|Year : 2020 | Volume
| Issue : 1 | Page : 18-21
Comparison of laparoscopic sleeve gastrectomy outcomes between elderly and young patients
Saad Althuwaini1, Fahad Bamehriz1, Abdullah Aldohayan1, Maram A Alaqel2, Rasha Abdulelah Bassas2, Rana A AlJunidel2
1 Department of General Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
2 Department of Surgery, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
|Date of Submission||01-Jan-2020|
|Date of Acceptance||09-Jan-2020|
|Date of Web Publication||3-Oct-2020|
Dr. Abdullah Aldohayan
Department of General Surgery, King Saud University Medical City, Riyadh 11461
Source of Support: None, Conflict of Interest: None
Background and Aim: There are conflicting results in the literature regarding the percentage of excess weight loss (%EWL) and the resolution of comorbidities postlaparoscopic sleeve gastrectomy between the young and elderly patients. We compared the resolution of comorbidities and the %EWL and investigated for significant complications after surgery between the young and elderly patients.
Methods: This was a retrospective case–control study which used the data collected from the electronic medical records at the Center of Excellence of Bariatric Surgery in King Saud University Medical City, Riyadh, Saudi Arabia, from 2011 to 2017. The variables collected included; length of hospital stay, resolution of comorbidities at 1, 6, and 12 months, complications postsurgery, and the %EWL.
Results: We included 56 patients (35 males and 21 females) with a mean age of 58.8 years (55 to 75 years) and mean body mass index of 39.5 kg/m2 (42–60 kg/m2). The length of stay was significantly longer in the elderly group compared to the younger group (3.14 vs. 2.33 days). The proportion of comorbidities in the older population was higher compared to the younger population. The resolution of the comorbidities was significantly higher at the last patient's follow-up in both older and younger population. The %EWL was above 50% in both age groups. There was one incidence of bleeding in the elderly group.
Conclusion: Bariatric surgery is relatively safe and effective in reducing the incidence of comorbid conditions even among elderly patients aged 60 years old and above. Therefore, we suggest that the age should not be a major impediment when considering bariatric surgery, particularly for the elderly patients. However, a meticulous assessment of other patient risk factors should also be considered prior to bariatric surgery.
Keywords: Bariatric surgery, comorbidities, elderly, laparoscopic sleeve gastrectomy, resolution
|How to cite this article:|
Althuwaini S, Bamehriz F, Aldohayan A, Alaqel MA, Bassas RA, AlJunidel RA. Comparison of laparoscopic sleeve gastrectomy outcomes between elderly and young patients. Saudi J Laparosc 2020;5:18-21
|How to cite this URL:|
Althuwaini S, Bamehriz F, Aldohayan A, Alaqel MA, Bassas RA, AlJunidel RA. Comparison of laparoscopic sleeve gastrectomy outcomes between elderly and young patients. Saudi J Laparosc [serial online] 2020 [cited 2021 Nov 30];5:18-21. Available from: https://www.saudijl.org/text.asp?2020/5/1/18/296782
| Introduction|| |
Obesity defined as a body mass index (BMI) >30 kg/m2 is a global health problem and is considered an international epidemic in both the elderly and children., Obese patients have a lower quality of life, decreased functional independence and are prone to much fatal comorbidity. According to the World Health Organization, the worldwide prevalence of obesity nearly tripled between 1975 and 2016 where 13% of adults (11% of men and 15% of women) suffer from obesity in 2016.,
Comorbidities such as diabetes, ischemic heart diseases, and hypertension (HTN), bone disease, and obstructive sleep apnea (OSA) were shown to decrease life expectancy, and resolving these comorbidities through bariatric surgery has been satisfactory in older group. The quality of life among obese people was shown to be reduced by obesity due to multiple comorbidities such as diabetes mellitus (DM), HTN, and hyperlipidemia. At present, surgery is the only long-term weight loss solution for morbidly obese patients. Bariatric surgery has been proven as the most effective treatment of morbid obesity and associated comorbidities, superior to medical treatment. Results from several studies have proven the safety of bariatric surgery in the elderly since they observed that morbidity and mortality rates have improved tremendously, as well as significant weight reduction.,,,, Sleeve gastrectomy (SG) has been showed to be as effective as gastric bypass, and more effective than gastric banding with less mortality and adverse symptoms even in the elderly population (>60) especially when considering resolving of comorbidities.,, Weight loss among elderly patients was comparable to younger patients and was found to be enough to resolve the comorbidities in most of the patients.
There is a scarcity of research focused on the resolution of comorbidities and percentage of excess weight loss (%EWL) among the obese elderly population and much more studies that were conducted in Saudi Arabia. Because of this, we conducted this study to compare the resolution of comorbidities and %EWL between elderly and young Saudi obese patients.
| Methods|| |
We conducted a retrospective case–control study which used the data collected from the electronic medical records at the Center of Excellence of Bariatric Surgery in King Saud University Medical City, Riyadh, Saudi Arabia, from 2011 to 2017. By convenient sampling method, we included patients who were obese and presented with comorbidities. Patients who have undergone redo surgeries and patients that did not present with any comorbidity were excluded from the study.
The variables collected included length of hospital stay, resolution of comorbidities at 1, 6, and at 12 months, complications postsurgery, and the %EWL. The operative BMI criterion was based on the Asia-Pacific guidelines for bariatric surgery. Demographics of these patients included age, gender, body weight, and BMI. The presence of comorbidities, including Type 2 DM2, HTN, hyperlipidemia, OSA, knee pain, and back pain, were noted. The operative variables included length of hospital stay and postoperative complications which were recorded and analyzed. Complications included early and late leak, bleeding, nausea, vomiting, and mortality. The patient follow-up visits were scheduled at 1 week, then at 1, 3, 6, and 12 months following the surgery at which the BMI and %EWL was calculated, and the remission of comorbid illnesses was noted. Improvement and resolution of comorbidities were based on the secondary endpoint.
Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0 (SPSS Inc., IBM, Armonk, New York, USA). Results were expressed as numbers and percentages (for categorical variables) and as mean, standard deviation, and range (for continuous variables). Independent t-test was used to determine the significant difference between means and Chi-square test was used to determine the significant difference between proportions. P < 0.05 was considered statistically significant. This study was ethically approved from the IRB Committee of the College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| Results|| |
We included a total of 56 patients (27 patients <60 years old and 29 patients >60 years old). The mean BMI of the elderly group was 49.25 ± 13.39 kg/m2 and the BMI of the younger group was 47.15 ± 8.35 kg/m2 (P = 0.4881, 95% confidence interval −3.931–8.131). The mean age of the all patients was 58.8 years, and the mean BMI for all patients was 39.5 kg/m2.
The mean length of stay was significantly longer in the elderly population compared to the younger population (3.14 vs. 2.33 days, P = 0.008). In general, there were no postoperative complications except for a bleeding episode in an elderly patient which was managed conservatively. The %EWL at 1 year was above 50% in both the age groups [Figure 1].
|Figure 1: A comparison of the percentage excess weight loss at 1, 3, 6, and 12 months of follow-up between patients <60 years old and patients >60 years old|
Click here to view
In the elderly population, DM, HTN, and OSA were statistically significant at 1-year follow-up (P > 0.05). All elderly patients resolved from OSA at 1 year (100%). There was a higher resolution rate of dyslipidemia (DLP) and back pain in the younger population (values). The proportion of DM2 and HTN was higher in the older population (53.3% and 70%) compared to the younger population (20% and 40%). The incidence of comorbidities was found to be significantly lower at the last patient follow-up (P > 0.05) [Figure 2]. A diabetes resolution criterion was hemoglobin (HBa1c) <7 with medication cessation and improvement were based on HBa1c <1 from the first measurement. HTN resolution based on the stoppage of medication and OSA resolution based on sleep study.
|Figure 2: A comparison of the resolution rate of comorbidities at 12 months after surgery between patients <60 years old and patients >60 years old|
Click here to view
| Discussion|| |
Resolving comorbidities is one of the most significant economical benefits of bariatric surgery especially in the elderly. This study demonstrated the improvement and resolution of DM and HTN significantly in both groups, with the elderly group having more resolution than the younger patients. Some of the comorbidities in this study showed improvement better in the younger patients (such as DLP and back pain); however, both groups showed significant resolution in the elderly group. Our finding is similar to the finding in a previous study where the resolution of DM2 and HTN was higher among the elderly group. However, there was a study that showed failure of patients to get diabetes remission after laparoscopic sleeve gastrectomy (LSG) despite a significant weight loss. This however means that weight loss is an important factor in remitting diabetes but some other mechanisms needed to be explored.
The National Institutes of Health guidelines established the age of >55 years as a relative contraindication to bariatric surgery due to higher morbidity and mortality in this age group. Furthermore, it has been suggested that age can decrease the efficacy of open bariatric surgery particularly in older patients. However, during recent years, bariatric surgery has shown to be safe for patients over 60 years with good results especially in resolving comorbidities and can be as safe as other GI procedures., Bariatric surgery was proven safe and effective for patients >60 years old with low morbidity and mortality, and with significant improvement in comorbidities., Bariatric surgery continued to be performed in elderly patients at a very low rate even with morbidly obese patients., Moreover, researches from several countries observed significantly good weight loss and resolution of comorbidities in elderly patient undergoing bariatric surgery.,, Laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG achieved good weight loss and resolution of comorbidities in the elderly population with the superiority of LRYGB in terms of diabetes remission but carried higher complication rates even at high volume centers. Similarly, LRYGB showed its superiority over LSG in DM remission, although weight loss was better with LSG compared to LRYGB, with a %EWL of 72.1% compared to 62.2% after 1 year, respectively. It has been reported that although the weight loss and improvement in obesity comorbidities were less in the older compared to the younger patients, they were clinically significant. The use of bariatric surgery in older adult patients was shown to have no significant differences in %EWL and length of stay across age groups at 6 m and 1 year and 2 years' follow-up, and no major or recurrent minor complications occurred in older patients. On the other hand, many researches that approved the safety of bariatric surgery in elderly, and that the mortality rate for SG has been 0%–3.2% in some studies., Furthermore, LSG is a technically less demanding procedure and requires significantly less operative time than LRYGB.,
In this current study, even though the %EWL in the elderly group was less than the younger group at 12 months of follow-up with a %EWL mean of 56.65 in elderly, and a mean of 61.80 in the younger group, it was still comparable. Several studies have shown that, with the evolution and advance of minimally invasive surgery in recent few years, bariatric surgery in elderly patients achieved significant weight reduction and resolution of comorbidities which goes along this current study.,
In the present study, the prevalence of diabetes in the elderly group was 53% which contributes to a higher complication rate compared to a prevalence of 20% in the younger group, although fortunately, there were no complications. SG is feasible in patients aged ≥60 years and SG can reduce the cardiovascular risk, medication needs, obesity-related mortality, and increase life expectancy for elderly patients. SG is effective and relatively safe for older bariatric patients in a 12-month follow-up and weight loss was comparable to younger patients and enough to resolve the comorbidities in most of the patients. In contrast, a study demonstrated a significant association between the age group 65+ years and increased risk of medical and overall complications in LSG. Another study demonstrated that bariatric surgery in elderly carry higher morbidity and mortality rate in addition to decreased EWL.
Reports suggested that a long follow-up period that extends up to 7 years' postbariatric surgery conducted on morbidly obese sleep apnea patients demonstrated that a significant decrease in the number of apneic episodes per hour of sleep and a significant improvement in all sleep-quality-related measures were seen after 1 year and 7 years. In contrast to our study, there was a 100% resolution in the six patients that had OSA.
In this study, we faced only one complication in elderly group which was bleeding from the stapler line and was managed conservatively with blood transfusion and pressure on the bleeding area. This has been reported that very few patients (particularly the elderly patients) experience perioperative mortality and complications within 30 days from surgery and that no patient in the elderly group converted to open surgery. The limitations of our study include the small sample size to come up with conclusive evidence on the resolution of comorbidities and %EWL of obese patients undergoing LSG. However, despite the relatively small sample size, we were able to highlight the significant decrease in the comorbidities at the last follow-up visit (after 1 year postoperative) of our patients, which agrees with previous studies on the benefits of bariatric surgery.,,,,,,
| Conclusion|| |
Bariatric surgery is relatively safe and effective in reducing the incidence of comorbid conditions even among elderly patients aged 60 years and above. Therefore, we suggest that the age should not be a major impediment when considering bariatric surgery, particularly for the elderly patients. However, a meticulous assessment of other patient risk factors should also be considered prior to bariatric surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Obesity and Overweight. World Health Organization; 2015.
Ahrens W, Pigeot I, Pohlabeln H, de Henauw S, Lissner L, Molnár D, et al
. Prevalence of overweight and obesity in European children below the age of 10. Int J Obes (Lond) 2014;38 Suppl 2:S99-107.
Huang CK, Garg A, Kuao HC, Chang PC, Hsin MC. Bariatric surgery in old age: A comparative study of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in an Asia center of excellence. J Biomed Res 2018;29:118.
St Peter SD, Craft RO, Tiede JL, Swain JM. Impact of advanced age on weight loss and health benefits after laparoscopic gastric bypass. Arch Surg 2005;140:165-8.
Johnson D, Drenick EJ. Therapeutic fasting in morbid obesity. Arch Intern Med 1977;137:1381-2.
Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev 2014;8:CD003641. doi: 10.1002/14651858.CD003641.pub4.
Varela JE, Wilson SE, Nguyen NT. Outcomes of bariatric surgery in the elderly. Am Surg 2006;72:865-9.
Sugerman HJ, DeMaria EJ, Kellum JM, Sugerman EL, Meador JG, Wolfe LG. Effects of bariatric surgery in older patients. Ann Surg 2004;240:243-7.
Gonzalez-Heredia R, Patel N, Sanchez-Johnsen L, Masrur M, Murphey M, Chen J, et al
. Does age influence bariatric surgery outcomes? Bariatr Surg Pract Patient Care 2015;10:74-8.
Parmar C, Mahawar KK, Carr WR, Schroeder N, Balupuri S, Small PK. Bariatric surgery in septuagenarians: A comparison with <60 Year olds. Obes Surg 2017;27:3165-9.
Lakdawala MA, Bhasker A, Mulchandani D, Goel S, Jain S. Comparison between the results of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass in the Indian population: A retrospective 1 year study. Obes Surg 2010;20:1-6.
Himpens J, Dapri G, Cadière GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: Results after 1 and 3 years. Obes Surg 2006;16:1450-6.
Fatima J, Houghton SG, Iqbal CW, Thompson GB, Que FL, Kendrick ML, et al
. Bariatric surgery at the extremes of age. J Gastrointest Surg 2006;10:1392-6.
Leivonen MK, Juuti A, Jaser N, Mustonen H. Laparoscopic sleeve gastrectomy in patients over 59 years: Early recovery and 12-month follow-up. Obes Surg 2011;21:1180-7.
Abbas M, Cumella L, Zhang Y, Choi J, Vemulapalli P, Melvin WS, et al
. Outcomes of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in patients older than 60. Obes Surg 2015;25:2251-6.
Dunkle-Blatter SE, St Jean MR, Whitehead C, Strodel W 3rd
, Bennotti PN, Still C, et al
. Outcomes among elderly bariatric patients at a high-volume center. Surg Obes Relat Dis 2007;3:163-9.
Wittgrove AC, Martinez T. Laparoscopic gastric bypass in patients 60 years and older: Early postoperative morbidity and resolution of comorbidities. Obes Surg 2009;19:1472-6.
Printen KJ, Mason EE. Gastric bypass for morbid obesity in patients more than fifty years of age. Surg Gynecol Obstet 1977;144:192-4.
O'Keefe KL, Kemmeter PR, Kemmeter KD. Bariatric surgery outcomes in patients aged 65 years and older at an American Society for Metabolic and Bariatric Surgery Center of Excellence. Obes Surg 2010;20:1199-205.
Livingston EH, Huerta S, Arthur D, Lee S, de Shields S, Heber D. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg 2002;236:576-82.
Pequignot A, Prevot F, Dhahri A, Rebibo L, Badaoui R, Regimbeau JM. Is sleeve gastrectomy still contraindicated for patients aged ≥60 years? A case-matched study with 24 months of follow-up. Surg Obes Relat Dis 2015;11:1008-13.
Qin C, Luo B, Aggarwal A, de Oliveira G, Kim JY. Advanced age as an independent predictor of perioperative risk after laparoscopic sleeve gastrectomy (LSG). Obes Surg 2015;25:406-12.
Pillar G, Peled R, Lavie P. Recurrence of sleep apnea without concomitant weight increase 7.5 years after weight reduction surgery. Chest 1994;106:1702-4.
Charuzi I, Lavie P, Peiser J, Peled R. Bariatric surgery in morbidly obese sleep-apnea patients: Short-and long-term follow-up. Am J Clin Nutr 1992;55:594S-6S.
Hazzan D, Chin EH, Steinhagen E, Kini S, Gagner M, Pomp A, et al
. Laparoscopic bariatric surgery can be safe for treatment of morbid obesity in patients older than 60 years. Surg Obes Relat Dis 2006;2:613-6.
[Figure 1], [Figure 2]