuroscientist and expert in the fields of nutrition, diet, and addiction.

James Mitchell, one of the authors of the JAMA study and chair of the Department of Clinical Neuroscience at the University of North Dakota Medical School, described the results of the recent report and of another published in 2001. The 2001 paper showed that one in five bariatric patients reported getting drunk on fewer drinks and about a third reported getting intoxicated in less time. A number of respondents, concerned about the effects they were seeing, decreased or stopped drinking.

The more recent JAMA study showed that the risk factors for developing alcohol problems post-surgery include pre-surgery smoking, recreational drug use, and regular alcohol use, Mitchell said.

A pair of researchers from the University of Cincinnati — Associate Professor of Psychiatry Stephen Benoit and research scientist Jon Davis — presented an overview of recent work connecting obesity and addiction. Because people have to eat to survive, many in the addiction field have resisted the idea offood addiction. That resistance has weakened since 2000, in response to studies investigating “hedonic eating” and dopamine release in the brain.

Research highlighted by Benoit and Davis showed that leptin, a hormone that inhibits appetite, also affects the release of dopamine, a key player in drug abuse circuitry. Other hormones possibly implicated in linking obesityand addiction are GLP-1, or glucagon like peptitide-1, whose levels skyrocket in patients after bariatric surgery, and ghrelin, a hormone considered a complement to leptin in controlling appetite that is produced in the part of the stomach frequently removed or bypassed in bariatric surgery.

“Clearly, being obese is affecting the addiction circuitry,” Benoit said.

New research by Davis, Benoit, and colleagues complicates the picture, highlighting how gastric bypass surgery can not only induce excessive drinking in people without alcohol problems before surgery, but can also reduce drinking in people who reported some level of alcohol consumption before surgery.

The study, which appeared in March in the journal Biological Psychiatry, surveyed more than 6,000 patients who received gastric bypass surgery and found that a significant number who reported occasional to frequent alcohol use before surgery reported decreased use afterward. The researchers then used lab rats to understand which hormones were involved, showing thatGLP-1 is implicated in inducing alcohol aversion while ghrelin can restore the rats’ appetite for alcohol.

Ashley Gearhardt, who is set to start as an assistant professor at theUniversity of Michigan in the fall after earning a doctoral degree from Yale University, used the existing psychiatric definition of substance dependenceto develop a diagnostic survey for “food addiction,” the Yale Food AddictionScale.

Gearhardt described the scale, already being used by researchers as a tool to diagnose food addiction, and outlined the results of initial studies using it.

One study of 233 normal-weight, college-aged women showed that 11.4 percent of them met the definition of food addiction, said seminar participant Ashley Gearhardt.

One study of 233 normal-weight, college-aged women showed that 11.4 percent of them met the definition of food addiction, Gearhardt said. Researchers also evaluated the scale against similar diagnostic criteria for binge-eating disorder to make sure they’re measuring something different. They found, in a study of 81 obese people seeking treatment for binge eating, that just 57 percent met the definition of food addiction. This finding shows, Gearhardt said, that while there is overlap, the two conditions are separate. In other research, Gearhardt and colleagues demonstrated similarities in brain activation between people who are substance dependent and those with high measures on the food addiction scale.

Mitchell suggested that researchers pay attention to cognitive decline and liver disease, because liver functioning has been shown to temporarily decline after surgery and because physicians are starting to see improving cognitive function in patients after bariatric surgery. Obesity has been linked to cognitive decline and an increased risk of Alzheimer’s disease.

During discussions about future courses of research, the scientists agreed that weight loss patients should be followed over longer periods of time and that more work is needed on the neural mechanisms linking obesity and the brain.

Bariatric surgery “was seen as merely an anatomical restriction,” Sogg said. “We now know that is the least of the reasons why it works. We have a pretty good idea that the real mechanism of action is all about gut-brain communication.”

Abandon Gastric Banding Bariatric Surgery, Say Experts

Kate Johnson

quoted from: http://www.medscape.com/viewarticle/767489?src=mp&spon=14

July 16, 2012 (San Diego, California) — Bariatric surgeons should abandon gastric banding in favor of sleeve gastrectomy or gastric bypass procedures, several researchers reported here at the American Society for Metabolic and Bariatric Surgery 29th Annual Meeting.

In the United States, the use of gastric banding is still "peaking," but elsewhere in the world it has largely fallen out of favor, said Michel Gagner, MD, in an interview with Medscape Medical News.

Dr. Gagner, from Hôpital du Sacré-Coeur in Montreal, Quebec, Canada, is a world-renowned bariatric surgeon who has established several bariatric surgery centers of excellence in the United States. He said he has virtually abandoned gastric banding, and performs sleeve gastrectomy in 90% of his cases.

His approach matches that of Luigi Angrisani, MD, director of the general and laparoscopic surgery unit at Giovanni Bosco Hospital in Naples, Italy.

Dr. Angrisani presented 10-year follow-up data from a prospective randomized trial comparing gastric bypass with banding, and said the evidence is clearly in favor of bypass.

"There is no point in doing further study comparing bypass with banding at this point," he told meeting attendees. "If you consider the revisions and the failures, only 26% of the banding patients had the band successfully implanted and a successful weight loss," he told Medscape Medical News in an interview. "That is not a nice result."

The study by Dr. Angrisani and colleagues involved 51 patients who were randomized from January to November 2000 to either laparoscopic adjustable gastric banding or laparoscopic Roux-en-Y gastric bypass.

In the banding group, mean age was 33.3 years and mean body mass index (BMI) was 43.4 kg/m²; in the bypass group, mean age was 34.7 years and mean BMI was 43.8 kg/m².

Of the 27 banding patients, 3 had hypertension and 1 had sleep apnea. Of the 24 bypass patients, 2 had hyperlipidemia, 1 had hypertension, and 1 had type 2 diabetes.

Ten years after surgery, 81.4% of the banding group and 87.5% of the bypass group remained in follow-up, reported Dr. Angrisani.

Of the 22 remaining banding patients, 9 (41%) had had their bands removed, leaving 13 for weight-loss evaluation.

The BMI of 6 of these 13 patients exceeded 35 kg/m², so the procedures were considered "failures"; only 7 patients in the banding group were successful in losing weight, he said.

In contrast, of the remaining 21 bypass patients, mean BMI dropped from 43.8 to 30.4 kg/m²; only 20% of the procedures in this group were considered failures.

There were no deaths in the study, and improvement in baseline comorbidities was similar in the 2 groups. However, reoperation rates were higher in the banding group than in the bypass group (41% vs 29%).

In the banding group, reasons for reoperation were pouch dilations (n = 3), band migration (n = 1), unsatisfactory weight loss (n = 4), and untreatable reflux (n = 1).

Reasons for reoperation in the bypass group were potentially life-threatening, said Dr. Angrisani — internal hernia (n = 1), cholecystectomy (n = 4), and incisional hernia (n = 1).

"The complications of bypass are iatrogenic," he told Medscape Medical News. "There is inadvertent bowel injury during manipulation of the bowel. When you do banding, you do not manipulate the bowel."

Like Dr. Gagner, Dr. Angrisani has virtually abandoned gastric banding, reserving it for a select group of smaller patients. An analysis of the Bariatric Outcomes Longitudinal Database (BOLD), presented separately at the meeting (as reported by Medscape Medical News), showed that from 2007 to 2010, banding and bypass surgery were performed in almost equal numbers in 540 hospitals in the United States (117,365 vs 138,222).

Europeans are ahead of the game, having started banding procedures before North America, and therefore detecting problems earlier, said Dr. Angrisani. "This is a very common story. While we as Europeans accept the messages from the US world of surgery, the US community does not accept data coming from Europe. So they are now living the experience we had in the last few years."

"It's a complete disaster, when you think that banding in the United States, based on the BOLD data, is the second-most common procedure," said Dr. Gagner. "Europeans are abandoning banding and the Americans are not getting the message. This abandonment that we see in Europe — we are probably going to see this in the next few years in the United States."

Although there is already a trend toward replacing banding with sleeve gastrectomy, lack of insurance coverage for the sleeve procedure remains a major barrier, he said. In the BOLD analysis, 21% of sleeve procedures were self-paid, compared with 5.7% of band procedures and 1.9% of bypass procedures.

"The European experience is more mature than the US experience with gastric banding," agreed John Morton, MD, from Stanford University in California, who reported the BOLD data at the meeting.

In an email to Medscape Medical News, Dr. Morton said that "although 6-year data for sleeve gastrectomy indicate that it is safe and effective, the potential long-term complications for the sleeve may not be fully apparent yet, and gastric banding may still be preferred due to it's favorable short-term safety profile."

Dr. Angrisani has disclosed no relevant financial relationships. Dr. Gagner reports being a speaker for Covidien, Ethicon, and Gore. Dr. Morton reports being a consultant for Vibrynt and Ethicon.

American Society for Metabolic and Bariatric Surgery (ASMBS) 29th Annual Meeting: Abstract PL 103. Presented June 20, 2012.

An Endocrinologist Talks about Hypoglycemia after Gastric Bypass

Post-gastric bypass hypoglycemia: A serious complication of bariatric surgery | Endocrine Today:

Post-gastric bypass hypoglycemia: A serious complication of bariatric surgery

• Endocrine Today, November 2010
  Dawn Belt Davis, MD, PhD

Obesity is a rapidly increasing problem in the United States and worldwide, with more than 30% of adult Americans now affected. Unfortunately, we are lacking in effective therapies to promote significant weight loss.

See Also

• Modified bariatric surgery led to remission of type 2 diabetes ...
• Study to compare bariatric surgery vs. medical therapy in ...
• Type 2 diabetes and surgery: band or bypass? | Endocrine ...

Although aggressive lifestyle modification is highly effective, it is plagued by difficulties with poor compliance, access and reimbursement. Medical therapy for obesity has limited efficacy and significant side effects, and with the recent withdrawal of sibutramine from the US market, there are limited options (See more info on this here). Therefore, more patients and providers are turning to bariatric surgery for the treatment of obesity and its comorbidities. Especially in the case of Roux-en-Y gastric bypass surgery, this is a highly effective therapy that can lead to significant weight loss and also improve metabolic parameters independent of weight loss.

Dawn Belt Davis

Roux-en-Y gastric bypass surgery involves attaching a small pouch of the upper stomach to the early part of the jejunum, thereby bypassing the majority of the stomach and the duodenum. This results in an increased sense of fullness and reduction in appetite, as well as alterations in hormonal release from the small intestine in response to food. This procedure has been found to lead to resolution of type 2 diabetes in up to 80% of patients. It has therefore been proposed as a potential “cure” for type 2 diabetes.

Evaluating risks of surgery

As with any therapy, Roux-en-Y gastric bypass surgery can result in adverse effects and complications. Although the immediate risks of morbidity and mortality from the surgery are low, the long-term risks associated with malabsorption and other complications are still being clarified as an increasing number of patients are undergoing this procedure.

One long-term risk is the development of postprandial hypoglycemia. This phenomenon was first described in the literature in 2005. The prevalence still remains unknown, but as endocrinologists we will undoubtedly be seeing more of these patients. Hypoglycemia typically does not present until 2 to 3 years after gastric bypass surgery. These hypoglycemic episodes are characterized by low blood sugars that occur 2 to 3 hours after a meal. Fasting hypoglycemia is typically not seen. The etiology seems to be excessive insulin secretion in response to the meal. It is well documented that patients are more insulin sensitive after gastric bypass surgery, but the pathophysiology of these specific patients who develop hypoglycemia remains unclear. It is hypothesized that it may be related to elevations in the incretin hormones glucagon-like peptide 1 and gastric inhibitory polypeptide, and their ability to stimulate additional insulin secretion. It has also been debated whether increased beta-cell mass may lead to excessive insulin secretion.

Unfortunately, the effect of this disorder on the lives of patients can be devastating and severe. They become trapped in a vicious cycle in which the very treatment of their hypoglycemia leads to yet another episode a few hours later. Hypoglycemic unawareness can develop relatively rapidly, as these patients may have several episodes per day. Patients can have loss of consciousness and seizures, which may result in motor vehicle accidents. Many patients go undiagnosed for extended periods of time, as there is limited awareness of this disorder in the medical community and the initial episodes are often mild with subtle symptoms.

There are limited resources to determine the appropriate treatment strategy for these patients, with most studies reporting only a small number of cases.

First-line treatment should be educating the patient to follow a diet with strict avoidance of high-glycemic-index carbohydrates and limited portions of any carbohydrate. In addition, acarbose (Precose, Bayer Pharmaceuticals) is often successful in patients with relatively mild disease to reduce carbohydrate absorption. In patients who do not respond to these initial therapies, the addition of medications to antagonize insulin activity or minimize insulin secretion can be helpful. Calcium-channel blockers, octreotide or diazoxide are other options that can be tried. In the most severe patients, partial pancreatectomy has been performed; unfortunately, it has not been universally successful at reversing the hypoglycemic episodes. It is unknown if reversal of the gastric bypass is a successful strategy.

Fostering awareness

As endocrinologists, we need to be aware of this complication and ask about symptoms in all patients after gastric bypass surgery. In my experience, many patients have been struggling to self-manage these symptoms and are relieved to learn that this is a recognized complication and treatment options exist. Many patients respond well to dietary modification and acarbose alone. Those patients with the most severe and difficult to control symptoms are challenging. Surgical options should be considered as a last resort, as their effectiveness is unclear and there is obvious associated morbidity. Ongoing research efforts continue to determine the underlying etiology of this disorder and therapeutic options, including nutritional, pharmacologic and surgical approaches.

In the meantime, treatment of these challenging patients requires a bit of creativity, good communication with the patient and the rest of the care team (nutritionists, bariatric surgeons and gastroenterologists), and attention to the latest advances in the literature. Most importantly, we will need to further determine the frequency of this complication and carefully consider this when we weigh the risks and benefits of Roux-en-Y gastric bypass procedures.

With an increasing number of these procedures being performed every year and with a recent push to consider this procedure as a curative therapy for type 2 diabetes, it is crucial to learn more about this serious complication so we can educate patients about the risks and hopefully identify those at highest risk before the procedure.

Dawn Belt Davis, MD, PhD, is an assistant professor in the section of endocrinology, diabetes and metabolism at the University of Wisconsin-Madison and is a member of the Endocrine Today Editorial Board.

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