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LETTERS

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Sensitivity to Alcohol in ObesePatients: A Possible Role forFood Addiction

Nicole M Avena, PhD

Gainesville, FL and Princeton, NJ

Mark S Gold, MD

Gainesville, FL

In the article, “Impaired alcohol metabolism after gastricbypass surgery: a case-crossover trial,” Woodard and col-leagues1 raise the important issue of considering the post-operative sensitivity to alcohol in patients who have under-gone gastric bypass surgery. The authors warn that cautionshould be used when consuming alcohol because patientswith postoperative bariatric surgery respond differently,both physically and psychologically, in that they are moresensitive to the effects of low doses of alcohol.

Although physiologic factors such as altered absorption andtime to the brain are important, other factors may contributeto the sensitivity to alcohol seen in these patients. If drugs andfood compete in the brain for the same reinforcement sites,abstinence from one may make abuse of the other more likely.Many morbidly obese patients undergoing gastric bypass sur-gery may meet clinical criteria for a pathologic attachment topalatable food, which, in some, can manifest as an “addiction”to food.2,3 Preclinical literature suggests that overeating of pal-table foods can result in behaviors and brain changes that areike those seen in addiction,4 with animals self-administeringucrose in a binge-type manner that results in morphine-likeithdrawal precipitated by naloxone or spontaneously by fast-

ng. Cross-sensitization to drugs of abuse has been noted, withnimals that overeat sugar showing locomotor sensitivity to aow dose of amphetamine. Moreover, of particular interest tohis paper is the finding that rats dependent on sugar also showproclivity to consume alcohol. These findings are supportedy a growing literature documenting comorbidity and over-apping neural circuitry associated with obesity and substancebuse.

Due to the abrupt changes in eating behavior that followhese operations, patients may begin to derive pleasure fromther reinforcers, such as alcohol or drugs of abuse. Althoughse is not often seen in morbidly obese patients, after-surgerybuse may be more common, possibly through sensitizationo the reinforcing effects of substances of abuse. This has been

uggested in other studies, which point to other addictions

451© 2011 by the American College of SurgeonsPublished by Elsevier Inc.

eg, narcotic addiction) postoperatively in patients undergo-ng gastric bypass surgery.5 Further, concern over other poten-tial addiction (eg, drug and alcohol) has been found to bepositively associated with weight regain in these patients aftersurgery.6 So, in addition to the pharmacologic and otherhanges that can increase alcohol sensitivity postsurgery, sur-eons should also consider the sensitivity to alcohol and otherrugs of abuse that may result from previously unrecognizedood addiction.

REFERENCES

1. Woodard GA, Downey J, Hernandez-Boussard T, Morton JM.Impaired alcohol metabolism after gastric bypass surgery: a case-crossover trial. J Am Coll Surg 2011;212:209–214.

2. Madan AK, Orth WS, Ternovits CA, Tichansky DS. Preoperativecarbohydrate “addiction” does not predict weight loss after lapa-roscopic gastric bypass. Obes Surg 2006;16:879–882.

3. Gearhardt AN, Corbin WR, Brownell KD. Preliminary validation ofthe Yale Food Addiction Scale. Appetite 2009;52:430–436.

4. Avena NM, Rada P, Hoebel BG. Evidence for sugar addiction:behavioral and neurochemical effects of intermittent, excessivesugar intake. Neurosci Biobehav Rev 2008;32:20–39.

5. Wendling A, Wudyka A, Narcotic addiction following gastricbypass surgery-a case study. Obes Surg 2011;21:680–683.

6. Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors ofweight regain after bariatric surgery. Obes Surg 2010;20:349–356.

Disclosure Information: Nothing to disclose.

Reply

John Morton, MD, MPH, FACS

Menlo Park, CA

I appreciate Drs Avena and Gold’s letter in response to ourarticle, “Impaired alcohol metabolism after gastric bypass sur-gery: a case-crossover trial.”1 Our article focused strictly onphysiologic changes in alcohol metabolism after Roux-en-Ygastric bypass, namely, higher peak breath alcohol levels andlonger time to zero breath alcohol levels after alcohol inges-tion. Drs Avena and Gold raise the intriguing question of foodaddiction and addiction transfer in their letter. Although theycite animal studies supporting the concept of food addiction,food “addiction” in humans remains to be established fact.Unlike addictions for nicotine and narcotics, in which abstain-ing is an option, food abstinence is not possible because food

is integral to life. Our relationship to food is highly complex,

ISSN 1072-7515/11/$36.00doi:10.1016/j.jamcollsurg.2011.05.022

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452 Letters J Am Coll Surg

ingrained, and redundant. Disinhibition may be a unifyingtrait for issues with food and substance abuse.2,3 However,here is no doubt that the obese patient has an altered relation-hip with food that bears further inquiry.

Drs Avena and Gold also note that abrupt changes in eatingehavior may lead patients to derive pleasure from otherources. It should be noted that bariatric surgery patients uni-ormly receive preoperative nutritional counseling as a keyomponent of Bariatric Surgery Center of Excellence pro-rams.4,5 This preoperative nutritional counseling allows pa-ients the opportunity to appropriately transition their eatingabits.6 Based on our study, before surgery, gastric bypass pa-ients should also have counseling regarding alcohol con-umption. Although the potential for weight regain and alco-ol abuse may be rarely possible postoperatively, the long-termenefit of gastric bypass is clear and evident, with substantialeight loss, comorbidity improvement, and survival bene-

it.7,8 To maximize the impressive outcomes engendered byastric bypass surgery, both preoperative counseling and post-perative surveillance are needed and desired.

REFERENCES

1. Woodard GA, Downey J, Hernandez-Boussard T, Morton JM.Impaired alcohol metabolism after gastric bypass surgery: a case-crossover trial. J Am Coll Surg 2011;212:209–214.

2. Bryant EJ, King NA, Blundell JE. Disinhibition: its effects onappetite and weight regulation. Obes Rev 2008;9:409–419.

3. Farhat T, Iannotti RJ, Simons-Morton BG. Overweight, obesity,youth, and health-risk behaviors. Am J Prev Med 2010;38:258–267.

4. Surgical Review Corporation. Available at: http://www.surgicalreview.org/. Accessed June 5, 2011.

5. American College of Surgeons. Bariatric Surgery Center NetworkAccreditation Program. Available at: http://www.acsbscn.org/Public/index.jsp. Accessed June 5, 2011.

6. Solomon H, Liu GY, Alami R, et al. Benefits to patients choosingpreoperative weight loss in gastric bypass surgery: new results of arandomized trial. J Am Coll Surg 2009;208:241–245.

7. Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes,and cardiovascular risk factors 10 years after bariatric surgery.N Engl J Med 2004;351:2683–2693.

8. Adams TD, Gress RE, Smith SC, et al. Long-term mortality aftergastric bypass surgery. N Engl J Med 2007;357:753–761.

Disclosure Information: Nothing to disclose.

Wedge Resection for GastricSubmucosal Tumors

Jeffrey B Albright, MD, FACS,Gerald McGwin, MS, PhD

Birmingham, AL

We read with great interest the article published by Lee andcolleagues,1 “Laparascopic wedge resection for gastric sub-

ucosal tumors: A size-location matched case-controltudy.” This highly commendable article compared the usef laparoscopy versus open resection of submucosal gastricumors and the impact on operative time and return ofowel function.This study found, when matched for tumor size and

ocation on the stomach, the laparoscopic group (n�50)ad a favorable time to return of oral tolerance and de-reased hospital length of stay, while the open resectionroup (n�50) had a shorter duration of surgery. After theatching process, there were no significant differences in

emographics, comorbidities, endophytic or exophytic na-ure of the tumor, or pathological findings. Further, allatients had negative margins and no recurrence after sim-lar duration of follow-up.

However, it is our concern that the design of this study isot as stated in the title of the article. In a case-controltudy, the investigator starts with individuals with a diseaser condition (cases) and compares them to those withouthe disease or condition (controls) with respect to someharacteristic or exposure of interest. This was not the casen the above study. In the study by Lee and colleagues,1 aetrospective nonrandomized study was performed com-aring two groups with operative approaches (ie, the expo-ure) that differed at the outset, and then followed them inime to compare outcomes of interest. This type of studyould be better described as a retrospective matched co-ort study.Unfortunately, this not just a semantic issue because the

tatistical analysis failed to account not only for the appro-riate study design (cohort vs. case-control study) but alsohe pair-matched nature of the study participants. It isnclear if the significance between the variables would haveeen different when using the proper tests. However, it ismportant that when conducting a study that the correctpproach to design and analysis be utilized, since failure too so may potentially diminish the integrity of the find-

ngs, and may ultimately lead to erroneous conclusions.egardless, we commend the authors for their aims of ad-ancing our understanding of the role of minimally inva-ive techniques for gastric tumor resection.

REFERENCE

1. Lee HH, Hur H, Jung H, et al. Laparoscopic wedge resection forgastric submucosal tumors: a size-location matched case-controlstudy. J Am Coll Surg 2011:212:195–199.

Disclosure Information: Nothing to disclose.