Surgery for Obesity and Related Diseases ] (2014) 00–00

Original article

Benefits and risks of bariatric surgery in patients aged more than 60 years Patrick Ritza,d,*, Philippe Topartb, Salomon Benchetritc, Géraud Tuyerasa,d, Benoit Lepaged, Jean Mouiele, Guillaume Becouarnb, François Pattouf, Jean-Marc Chevallierg a

Centre Intégré Obésité, Endocrinology Metabolism and Nutrition Department, CHU Toulouse, France b Bariatric Surgery Department, Clinique de l’Anjou, Angers, France c Centre Péricaud, Lyon, France d USMR 1027 Inserm Université Paul Sabatier, CHU Toulouse, France e Obesity Center, Clinique St George, Nice, France f General and Endocrine Surgery, CHRU Lille, INSERM UMR 859, Université de Lille-Nord de France, Lille, France g Hôpital Européen Georges Pompidou, Paris, France Received July 12, 2013; accepted December 10, 2013

Abstract

Background: The benefits and risks of bariatric surgery are debated in older patients. The objective of this study was to compare the weight changes and adverse outcomes in patients 460 years and in younger ones. Methods: The French SOFFCO registry was screened for gastric bypass (RYGB), gastric banding (LAGB), or sleeve gastrectomy (SG) performed between 2007 and 2010. Adverse outcomes and weight changes (%) over 12 months were compared between patients o40 years (N ¼ 1379), between 40–59 years (N ¼ 1065), and 460 years (N ¼ 164). Results: After a RYGB surgical (12.3 versus 3.8%; P ¼ .03) and nonsurgical (7.0% versus .8%; P ¼ .01) complications were more prevalent in patients above 60 years than in those below 40. No increased prevalence of surgical and nonsurgical complications was seen after a LAGB or a SG. Weight loss (% of initial weight) was lower after a LAGB than after a RYGB or a SG. After LAGB weight loss (%) did not differ between patients above 60 years and those aged o40 (difference 1.7 ⫾ 1.5%, P ¼ .26). After a RYGB weight loss (%) was lower in patients aged 460 years (5.6 ⫾ 1.7%, P ¼ .001) than in those aged o40 years. After a SG, weight loss (%) was lower in patients aged 460 years (7.0 ⫾ 2.6%, P ¼ .01) than in those aged o40 years. Conclusion: Bariatric surgery can be a short-term effective and safe therapeutic option in elderly patients. LAGB or SG appears to be an alternative strategy to RYGB, with lower adverse outcome rate. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Keywords:

Obesity surgery; Elderly; Gastric bypass; Adjustable gastric banding; Sleeve gastrectomy; Surgical adverse outcomes

Despite the high prevalence of obesity and the higher prevalence of related comorbidities observed in older patients than in younger patients [1,2], it is only recently that bariatric surgery is considered and is no longer contraindicated in *

Correspondence: Patrick Ritz, Unités de nutrition, CHU de Toulouse, 26 Chemin de Pouvourville, 31059 Toulouse, France. E-mail: [email protected]

patients above 60 years. The National Institutes of Health has recognized the possibility of surgery in patients above 60 years in 2006 and the French National Authority for Health did so in 2009 [3]. The rationale for this caution was the early reports of impressive mortality [4,5] and adverse surgery outcomes [6]. These studies reported records from national surveys and registries, dating from 1996–2002, mainly from patients having had a gastric bypass ([5,6]; RYGB).

http://dx.doi.org/10.1016/j.soard.2013.12.012 1550-7289 r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.

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P. Ritz et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00

Recent reports have challenged these early findings [2,7– 18]. In case control studies, mortality is not higher than in younger groups [2,9]. Early postsurgical complications appear at a similar rate in young and older patients after a gastric banding but at a much higher rate in elders after a gastric bypass. The weight loss is similar between young and old patients after a gastric bypass with values between 54 and 74.8% excess weight loss at 12 months [2,9]. This remains valid at 5 years [19]. A large number of these studies rely on a small number of patients, some from a single institution. Few studies compare data obtained with different procedures. Two recent reviews [20,21] analyzed these data and concluded in 2 different directions. The conclusion was either “bariatric surgery can be safely performed and be clinically effective in the elderly” [21] or “in the elder people the risks from bariatric surgery outweigh the benefits”[20], highlighting that a consensus has not been achieved and that more data are required on this topic. Therefore, the aim of this study was to report data from the registry of the SOFFCO (French and French-speaking Society for Obesity Surgery). Since 2007, a national initiative recommended that French bariatric surgeons enter on a dedicated website and for each patient, anthropometric data, weight changes, and adverse outcomes after bariatric surgery, whatever the procedure performed. The data therefore reflect the experience of most of the French bariatric surgeons.

weight data during the first year of follow-up were excluded (n ¼ 399). Fig. 1 shows the flow of patients retained. Adverse outcomes Adverse outcomes were recorded in prespecified categories. Surgical complications occurring within the first year were: intestinal perforation, vomiting, occlusion, intraabdominal abscess, fistula, peritonitis, anastomotic stenosis, bleeding, splenectomy, and stapling of the nasogastric tube. Nonsurgical complications were: deep vein thrombosis, pulmonary embolism, infection, anemia, malnutrition, acute psychiatric disorder, and death. Weight changes Weight changes were calculated with reference to presurgery value and expressed as a weight loss in percent of the initial value. Statistics Since only 23.5% of the 2998 extracted from the registry had weight values either at 18 or at 24 months, the analysis was limited to the first year after surgery. Weight changes over time were estimated using linear mixed models adjusted for time, age category, surgical procedure, gender, presurgery body mass index (BMI), and their significant

Methods Patients Data from patients having bariatric surgery anywhere in France, between January 2007 and July 2010 were entered prospectively in the registry by each surgeon who performed the surgical procedure (list in Appendix 1). Each surgeon had a personal secured login to enter the data and could only see the data from their patients. Patients were operated on according to the indications of bariatric surgery defined by the French National Authority for Health [3], which are very similar to those across Europe and in the US. In July 2010, permission was given by the president of the SOFFCO to extract data from the registry. Anthropometrics Patient weights, height, age, and gender were entered by the surgeon. Weights were measured before surgery and at regular intervals (1, 3, 6, 9, 12, 18 and 24 mo). Surgical procedures The type of procedure was recorded. Out of the initial 3064 patients considered, only those having had a RYGB, an adjustable gastric banding (LAGB), or a sleeve gastrectomy (SG) were included (n ¼ 2998). Patients without any

Fig. 1. Flow diagram.

Bariatric Surgery in Elders / Surgery for Obesity and Related Diseases ] (2014) 00–00 Table 1 Surgical procedure breakdown according to age categories n (%) patients LAGB RYGB SG

Age o40 yr (N ¼ 1379)

40–59 yr (N ¼ 1065)

Age 460 yr (N ¼ 154)

802 (61.5) 366 (44.4) 211 (45.0)

453 (34.7) 401 (48.7) 211 (45.0)

50 (3.8) 57 (6.9) 47 (10.0)

LAGB ¼ laparoscopic adjustable gastric band; RYGB ¼ roux-en-Y gastric bypass; SG ¼ sleeve gastrectomy.

interactions with time. Three age categories were set (o40 yr, N ¼ 1379; 40–59 yr, N ¼ 1065; 460 yr, N ¼ 154). Time was included in the model as both fixed and random effects with an unstructured variance-covariance matrix. To improve the fit of the model, square root of time was also included as a fixed effect. Comparisons between procedures or age categories were based on linear combinations of estimators and Wald tests. Significance was accepted at a level of 5%. Statistical analyses were performed with Stata SE 11.1 (StataCorp, College Station, TX).

Table 3 Adverse outcomes in the 30 days after the surgical procedure [number of events (% of the population in brackets]

Surgical outcome Vomiting Occlusion Abscess Fistula Peritonitis Anastomotic stenosis Bleeding Splenectomy Nasogastric stapling Nonsurgical Deep vein thrombosis Embolism Infection Anemia Malnutrition Psychiatric Death

LAGB (N ¼ 1305)

RYGB (N ¼ 824)

SG (N ¼ 469)

8 (.61) 2 (.15) – – – – 1 (.08) – –

4 (.49) 8 (.97) 3 (.36) 7 (.85) 4 (.49) 7 (.85) 13 (1.58) 2 (.24) 2 (.24)

– – 2 (.43) 4 (.85) – – 3 (.64) – –

1 1 2 1

3 6 5 3 1

1 3 5 1

(.08) (.08) (.15) (.08)

1 (.08)

The study population was 2598 patients having a RYGB (31.7%), or an LAGB (50.2%), or a SG (18.1%), with 80.4% women, a mean BMI of 42.7 ⫾ 6.1 kg/m2, a mean age of 40.2 ⫾ 8.9 years. Laparoscopy was performed in 98.4% of all procedures. 14.2% of the interventions were redo surgery (mostly after a LAGB in 66% and a vertical banded gastroplasty in 13.9%). A larger proportion of people from the younger group (o40 yr) had an LAGB, and a greater proportion of the older group (460 yr) had a SG (P o .001; Table 1). Table 2 shows the comorbidities associated with obesity at the time of surgery. Most comorbidities were more frequent as age increased, especially in the patients aged 460 years. Table 3 displays the adverse outcomes per procedure. There were more adverse outcomes after a RYGB or a SG than after an LAGB. This was the case for surgical and nonsurgical complications. One death was reported after an

(.21) (.64) (1.07) (.21)

1 (.21) 0

1 (.12)

LAGB (.08% of the patients) and after RYGB (.12% of the patients). No death was reported after a SG in the study population. Table 4 reports the effect of age categories on adverse outcomes. Surgical complications were more prevalent in patients aged 460 years after a RYGB than in those o40 (12.3 versus 3.8%; P ¼ .03). An increased rate of nonsurgical complications was also observed in patients aged 460 years (7.0% versus .8%; P ¼ .01). However, the increased prevalence of surgical and nonsurgical complications for the older patients was only present after a RYGB and not after the LAGB or the SG. Weight loss was expressed as a percentage of initial weight. In the analyses stratified on the age categories, weight loss was lower after an LAGB than after a RYGB or Table 4 Prevalence (number and % in brackets) of the adverse outcomes after surgery in the different age categories

Table 2 Prevalence of comorbidities (number and % in brackets) associated with obesity at the time of surgery All patients o40 yr 40–59 yr 460 yr P for N ¼ 2598 N ¼ 1379 N ¼ 1065 N ¼ 154 age*

*

(.36) (.73) (.61) (.36) (0.12)

LAGB ¼ laparoscopic adjustable gastric banding; RYGB ¼ Roux-en-Y gastric bypass; SG ¼ sleeve gastrectomy.

Results

Hypertension Diabetes Arthrosis Sleep apnea Dyslipidemia Coronary heart disease Hypoventilation

3

503 324 651 349 415 124

(19.4) (12.5) (25) (13.4) (16.0) (4.8)

318 (12.2)

Pearson’s χ2 test.

149 102 340 119 191 58

(10.8) (7.4) (24.7) (8.6) (13.9) (4.2)

277 167 276 184 189 52

(26.0) (15.7) (25.9) (17.3) (17.8) (4.9)

77 55 35 46 35 14

(49.7) (35.7) (22.6) (29.7) (22.7) (9.1)

o .0001 o .0001 .61 o .0001 .002 .03

176 (12.8) 125 (11.7) 17 (11.0) .67

LAGB

RYGB

SG

Number of patients Surgical complications Medical complications Number of patients Surgical complications Medical complications Number of patients Surgical complications Medical complications

Age o40 yr

Age 40-59 yr

802 7 3 366 14 3 211 5 6

463 3 1 401 23 8 211 3 4

(.9) (.4) (3.8) (.8) (2.4) (2.8%)

(.7) (.2) (5.7) (2.0) (1.4) (1.9)

Age 460 yr 50 1 1 57 7 4 47 2 0

P*

(2.0) (2.0)

.49 .23

(12.3) (7.0)

.03 .01

(4.3) (0.0)

.40 .72

LAGB ¼ laparoscopic adjustable gastric banding; RYGB ¼ roux-en-Y gastric bypass; SG ¼ sleeve gastrectomy; yr: years. * Fisher's exact test.

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Table 5 Comparison of percentage of weight loss at 1 year after surgery, between the procedures in the different age categories, for patients with a BMI of 41.7 kg/m2

LAGB (reference) RYGB SG

Age o 40 yr

Age 40–59 yr

Age 460 yr

– þ13.8 ⫾ .81 (P o .001) þ10.9 ⫾ 1.03 (P o .001)

– þ12.5 ⫾ .83 (P o .001) þ10.1 ⫾ 1.23 (P o .001)

– þ9.2 ⫾ 1.95 (P o .001) þ5.5 ⫾ 2.50 (P ¼ .03)

BMI ¼ body mass index; LAGB ¼ laparoscopic adjustable gastric banding; RYGB ¼ Roux-en-Y gastric bypass; SG ¼ sleeve gastrectomy. Percentages of weight loss were estimated using linear mixed models adjusted on gender, surgical procedure, presurgery BMI, and their interactions with time.

Discussion

are much more frequent [21]. The present study reports similar findings with a complication rate in agreement with what was recently published. Bariatric surgery for patients aged 460 years seems to be effective with an acceptable rate of adverse outcome [21] although this is still discussed [20]. In the present study, the percentage of weight loss was significantly lower in aged patients than in younger patients (Fig. 1), as reported in earlier studies [9,12,19]. At 1 year, it amounted to 20% after LAGB, 25% after SG, and 30% after RYGB. However, a 5–10% decrease in weight is recommended for improving obesity-related comorbidities [19]. The nonsurgical weight loss strategies lead to a 2–3% weight loss on average [21]. Therefore, the weight loss achieved with surgical techniques is likely to improve comorbidities, as described by most authors. Whether this amount of weight loss is associated with long-term complications, such as loss of autonomy, is a matter of concern. On the other hand, obesity and especially a BMI 435 kg/m2 conveys an

Obesity prevalence and its surgical treatment as LAGB, RYGB, and SG are increasing worldwide. At the same time, mean life expectancy increases accelerating the community demand for obesity treatment in elderly patients. This study shows that aged patients can benefit from bariatric surgery despite a higher rate of adverse surgical and medical outcomes after an RYGB. In contrast, this age-related complication rate was not observed after LAGB or SG. For this age category, weight loss tended to be lower after RYGB or SG than in younger patients; this was not the case after an LAGB. Prospective and retrospective studies have analyzed bariatric surgery outcomes in aged patients. Flum et al. [5] and Livingston et al. [6] found an increased risk of complications and deaths in patients 465 years. In these studies, many patients had an open surgical treatment or a laparoscopic procedure performed at the beginning of the RYGB learning curve, the procedures were performed 10– 15 years ago, and the patients were probably frail (under the Medicaid scheme). Recent studies highlighted the safety of bariatric surgery in this age category. Improvement of intraoperative surgical management and optimization of perioperative care have decreased the complications’ rate. However, aged patients are more exposed to adverse outcome because of the underlying comorbidities, which

Fig. 2. Mean weight loss (%) according to the type of intervention, stratified by age category.

a SG (Table 5, Fig. 1). Weight loss differences observed between LAGB, RYGB, and SG were similar for women and for men. In the analyses stratified on the type of surgical procedure, we observed after LAGB that the percentage of weight loss with time did not differ between patients aged 460 years and those aged o40 (difference 1.7 ⫾ 1.5%, P ¼ .26). Patients aged 40–59 years appeared to lose slightly more than those aged o40 years (1.3 ⫾ 0.6%, P ¼ .04). After a RYGB, the percentage of weight loss with time was lower in patients aged 40–59 years (-1.8 ⫾ 0.9%, P ¼ .05) and in those aged 460 years (-5.6 ⫾ 1.7%, P ¼ .001) than in those aged o40 years. After a SG, the percentage of weight loss with time did not differ in patients aged 40–59 years (-0.9 ⫾ 1.5%, P ¼ .54) but was lower in those aged 460 years (7.0 ⫾ 2.6%, P ¼ .01) than in those aged o40 years (Fig. 2 A, B, C).

Bariatric Surgery in Elders / Surgery for Obesity and Related Diseases ] (2014) 00–00

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The strength of this study is that it is based on a national registry; surgeons being asked to enter the results in a dedicated website. Therefore, it reflects the day-by-day practice and results. The large number of patients allows proper statistical calculations. It is the first published study to compare the 3 most performed surgical procedures, and the second to report data on the outcomes of sleeve gastrectomy in an elderly population. It would certainly be more powerful if it had been performed in a single institution. However, the variety induced by procedures performed in multiple sites is interesting as it gives an average picture of different practices. The limitations of the study are those of a registry. Surgeons are asked to enter the data, but no monitoring of the data source was possible. Another limitation is that it is only a 1-year study. Data were available at 18 or 24 months but with too many missing values (76.5%) making the modeling hazardous. This is paramount of this type of experience and only 12% of the patients had all the weight measurements between surgery and 12 months postoperatively (Fig. 3). Figure 3. Weight loss (%) according to the age category, stratified by the type of intervention.

increased risk of impairment of activities of the daily living (RR 1.76, 95% CI 1.28–2.41; [22]. Silecchia et al. [16], Chevallier et al. [23] and Busetto et al. [12] proposed LAGB as a safe and effective treatment for aged patient suffering from obesity with a low rate of complications and a significant decrease of comorbidities and medications. An increase in the quality of life (þ22%) was suggested by Clough et al. [24]. Meanwhile, recent studies on RYGB cohorts have shown similar weight losses and adverse outcomes for aged and younger patients. Quebbemann et al. (2005) [15] concluded that RYGB seems to be as safe as, and more effective than, the LAGB in this age group. Willkomm et al. [2] reported a very similar readmission rate (6.0 in young versus 7.4% above 65 yr) in almost 1500 patients from a single institution. They even reported a 2.5 times better follow-up at 2 years in aged patients. Dorman et al. [18] in a survey on 448,000 patients concluded that patients above 65 years did not experience a higher risk of major complications. The average length of stay was slightly higher. In the present study, the adverse outcome for RYGB is higher than after LAGB or SG. Despite an expert consensus in 2012 [25] proposing SG as a surgical option in the elderly, the published data on safety and effectiveness are scant. van Rutte et al. [26] analyzed data on 135 patients above 55 years having a SG (50 above 60 yr and 12 above 65 yr). Eleven percent of the patients had early adverse outcomes, marginally more in those above 65 years. In the present study, the percentage of weight loss is greater after an SG than after an LAGB, with a similar outcome rate.

Conclusion Obesity of an aged patient is an important healthcare issue. The present study suggests that bariatric surgery can be an effective and safe therapeutic option in the short-term. LAGB or SG appears to be an alternative strategy to RYGB, with lower adverse outcome rate. More long-term data are needed. Acknowledgments We thank the SOFFCO for allowing the access to the registry and Dr. S. Benchetrit and Alain Tamer (Infodev) for extracting the data. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Appendix 1 The alphabetic list of surgeons who participated in collecting the data is: Abbadi AC, Abittan R, Ain JF, Anduze-Acher Y, Ast M, Attal E, Bauchu JY, Beaune B, Becaud A, Becouarn G, Benchetrit S, Bercovivi D, Berger E, Bertrand JC, Blanc P, Blanche JP, Bonnichon A, Bordigoni A, Brachet A, Branche D, Chabert M, Chevallier JM, Danan M, Dirajlal A, Dost C, Farthouat P, Frecon G, Fredmeaux A, Frering V, Gelez C, Genier F, Georgeac C, Gontier R, Guillermet P, Herbiere P, Huten N, Janody P, Juglard G, Kadji M, Keller P, Kolmer S, Krawczykowski D, Kuperas C, Ledaguenel P, Lepere M, Lesage A, Leynaud G, Liagre A, Merabet M, Meyer T, Molasoko JM, Mouiel J,

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Benefits and risks of bariatric surgery in patients aged more than 60 years.

The benefits and risks of bariatric surgery are debated in older patients. The objective of this study was to compare the weight changes and adverse o...
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