Danish Center for Clinical Health Service Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
Scand J Pain. 2020 Apr 28;20(2):239-251. doi: 10.1515/sjpain-2019-0092.
Background and aims Bariatric surgery remains a mainstay for treatment of morbid obesity. However, long-term adverse outcomes include chronic abdominal pain and persistent opioid use. The aim of this review was to assess the existing data on prevalence, possible mechanisms, risk factors, and outcomes regarding chronic abdominal pain and persistent opioid use after bariatric surgery. Methods PubMed was screened for relevant literature focusing on chronic abdominal pain, persistent opioid use and pharmacokinetic alterations of opioids after bariatric surgery. Relevant papers were cross-referenced to identify publications possibly not located during the ordinary screening. Results Evidence regarding general chronic pain status after bariatric surgery is sparse. However, our literature review revealed that abdominal pain was the most prevalent complication to bariatric surgery, presented in 3-61% of subjects with health care contacts or readmissions 1-5 years after surgery. This could be explained by behavioral, anatomical, and/or functional disorders. Persistent opioid use and doses increased after bariatric surgery, and 4-14% initiated a persistent opioid use 1-7 years after the surgery. Persistent opioid use was associated with severe pain symptoms and was most prevalent among subjects with a lower socioeconomic status. Alteration of absorption and distribution after bariatric surgery may impact opioid effects and increase the risk of adverse events and development of addiction. Changes in absorption have been briefly investigated, but the identified alterations could not be separated from alterations caused solely by excessive weight loss, and medication formulation could influence the findings. Subjects with persistent opioid use after bariatric surgery achieved lower weight loss and less metabolic benefits from the surgery. Thus, remission from comorbidities and cost effectiveness following bariatric surgery may be limited in these subjects. Conclusions Pain, especially chronic abdominal, and persistent opioid use were found to be prevalent after bariatric surgery. Physiological, anatomical, and pharmacokinetic changes are likely to play a role. However, the risk factors for occurrence of chronic abdominal pain and persistent opioid use have only been scarcely examined as have the possible impact of pain and persistent opioid use on clinical outcomes, and health-care costs. This makes it difficult to design targeted preventive interventions, which can identify subjects at risk and prevent persistent opioid use after bariatric surgery. Future studies could imply pharmacokinetic-, pharmacodynamics-, and physiological-based modelling of pain treatment. More attention to social, physiologic, and psychological factors may be warranted in order to identify specific risk profiles of subjects considered for bariatric surgery in order to tailor and optimize current treatment recommendations for this population.
减重手术仍然是治疗病态肥胖的主要手段。然而，长期不良后果包括慢性腹痛和持续使用阿片类药物。本综述的目的是评估现有关于减重手术后慢性腹痛和持续使用阿片类药物的患病率、可能机制、危险因素和结果的数据。
对关注减重手术后慢性腹痛、持续使用阿片类药物和阿片类药物药代动力学改变的文献进行了 PubMed 筛查。交叉引用相关文献以确定在常规筛查中可能未找到的出版物。
关于减重手术后一般慢性疼痛状况的证据很少。然而，我们的文献综述显示，腹痛是减重手术后最常见的并发症，在手术后 1-5 年内有医疗接触或再次入院的患者中，3%-61%的患者出现腹痛。这可以用行为、解剖和/或功能障碍来解释。减重手术后，持续使用阿片类药物的剂量增加，4%-14%的患者在手术后 1-7 年内开始持续使用阿片类药物。持续使用阿片类药物与严重疼痛症状有关，在社会经济地位较低的患者中最为常见。减重手术后吸收和分布的改变可能会影响阿片类药物的作用，并增加不良事件和成瘾的风险。吸收的改变已被简要研究，但所鉴定的改变不能与仅由体重过度减轻引起的改变分开，药物制剂可能会影响研究结果。减重手术后持续使用阿片类药物的患者体重减轻和手术带来的代谢益处较少。因此，这些患者的并发症缓解和减重手术的成本效益可能会受到限制。
减重手术后发现疼痛（尤其是慢性腹痛）和持续使用阿片类药物较为常见。生理、解剖和药代动力学变化可能起作用。然而，慢性腹痛和持续使用阿片类药物的发生危险因素以及疼痛和持续使用阿片类药物对临床结果和医疗保健成本的可能影响仅得到了很少的检查。这使得设计针对减重手术后慢性腹痛和持续使用阿片类药物的靶向预防干预措施变得困难，这些措施可以识别有风险的患者，并预防减重手术后持续使用阿片类药物。未来的研究可能需要对疼痛治疗进行基于药代动力学、药效学和生理学的建模。为了确定考虑接受减重手术的患者的特定风险概况，可能需要更多关注社会、生理和心理因素，以便为这一人群定制和优化当前的治疗建议。
