Surgery for Obesity and Related Diseases ] (2015) 00–00
Original article
Is sleeve gastrectomy still contraindicated for patients aged Z60 years? A case-matched study with 24 months of follow-up Aurelien Pequignot, M.D.a, Flavien Prevot, M.D.a, Abdennaceur Dhahri, M.D.a, Lionel Rebibo, M.D.a, Rachid Badaoui, M.D.b, Jean Marc Regimbeau, M.D., Ph.D.a,* a
Departments of Digestive Surgery, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France b Departments of Anesthesiology, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France Received August 14, 2014; accepted November 15, 2014
Abstract
Background: Current guidelines consider that bariatric surgery is relatively contraindicated in elderly adults (aged Z60 years). The objective of this study was to evaluate obesity-related morbidity after sleeve gastrectomy (SG) according to whether patients were aged Z60 years or o60 years. Methods: Forty-two patients aged Z60 years (the elderly group) were matched 1:2 with 84 patients aged o60 (the control group). The primary objective was to compare weight change and the remission rate of co-morbidities in the 2 groups after 24 months of follow-up. The secondary endpoints were short-term and midterm postoperative outcomes (operating time, the frequency of conversion to laparotomy, the length of hospital stay, postoperative complications, mortality, and the SG failure rate). Results: No significant differences were observed between the elderly and control groups in terms of the mean operating time (83 minutes in both groups; P ¼ .90), length of stay (3.2 versus 3.4 days, respectively; P ¼ .51), morbidity rate (4.7% versus 9.5%, P ¼ .35), or mortality rate (0% in both groups). The mean excess weight loss was significantly lower in the elderly group than in the control group at 12 months (56.2% versus 71.4%, respectively; P o .01) and 24 months (51.8% versus 73.5%, P o .01). Similar statistically significant differences were observed between the elderly group and control group for remission of metabolic syndrome (95% versus 90%, respectively; P ¼ .55), type 2 diabetes mellitus (87% versus 71%, respectively; P ¼ .13), hypertension (81% versus 77%, respectively; P ¼ .71), and dyslipidemia (94% versus 74%, respectively; P ¼ .09) at 24 months after SG. Conclusion: Results support the safety and efficacy of SG for morbid obesity in patients aged Z60 years. In contrast to weight loss, the long-term morbidity rate and remission of obesity-related co-morbidities were similar in the participants aged Z60 years and those aged o60 years. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Sleeve gastrectomy; Elderly patients; Morbidity; Mortality; Excess weight loss; Co-morbidities
In many industrialized countries, the prevalence of morbid obesity has increased significantly during the last 10 years and has been estimated at 10%–30% in the *
Correspondence: J.-M. Regimbeau, Department of Digestive Surgery, CHU Nord, Place Victor Pauchet, F-80054 Amiens cedex 01, France. E-mail: [email protected]
European adult population (according to the World Health Organization) [1]. Bariatric surgery has been validated for the treatment of (1) patients with severe obesity (i.e., a body mass index [BMI] of 35–40 kg/m²) and co-morbidities and (2) patients with extreme obesity (i.e., a BMI 440 kg/m²) [2–3]. Bariatric surgery not only reduces the co-morbidities associated with obesity [4–8] but also increases overall
http://dx.doi.org/10.1016/j.soard.2014.11.015 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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A. Pequignot et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
survival in this population of patients [9]. In view of a lower impact on weight loss and obesity-associated co-morbidities, the current guidelines consider that bariatric surgery is relatively contraindicated in elderly patients. However, there is no consensus on the upper age limit in the literature, and values ranging from 50 to 65 years have been suggested. Morbid obesity in patients aged 460 years is a real health problem, with more frequent weight-comorbidities [10–11], greater medication use, and a higher mortality rate [12–13]. A recent study reported that 10.1% of all bariatric operations in academic centers were performed on patients aged Z60 years [14]. However, several studies show that potential health benefits of bariatric surgery in this population must be considered afresh [15– 17]. The objective of the present single-center study was to evaluate the short-term and long-term postoperative outcomes for sleeve gastrectomy (SG), a safe and effective procedure, in a morbidly obese elderly population. Materials and methods The study population The present study was based on a retrospective review of the authors’ departments prospective database; to identify and assess all SG patients aged Z60 years (the elderly group, n = 42, accounting for 7% of the patients in the database) with full follow-up for at least 24 months. The elderly patients were matched 1:2 with another group of 84 patients aged o60 years (the control group). Preoperative, intraoperative, and postoperative data for all patients were analyzed retrospectively. Indication for surgery and preoperative assessment According to the French national guidelines [3], the indication for bariatric surgery was validated in a multidisciplinary care team meeting. Each patient underwent surgical consultations, a nutritional and dietary analysis, and respiratory, endocrine, and psychological assessments. Helicobacter pylori infections and hiatus hernia were screened for and ruled out in subsequently operated patients. Surgical procedures The authors’ intraoperative procedures for SG have been described elsewhere [18–19]. Laparoscopic SG was performed in all cases. Division of the vascular supply of the gastric greater curvatures was initiated 6 cm from the pylorus and proceeded upward to the angle of His by using the LigaSure Vessel Sealing System (Covidien, Norwalk, CT). A 34Fr gastric bougie was used for all SGs performed during the study period. The staple line was not reinforced. After stomach clamping, a methylene blue test was used to screen for staple line leakage. The patient was taken to a recovery room, and the nasogastric tube was removed upon
awakening. The authors’ hospital is a regional referral center for SG, and the operation can now be performed as an outpatient procedure for selected patients [20]; however, this was not the case for any of the patients in the present series. The postoperative management of complications (especially gastric staple line leakage, affecting 2.5% of the patients in the present series) [21] was validated for each individual patient by a specific, multidisciplinary team meeting (comprising a bariatric surgeon, a gastroenterologist, a nutritionist, and a radiologist). When weight loss at 24 months was judged unsatisfactory, gastric volumetry was performed to evaluate the need for repeat SG [22]. The residual gastric volume was defined as the volume between the gastroesophageal junction and the pylorus, after gastric distention with carbon dioxide. The case-matching procedure The matching procedure was performed manually with respect to demographic criteria (gender and body mass index [BMI]) and a number of obesity-associated co-morbidities (including type 2 diabetes mellitus, hypertension, dyslipidemia, and metabolic syndrome). The elderly patients (aged Z60 years; n ¼ 42) were matched 1:2 with another group of 84 patients aged o60 years (the control group). Type 2 diabetes mellitus was defined using criteria proposed by the American Diabetes Association, with a fasting blood glucose (FBG) level Z126 mg/dL or a blood HbA1c level Z6.5% (as confirmed by repeating the test on a different day) and/or the requirement for one or more antidiabetic medications. Arterial hypertension was defined as a blood pressure above 140/90 mm Hg. Dyslipidemia was characterized by elevated serum triglyceride levels (Z150 mg/dL), elevated serum small low-density lipoprotein cholesterol levels (Z160 mg/dL), and low serum HDL cholesterol (r40 mg/dL in men and r50 mg/dL in women). In daily practice, the authors use the National Cholesterol Education Program-Adult Treatment Panel III definition of metabolic syndrome (3 of the 5 following criteria are required: abdominal girth 488 cm in women or 4102 cm in men; systolic and diastolic blood pressures 4130 and 480 mm Hg, respectively; triglyceride levels above 150 mg/dL; HDL cholesterol levels o50 mg/dL in women and o40 mg/dL in men; and a FBG level above 110 mg/dL) [23]. Inclusion criteria Patients included in the study had to meet the following criteria: primary SG and BMI between 35 and 40 kg/m2 with obesity-related co-morbidities or BMI 440 kg/m2 with or without obesity-related co-morbidities. Patients with less than 24 months of follow-up and those undergoing surgical procedures other than primary SG were excluded from the study.
Sleeve Gastrectomy for Elderly Patients / Surgery for Obesity and Related Diseases ] (2015) 00–00
Endpoints and study design The primary objective was to compare weight change and the remission of co-morbidities in the 2 groups after 24 months of follow-up. The secondary endpoints were shortterm and midterm postoperative outcomes (operating time, the frequency of conversion to laparotomy, the length of hospital stay, postoperative complications, mortality, and the SG failure rate). Postoperative complications were graded according to the Clavien-Dindo classification [24] when they occurred within 90 days of surgery or at any time before discharge from hospital. Major complications were defined as Clavien grade 3 and 4 events. The quality of the outcome of SG was defined according to Reinhold’s criteria. Success, moderate effectiveness, and failure were defined as a percentage excess weight loss (%EWL) of 450%, 25%–50%, and o25%, respectively. Comorbidities were considered in remission when use of prescribed medication could be stopped, with normal serum values. Improvement of co-morbidities was not analyzed in this study. The remission of type 2 diabetes mellitus was defined as a normal FBG level, a normal HbA1c level (o6.5%), and the absence of antidiabetic drugs or insulin. The remission of dyslipidemia was defined as normal serum lipid values and the absence of cholesterol-lowering drugs. The remission of arterial hypertension was defined as normal blood pressure values and the absence of antihypertensive drugs.
Statistical analysis Patient characteristics were expressed as the mean (range) for continuous data and the percentage (number) for categorical data. Categorical data were analyzed with Pearson’s χ2 test. All statistical tests were performed with the SPSS software (version 18.0 for Windows, SPSS Inc., Chicago, IL). The threshold for statistical significance was set at P o .05. To assess the validity of results, the study’s
3
power was determined post hoc. With a difference of 21.7% (73.5% less 51.8%), a one-side alpha risk of .05%, and a sample size of 126 patients, the power of the present retrospective series was .761. Results The study population The mean age was 62 years (range: 60–68 years) in the elderly group and 41.3 years (range: 22–59 years) in the control group. The mean BMI was 46.7 kg/m² (range: 37– 62.7 kg/m²) in the elderly group and 46.8 kg/m² (range: 37.3–63.7 kg/m²) in the control group. Demographic characteristics are summarized in Table 1. No significant intergroup differences were observed, other than for the rate of type 2 diabetes mellitus (64.3% in the elderly group versus 45.2% in the control group; P ¼ .05). Perioperative and postoperative data Perioperative and postoperative data are summarized in Table 2. There were no SG conversations to laparotomy in either group. No significant intergroup differences were observed in terms of the mean operating time (83 minutes in both groups, P ¼ .90) and the mean length of stay (3.2 in the elderly group versus 3.4 days in the control group, P ¼ .51). Forty patients (95%) in the elderly group and 76 patients (90%) in the control group presented uncomplicated postoperative courses. No significant intergroup difference in the morbidity rate (4.7% in the elderly group versus 9.5% in the control group, P ¼ .35) was observed. Major complications occurred in one patient in the elderly group (gastric leakage) and in 3 patients in the control group (2 cases of bleeding and 1 case of gastric stenosis). Lastly, significant intergroup differences were not observed in the need for revisional surgery (2.4% in both groups; P ¼ .99) or endoscopic management (4.8% in the elderly group versus 2.4% in the control group; P ¼ .48).
Table 1 Demographic characteristics of the study subgroups Characteristic
Elderly group
Control group
P value
Age, mean (range) Gender, % (n) BMI BMI 440, % (n) BMI 450, % (n) BMI 460, % (n) Number of co-morbidities Type 2 diabetes mellitus, % (n) Dyslipidemia, % (n) Hypertension, % (n) Obstructive sleep apnea syndrome, % (n) Metabolic syndrome, % (n)
62 (60–68) 45 (19) 46.7 (37–62.7) 88.1 (37) 23.8 (10) 4.8 (2) 2.5 (0–5) 64.3 (27) 42.8 (18) 57.1 (27) 40.5 (17) 50 (21)
41.3 (22–59) 23 (19) 46.8 (37.3–63.7) 89.3 (75) 25 (21) 7.1 (6) 2 (0–5) 45.2 (38) 40.5 (34) 46.4 (39) 34.5 (29) 35.7 (30)
o.01 .97 .90 .69 .85 .59 .11 .05 .84 .06 .54 .14
Abbreviation: BMI ¼ body mass index.
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Table 2 Surgical data and postoperative outcomes Elderly group Control group P value Operating time, min Length of hospital stay, days Postoperative complications, % (n) Major complications (Grade ¼ 3) Postoperative mortality, % (n) Revisional surgery, % (n) Endoscopic treatment, % (n)
83 (45–150) 3.2 (2–5) 4.7 (2) 1 0 2.4 (1) 4.8 (2)
83 (30–180) 3.4 (2–4) 9.5 (8) 3 0 2.4 (2) 2.4 (2)
.90 .51 .35
.99 .48
Weight change data after 24 months of postoperative follow-up The %EWL was significantly lower in the elderly group versus the control group at 3 months (32.7% versus 37.6%, respectively; P ¼ .01), 6 months (48.3% versus 59.3%, respectively; P o .01), 12 months (56.2% versus 71.4%, respectively; P o .01), 18 months (51.8% versus 77.1%, respectively; P o .01), and 24 months (51.8% versus 73.5%, respectively, P o .01) (Fig. 1). The SG success rate was significantly lower in the elderly group (17%, versus 66% in the control group; P o .01), whereas the moderate effectiveness rate was significantly higher in the elderly group (21%, versus 12% in the control group; P o .01). No significant intergroup difference was observed in the SG failure rate after 24 months of followup (4% in the elderly group versus 6% in the control group; P ¼ .66, Table 3). In univariate analyses, none of the following parameters was predictive of SG failure at 24 months: gender (25% versus 18% in the elderly and control groups, respectively; P ¼ .75), BMI 440 (100% versus 87%, respectively; P ¼ .44), type 2 diabetes mellitus (75% versus 63%, respectively; P ¼ .64), dyslipidemia (50% versus 42%, respectively; P ¼ .76), hypertension (25% versus 68%, respectively; P ¼ .08), and metabolic syndrome (50% in both groups; P ¼ 1). There was no significant difference in the %EWL at 24 months when
Table 3 Success, moderate effectiveness, and failure after 24 months of postoperative follow-up %EWL, % (n)
Elderly group
Control group
P value
450 25–50 o25
40.5 (17) 50 (21) 9.5 (4)
79 (66) 14 (12) 7 (6)
o.01 o.01 .66
Abbreviation: %EWL ¼ percentage excess weight loss.
comparing elderly diabetic patients receiving or not receiving insulin therapy (41.4% and 54%, respectively; P ¼ .25). The course of co-morbidities after 24 months of postoperative follow-up The remission rates of the various obesity-associated co-morbidities are detailed in Table 4. Unlike type 2 diabetes mellitus and metabolic syndrome, remission of hypertension were significantly lower in the elderly group than in the control group at 6 months after SG (0% versus 36%, respectively; P o .01); the same was true of metabolic syndrome (5% versus 47%, respectively; P o .01). However, at 24 months after SG, similar significant remissions of metabolic syndrome (95% versus 90%, P ¼ .55), type 2 diabetes mellitus (87% versus 71%, P ¼ .13), hypertension (81% versus 77%, P ¼ .71), and dyslipidemia (94% versus 74%, P ¼ .09) were observed in both groups. Discussion In view of concerns about the increased risk of anesthesia and less weight control efficacy, advanced age has been considered to be a relative contraindication to bariatric surgery. However, it appears that advanced age is not a contraindication for oncological procedures, such as total gastrectomy and pancreaticoduodenectomy. Although the prevalence of morbid obesity in the elderly is on the rise [25], surgery is performed less frequently in this population.
Fig. 1. Weight change data (%EWL) after 24 months of postoperative follow-up.
Sleeve Gastrectomy for Elderly Patients / Surgery for Obesity and Related Diseases ] (2015) 00–00 Table 4 Remission of co-morbidities after sleeve gastrectomy Co-morbidity, % (n) Elderly group Control group P value 6 months
Diabetes mellitus Hypertension Dyslipidemia Metabolic syndrome 12 months Diabetes mellitus Hypertension Dyslipidemia Metabolic syndrome 24 months Diabetes mellitus Hypertension Dyslipidemia Metabolic syndrome
17 (4) 0 (0) 31 (5) 5 (1) 62 (15) 61 (16) 68 (11) 74 (14) 87 (21) 81 (21) 94 (15) 95 (18)
34 36 32 47 66 64 56 77 71 77 74 90
(13) (14) (11) (14) (25) (25) (19) (23) (27) (30) (25) (27)
.13 o.01 .94 o .01 .79 .83 .38 .81 .13 .71 .09 .55
The present results confirmed that SG is feasible in patients aged Z60. There were no significant intergroup differences in the operating time (83 minutes in both groups; P ¼ .90), the mean length of stay (3.2 days in the elderly group versus 3.4 days in the control group; P ¼ .51), or the morbidity rate (4.7% versus 9.5%, respectively; P ¼ .35). The mean %EWL was significantly lower in the elderly group at 6 months (P o .01), 12 months (P o .01), and 24 months (P o .01). The literature data on this subject are heterogeneous. A few studies [12–13] have described elderly age, male gender, electrolyte disorders, and congestive heart failure as being independent risk factors for mortality after bariatric surgery. Other publications have considered elderly age as an independent risk factor for failure of postoperative excess weight loss. Contreras et al. [26] showed that the %EWL was higher for young patients (under the age of 45). Sugerman et al. [15] and St Peter et al. [27] reported that the %EWL was lower for elderly (aged Z60 years) patients. However, a number of recent studies of laparoscopic bariatric procedures have highlighted the safety and efficiency of bariatric surgery in the elderly population. These positive results may be due to improvements in laparoscopic surgical procedures and perioperative care. Hazzan et al. [28] and O’Keefe et al. [29] (in analyses of patients undergoing Roux-en-Y gastric bypass, adjustable gastric banding, and SG) described a low morbidity rate (7.3% at postoperative day 30) after bariatric surgery in an elderly population, with no postoperative deaths. Fatima et al. [30] observed a low mortality rate (.7% at postoperative day 30) for elderly (aged Z60 years) patients and young (r18) patients and concluded that in high-volume centers, bariatric surgery is safe and effective for patients with morbid obesity at both extremes of age. Publications on postoperative outcomes after SG in elderly patients are less common. Van Rutte et al. [1] did not observe significant differences in the 30-day complication rate (P ¼ .054) when comparing 3 age groups (55–59 years, 60–64 years, and 65 years and older). The short-term mortality rate was 0%. In a prospective analysis of 55
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patients undergoing SG (43 were aged o58 years and 12 were aged 459 years), Leivonen et al. [31] showed that older patients had a shorter operating time and a longer hospital stay (P 4 .05). Major, early-onset complications were more frequent in the older age group (42%, versus 9% in the younger group; P ¼ .02) but late complications were less common (17%, versus 44% in the younger group; P 4 .05). The main finding of the present study relates to the remission of obesity-related co-morbidities. To the best of the authors’ knowledge, there are few literature data on this subject. The present results showed that, 24 months after SG, the remission rates for metabolic syndrome, type 2 diabetes mellitus, hypertension, and dyslipidemia comorbidities were similar and statistically significant in both groups. These results show that SG can (1) reduce the cardiovascular risk, medication needs, and obesity-related mortality and (2) increase life expectancy for selected elderly patients. The present data agree with the report by Leivonen et al. [31], in which the co-morbidity remission rates at 12 months were similar in the elderly and control groups. However, some publications have considered elderly age as an independent risk factor for the failure of remission from obesity-related co-morbidities. St Peter et al. [27] described an average reduction of 1.7 co-morbid conditions in older patients and an average of 2.3 in younger patients (P ¼ .05). One year after surgery, Sugerman et al. [15] observed a greater improvement in hypertension and orthopedic problems (P ¼ .001) in a younger group than in an elderly group; however, there were no statistical significant differences in improvements in other obesity-related co-morbidities. Recently, the French SOFFCO registry [32] was screened for gastric bypass, gastric banding, or SG, to analyze weight loss and other postoperative outcomes in 164 patients aged Z60 years and 2444 patients aged o60 years. Unfortunately, the progression or improvement of obesity-related co-morbidities was not analyzed. The present results evidenced significantly lower weight loss after 24 months of follow-up in the elderly group, with no difference in the remission of obesity-related co-morbidities; this single-center, descriptive analysis was unable to explain this finding, and no potentially explanatory literature data could be found. A larger, prospective study with screening for multiple risk factors should be performed to address this issue. Conclusion Sleeve gastrectomy appears to be a safe, effective bariatric procedure for morbid obesity in patients aged Z60 years. Elderly and control patients had similar morbidity rates and co-morbidities remission rates after 24 months of follow-up, although weight loss was lower in the elderly group. Although direct comparisons with other bariatric
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procedures (mainly Roux-en-Y gastric bypass) should now be performed, SG appears to be a viable treatment option for obese elderly patients. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] van Rutte PW, Smulders JF, de Zoete JP, Nienhuijs SW. Sleeve gastrectomy in older obese patients. Surg Endosc 2013;27:2014–9. [2] NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med 1991;115: 956–61. [3] Gastrectomie Longitudinale [sleeve gastrectomy] pour obésité [monograph on the Internet]. Le Plaine, France: Haute Autorité de Santé; 2008. Available from: http://www.has-sante.fr/portail/upload/docs/ application/pdf/rapport_gastrectomie_longitudinale.pdf. [4] Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254: 410–20. [5] Péquignot A, Dhahri A, Verhaeghe P, Desailloud R, Lalau JD, Regimbeau JM. Efficiency of laparoscopic sleeve gastrectomy on metabolic syndrome disorders: two years results. J Visc Surg 2012;149:e350–5. [6] Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA 2014;149:275–87. [7] Brethauer SA, Aminian A, Romero-Talamás H, et al. Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Ann Surg 2013;258: 628–36. [8] Padwal R, Klarenbach S, Wiebe N, et al. Bariatric surgery: a systematic review of the clinical and economic evidence. J Gen Intern Med 2011;26:1183–94. [9] Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357: 741–52. [10] Han TS, Tajar A, Lean ME. Obesity and weight management in the elderly. Br Med Bull 2011;97:169–96. [11] Han TS, Wu FC, Lean ME. Obesity and weight management in the elderly: a focus on men. Best Pract Res Clin Endocrinol Metab 2013;27:509–25. [12] Flum DR, Salem L, Elrod JA, Dellinger EP, Cheadle A, Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294:1903–8. [13] Livingston EH, Langert J. The impact of age and Medicare status on bariatric surgical outcomes. Arch Surg 2006;141:1115–20. [14] Gebhart A, Young MT, Nguyen NT. Bariatric surgery in the elderly: 2009–2013. Surg Obes Relat Dis. Epub 2014 Apr 24.
[15] 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. [16] Soto FC, Gari V, de la Garza JR, Szomstein S, Rosenthal RJ. Sleeve gastrectomy in the elderly: a safe and effective procedure with minimal morbidity and mortality. Obes Surg 2013;23:1445–9. [17] Taylor CJ, Layani L. Laparoscopic adjustable gastric banding in patients Z60 years old. Obes Surg 2006;16:1579–83. [18] Kueper MA, Kramer KM, Kirschniak A, Königsrainer A, Pointner R, Granderath FA. Laparoscopic sleeve gastrectomy: standardized technique of a potential stand-alone bariatric procedure in morbidly obese patients. World J Surg 2008;32:1462–5. [19] Dhahri A, Verhaeghe P, Hajji H, et al. Sleeve gastrectomy: technique and results. J Visc Surg 2010;147:e39–46. [20] Billing PS, Crouthamel MR, Oling S, Landerholm RW. Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases. Surg Obes Relat Dis 2014;10:101–5. [21] Rebibo L, Blot C, Verhaeghe P, Cosse C, Dhahri A, Regimbeau JM. Effect of perioperative management on short-term outcomes after sleeve gastrectomy: a 600-patient single-center cohort study. Surg Obes Relat Dis 2014 Jan 9. (Epub). [22] Deguines JB, Verhaeghe P, Yzet T, Robert B, Cosse C, Regimbeau JM. Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure? Surg Obes Relat Dis 2013;9:660–6 [23] Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of The National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285:2486–97. [24] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. [25] Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States—no statistically significant chance since 2003–2004. NCHS Data Brief 2007;1:1–8. [26] Contreras JE, Santander C, Court I, Bravo J. Correlation between age and weight loss after bariatric surgery. Obes Surg 2013;23:1286–9. [27] 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. [28] Hazzan D, Chin EH, Steinhagen E, 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. [29] 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. [30] Fatima J, Houghton SG, Iqbal CW, et al. Bariatric surgery at the extremes of age. J Gastrointest Surg 2006;10:1392–6. [31] 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. [32] Ritz P, Topart P, Benchetrit S, et al. Benefits and risks of bariatric surgery in patients aged more than 60 years. Surg Obes Relat Dis Epub 2014 Jan 9.
Original article
Is sleeve gastrectomy still contraindicated for patients aged Z60 years? A case-matched study with 24 months of follow-up Aurelien Pequignot, M.D.a, Flavien Prevot, M.D.a, Abdennaceur Dhahri, M.D.a, Lionel Rebibo, M.D.a, Rachid Badaoui, M.D.b, Jean Marc Regimbeau, M.D., Ph.D.a,* a
Departments of Digestive Surgery, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France b Departments of Anesthesiology, Amiens University Medical Center and Jules Verne University of Picardie, Amiens, France Received August 14, 2014; accepted November 15, 2014
Abstract
Background: Current guidelines consider that bariatric surgery is relatively contraindicated in elderly adults (aged Z60 years). The objective of this study was to evaluate obesity-related morbidity after sleeve gastrectomy (SG) according to whether patients were aged Z60 years or o60 years. Methods: Forty-two patients aged Z60 years (the elderly group) were matched 1:2 with 84 patients aged o60 (the control group). The primary objective was to compare weight change and the remission rate of co-morbidities in the 2 groups after 24 months of follow-up. The secondary endpoints were short-term and midterm postoperative outcomes (operating time, the frequency of conversion to laparotomy, the length of hospital stay, postoperative complications, mortality, and the SG failure rate). Results: No significant differences were observed between the elderly and control groups in terms of the mean operating time (83 minutes in both groups; P ¼ .90), length of stay (3.2 versus 3.4 days, respectively; P ¼ .51), morbidity rate (4.7% versus 9.5%, P ¼ .35), or mortality rate (0% in both groups). The mean excess weight loss was significantly lower in the elderly group than in the control group at 12 months (56.2% versus 71.4%, respectively; P o .01) and 24 months (51.8% versus 73.5%, P o .01). Similar statistically significant differences were observed between the elderly group and control group for remission of metabolic syndrome (95% versus 90%, respectively; P ¼ .55), type 2 diabetes mellitus (87% versus 71%, respectively; P ¼ .13), hypertension (81% versus 77%, respectively; P ¼ .71), and dyslipidemia (94% versus 74%, respectively; P ¼ .09) at 24 months after SG. Conclusion: Results support the safety and efficacy of SG for morbid obesity in patients aged Z60 years. In contrast to weight loss, the long-term morbidity rate and remission of obesity-related co-morbidities were similar in the participants aged Z60 years and those aged o60 years. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Sleeve gastrectomy; Elderly patients; Morbidity; Mortality; Excess weight loss; Co-morbidities
In many industrialized countries, the prevalence of morbid obesity has increased significantly during the last 10 years and has been estimated at 10%–30% in the *
Correspondence: J.-M. Regimbeau, Department of Digestive Surgery, CHU Nord, Place Victor Pauchet, F-80054 Amiens cedex 01, France. E-mail: [email protected]
European adult population (according to the World Health Organization) [1]. Bariatric surgery has been validated for the treatment of (1) patients with severe obesity (i.e., a body mass index [BMI] of 35–40 kg/m²) and co-morbidities and (2) patients with extreme obesity (i.e., a BMI 440 kg/m²) [2–3]. Bariatric surgery not only reduces the co-morbidities associated with obesity [4–8] but also increases overall
http://dx.doi.org/10.1016/j.soard.2014.11.015 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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A. Pequignot et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
survival in this population of patients [9]. In view of a lower impact on weight loss and obesity-associated co-morbidities, the current guidelines consider that bariatric surgery is relatively contraindicated in elderly patients. However, there is no consensus on the upper age limit in the literature, and values ranging from 50 to 65 years have been suggested. Morbid obesity in patients aged 460 years is a real health problem, with more frequent weight-comorbidities [10–11], greater medication use, and a higher mortality rate [12–13]. A recent study reported that 10.1% of all bariatric operations in academic centers were performed on patients aged Z60 years [14]. However, several studies show that potential health benefits of bariatric surgery in this population must be considered afresh [15– 17]. The objective of the present single-center study was to evaluate the short-term and long-term postoperative outcomes for sleeve gastrectomy (SG), a safe and effective procedure, in a morbidly obese elderly population. Materials and methods The study population The present study was based on a retrospective review of the authors’ departments prospective database; to identify and assess all SG patients aged Z60 years (the elderly group, n = 42, accounting for 7% of the patients in the database) with full follow-up for at least 24 months. The elderly patients were matched 1:2 with another group of 84 patients aged o60 years (the control group). Preoperative, intraoperative, and postoperative data for all patients were analyzed retrospectively. Indication for surgery and preoperative assessment According to the French national guidelines [3], the indication for bariatric surgery was validated in a multidisciplinary care team meeting. Each patient underwent surgical consultations, a nutritional and dietary analysis, and respiratory, endocrine, and psychological assessments. Helicobacter pylori infections and hiatus hernia were screened for and ruled out in subsequently operated patients. Surgical procedures The authors’ intraoperative procedures for SG have been described elsewhere [18–19]. Laparoscopic SG was performed in all cases. Division of the vascular supply of the gastric greater curvatures was initiated 6 cm from the pylorus and proceeded upward to the angle of His by using the LigaSure Vessel Sealing System (Covidien, Norwalk, CT). A 34Fr gastric bougie was used for all SGs performed during the study period. The staple line was not reinforced. After stomach clamping, a methylene blue test was used to screen for staple line leakage. The patient was taken to a recovery room, and the nasogastric tube was removed upon
awakening. The authors’ hospital is a regional referral center for SG, and the operation can now be performed as an outpatient procedure for selected patients [20]; however, this was not the case for any of the patients in the present series. The postoperative management of complications (especially gastric staple line leakage, affecting 2.5% of the patients in the present series) [21] was validated for each individual patient by a specific, multidisciplinary team meeting (comprising a bariatric surgeon, a gastroenterologist, a nutritionist, and a radiologist). When weight loss at 24 months was judged unsatisfactory, gastric volumetry was performed to evaluate the need for repeat SG [22]. The residual gastric volume was defined as the volume between the gastroesophageal junction and the pylorus, after gastric distention with carbon dioxide. The case-matching procedure The matching procedure was performed manually with respect to demographic criteria (gender and body mass index [BMI]) and a number of obesity-associated co-morbidities (including type 2 diabetes mellitus, hypertension, dyslipidemia, and metabolic syndrome). The elderly patients (aged Z60 years; n ¼ 42) were matched 1:2 with another group of 84 patients aged o60 years (the control group). Type 2 diabetes mellitus was defined using criteria proposed by the American Diabetes Association, with a fasting blood glucose (FBG) level Z126 mg/dL or a blood HbA1c level Z6.5% (as confirmed by repeating the test on a different day) and/or the requirement for one or more antidiabetic medications. Arterial hypertension was defined as a blood pressure above 140/90 mm Hg. Dyslipidemia was characterized by elevated serum triglyceride levels (Z150 mg/dL), elevated serum small low-density lipoprotein cholesterol levels (Z160 mg/dL), and low serum HDL cholesterol (r40 mg/dL in men and r50 mg/dL in women). In daily practice, the authors use the National Cholesterol Education Program-Adult Treatment Panel III definition of metabolic syndrome (3 of the 5 following criteria are required: abdominal girth 488 cm in women or 4102 cm in men; systolic and diastolic blood pressures 4130 and 480 mm Hg, respectively; triglyceride levels above 150 mg/dL; HDL cholesterol levels o50 mg/dL in women and o40 mg/dL in men; and a FBG level above 110 mg/dL) [23]. Inclusion criteria Patients included in the study had to meet the following criteria: primary SG and BMI between 35 and 40 kg/m2 with obesity-related co-morbidities or BMI 440 kg/m2 with or without obesity-related co-morbidities. Patients with less than 24 months of follow-up and those undergoing surgical procedures other than primary SG were excluded from the study.
Sleeve Gastrectomy for Elderly Patients / Surgery for Obesity and Related Diseases ] (2015) 00–00
Endpoints and study design The primary objective was to compare weight change and the remission of co-morbidities in the 2 groups after 24 months of follow-up. The secondary endpoints were shortterm and midterm postoperative outcomes (operating time, the frequency of conversion to laparotomy, the length of hospital stay, postoperative complications, mortality, and the SG failure rate). Postoperative complications were graded according to the Clavien-Dindo classification [24] when they occurred within 90 days of surgery or at any time before discharge from hospital. Major complications were defined as Clavien grade 3 and 4 events. The quality of the outcome of SG was defined according to Reinhold’s criteria. Success, moderate effectiveness, and failure were defined as a percentage excess weight loss (%EWL) of 450%, 25%–50%, and o25%, respectively. Comorbidities were considered in remission when use of prescribed medication could be stopped, with normal serum values. Improvement of co-morbidities was not analyzed in this study. The remission of type 2 diabetes mellitus was defined as a normal FBG level, a normal HbA1c level (o6.5%), and the absence of antidiabetic drugs or insulin. The remission of dyslipidemia was defined as normal serum lipid values and the absence of cholesterol-lowering drugs. The remission of arterial hypertension was defined as normal blood pressure values and the absence of antihypertensive drugs.
Statistical analysis Patient characteristics were expressed as the mean (range) for continuous data and the percentage (number) for categorical data. Categorical data were analyzed with Pearson’s χ2 test. All statistical tests were performed with the SPSS software (version 18.0 for Windows, SPSS Inc., Chicago, IL). The threshold for statistical significance was set at P o .05. To assess the validity of results, the study’s
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power was determined post hoc. With a difference of 21.7% (73.5% less 51.8%), a one-side alpha risk of .05%, and a sample size of 126 patients, the power of the present retrospective series was .761. Results The study population The mean age was 62 years (range: 60–68 years) in the elderly group and 41.3 years (range: 22–59 years) in the control group. The mean BMI was 46.7 kg/m² (range: 37– 62.7 kg/m²) in the elderly group and 46.8 kg/m² (range: 37.3–63.7 kg/m²) in the control group. Demographic characteristics are summarized in Table 1. No significant intergroup differences were observed, other than for the rate of type 2 diabetes mellitus (64.3% in the elderly group versus 45.2% in the control group; P ¼ .05). Perioperative and postoperative data Perioperative and postoperative data are summarized in Table 2. There were no SG conversations to laparotomy in either group. No significant intergroup differences were observed in terms of the mean operating time (83 minutes in both groups, P ¼ .90) and the mean length of stay (3.2 in the elderly group versus 3.4 days in the control group, P ¼ .51). Forty patients (95%) in the elderly group and 76 patients (90%) in the control group presented uncomplicated postoperative courses. No significant intergroup difference in the morbidity rate (4.7% in the elderly group versus 9.5% in the control group, P ¼ .35) was observed. Major complications occurred in one patient in the elderly group (gastric leakage) and in 3 patients in the control group (2 cases of bleeding and 1 case of gastric stenosis). Lastly, significant intergroup differences were not observed in the need for revisional surgery (2.4% in both groups; P ¼ .99) or endoscopic management (4.8% in the elderly group versus 2.4% in the control group; P ¼ .48).
Table 1 Demographic characteristics of the study subgroups Characteristic
Elderly group
Control group
P value
Age, mean (range) Gender, % (n) BMI BMI 440, % (n) BMI 450, % (n) BMI 460, % (n) Number of co-morbidities Type 2 diabetes mellitus, % (n) Dyslipidemia, % (n) Hypertension, % (n) Obstructive sleep apnea syndrome, % (n) Metabolic syndrome, % (n)
62 (60–68) 45 (19) 46.7 (37–62.7) 88.1 (37) 23.8 (10) 4.8 (2) 2.5 (0–5) 64.3 (27) 42.8 (18) 57.1 (27) 40.5 (17) 50 (21)
41.3 (22–59) 23 (19) 46.8 (37.3–63.7) 89.3 (75) 25 (21) 7.1 (6) 2 (0–5) 45.2 (38) 40.5 (34) 46.4 (39) 34.5 (29) 35.7 (30)
o.01 .97 .90 .69 .85 .59 .11 .05 .84 .06 .54 .14
Abbreviation: BMI ¼ body mass index.
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Table 2 Surgical data and postoperative outcomes Elderly group Control group P value Operating time, min Length of hospital stay, days Postoperative complications, % (n) Major complications (Grade ¼ 3) Postoperative mortality, % (n) Revisional surgery, % (n) Endoscopic treatment, % (n)
83 (45–150) 3.2 (2–5) 4.7 (2) 1 0 2.4 (1) 4.8 (2)
83 (30–180) 3.4 (2–4) 9.5 (8) 3 0 2.4 (2) 2.4 (2)
.90 .51 .35
.99 .48
Weight change data after 24 months of postoperative follow-up The %EWL was significantly lower in the elderly group versus the control group at 3 months (32.7% versus 37.6%, respectively; P ¼ .01), 6 months (48.3% versus 59.3%, respectively; P o .01), 12 months (56.2% versus 71.4%, respectively; P o .01), 18 months (51.8% versus 77.1%, respectively; P o .01), and 24 months (51.8% versus 73.5%, respectively, P o .01) (Fig. 1). The SG success rate was significantly lower in the elderly group (17%, versus 66% in the control group; P o .01), whereas the moderate effectiveness rate was significantly higher in the elderly group (21%, versus 12% in the control group; P o .01). No significant intergroup difference was observed in the SG failure rate after 24 months of followup (4% in the elderly group versus 6% in the control group; P ¼ .66, Table 3). In univariate analyses, none of the following parameters was predictive of SG failure at 24 months: gender (25% versus 18% in the elderly and control groups, respectively; P ¼ .75), BMI 440 (100% versus 87%, respectively; P ¼ .44), type 2 diabetes mellitus (75% versus 63%, respectively; P ¼ .64), dyslipidemia (50% versus 42%, respectively; P ¼ .76), hypertension (25% versus 68%, respectively; P ¼ .08), and metabolic syndrome (50% in both groups; P ¼ 1). There was no significant difference in the %EWL at 24 months when
Table 3 Success, moderate effectiveness, and failure after 24 months of postoperative follow-up %EWL, % (n)
Elderly group
Control group
P value
450 25–50 o25
40.5 (17) 50 (21) 9.5 (4)
79 (66) 14 (12) 7 (6)
o.01 o.01 .66
Abbreviation: %EWL ¼ percentage excess weight loss.
comparing elderly diabetic patients receiving or not receiving insulin therapy (41.4% and 54%, respectively; P ¼ .25). The course of co-morbidities after 24 months of postoperative follow-up The remission rates of the various obesity-associated co-morbidities are detailed in Table 4. Unlike type 2 diabetes mellitus and metabolic syndrome, remission of hypertension were significantly lower in the elderly group than in the control group at 6 months after SG (0% versus 36%, respectively; P o .01); the same was true of metabolic syndrome (5% versus 47%, respectively; P o .01). However, at 24 months after SG, similar significant remissions of metabolic syndrome (95% versus 90%, P ¼ .55), type 2 diabetes mellitus (87% versus 71%, P ¼ .13), hypertension (81% versus 77%, P ¼ .71), and dyslipidemia (94% versus 74%, P ¼ .09) were observed in both groups. Discussion In view of concerns about the increased risk of anesthesia and less weight control efficacy, advanced age has been considered to be a relative contraindication to bariatric surgery. However, it appears that advanced age is not a contraindication for oncological procedures, such as total gastrectomy and pancreaticoduodenectomy. Although the prevalence of morbid obesity in the elderly is on the rise [25], surgery is performed less frequently in this population.
Fig. 1. Weight change data (%EWL) after 24 months of postoperative follow-up.
Sleeve Gastrectomy for Elderly Patients / Surgery for Obesity and Related Diseases ] (2015) 00–00 Table 4 Remission of co-morbidities after sleeve gastrectomy Co-morbidity, % (n) Elderly group Control group P value 6 months
Diabetes mellitus Hypertension Dyslipidemia Metabolic syndrome 12 months Diabetes mellitus Hypertension Dyslipidemia Metabolic syndrome 24 months Diabetes mellitus Hypertension Dyslipidemia Metabolic syndrome
17 (4) 0 (0) 31 (5) 5 (1) 62 (15) 61 (16) 68 (11) 74 (14) 87 (21) 81 (21) 94 (15) 95 (18)
34 36 32 47 66 64 56 77 71 77 74 90
(13) (14) (11) (14) (25) (25) (19) (23) (27) (30) (25) (27)
.13 o.01 .94 o .01 .79 .83 .38 .81 .13 .71 .09 .55
The present results confirmed that SG is feasible in patients aged Z60. There were no significant intergroup differences in the operating time (83 minutes in both groups; P ¼ .90), the mean length of stay (3.2 days in the elderly group versus 3.4 days in the control group; P ¼ .51), or the morbidity rate (4.7% versus 9.5%, respectively; P ¼ .35). The mean %EWL was significantly lower in the elderly group at 6 months (P o .01), 12 months (P o .01), and 24 months (P o .01). The literature data on this subject are heterogeneous. A few studies [12–13] have described elderly age, male gender, electrolyte disorders, and congestive heart failure as being independent risk factors for mortality after bariatric surgery. Other publications have considered elderly age as an independent risk factor for failure of postoperative excess weight loss. Contreras et al. [26] showed that the %EWL was higher for young patients (under the age of 45). Sugerman et al. [15] and St Peter et al. [27] reported that the %EWL was lower for elderly (aged Z60 years) patients. However, a number of recent studies of laparoscopic bariatric procedures have highlighted the safety and efficiency of bariatric surgery in the elderly population. These positive results may be due to improvements in laparoscopic surgical procedures and perioperative care. Hazzan et al. [28] and O’Keefe et al. [29] (in analyses of patients undergoing Roux-en-Y gastric bypass, adjustable gastric banding, and SG) described a low morbidity rate (7.3% at postoperative day 30) after bariatric surgery in an elderly population, with no postoperative deaths. Fatima et al. [30] observed a low mortality rate (.7% at postoperative day 30) for elderly (aged Z60 years) patients and young (r18) patients and concluded that in high-volume centers, bariatric surgery is safe and effective for patients with morbid obesity at both extremes of age. Publications on postoperative outcomes after SG in elderly patients are less common. Van Rutte et al. [1] did not observe significant differences in the 30-day complication rate (P ¼ .054) when comparing 3 age groups (55–59 years, 60–64 years, and 65 years and older). The short-term mortality rate was 0%. In a prospective analysis of 55
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patients undergoing SG (43 were aged o58 years and 12 were aged 459 years), Leivonen et al. [31] showed that older patients had a shorter operating time and a longer hospital stay (P 4 .05). Major, early-onset complications were more frequent in the older age group (42%, versus 9% in the younger group; P ¼ .02) but late complications were less common (17%, versus 44% in the younger group; P 4 .05). The main finding of the present study relates to the remission of obesity-related co-morbidities. To the best of the authors’ knowledge, there are few literature data on this subject. The present results showed that, 24 months after SG, the remission rates for metabolic syndrome, type 2 diabetes mellitus, hypertension, and dyslipidemia comorbidities were similar and statistically significant in both groups. These results show that SG can (1) reduce the cardiovascular risk, medication needs, and obesity-related mortality and (2) increase life expectancy for selected elderly patients. The present data agree with the report by Leivonen et al. [31], in which the co-morbidity remission rates at 12 months were similar in the elderly and control groups. However, some publications have considered elderly age as an independent risk factor for the failure of remission from obesity-related co-morbidities. St Peter et al. [27] described an average reduction of 1.7 co-morbid conditions in older patients and an average of 2.3 in younger patients (P ¼ .05). One year after surgery, Sugerman et al. [15] observed a greater improvement in hypertension and orthopedic problems (P ¼ .001) in a younger group than in an elderly group; however, there were no statistical significant differences in improvements in other obesity-related co-morbidities. Recently, the French SOFFCO registry [32] was screened for gastric bypass, gastric banding, or SG, to analyze weight loss and other postoperative outcomes in 164 patients aged Z60 years and 2444 patients aged o60 years. Unfortunately, the progression or improvement of obesity-related co-morbidities was not analyzed. The present results evidenced significantly lower weight loss after 24 months of follow-up in the elderly group, with no difference in the remission of obesity-related co-morbidities; this single-center, descriptive analysis was unable to explain this finding, and no potentially explanatory literature data could be found. A larger, prospective study with screening for multiple risk factors should be performed to address this issue. Conclusion Sleeve gastrectomy appears to be a safe, effective bariatric procedure for morbid obesity in patients aged Z60 years. Elderly and control patients had similar morbidity rates and co-morbidities remission rates after 24 months of follow-up, although weight loss was lower in the elderly group. Although direct comparisons with other bariatric
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procedures (mainly Roux-en-Y gastric bypass) should now be performed, SG appears to be a viable treatment option for obese elderly patients. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] van Rutte PW, Smulders JF, de Zoete JP, Nienhuijs SW. Sleeve gastrectomy in older obese patients. Surg Endosc 2013;27:2014–9. [2] NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med 1991;115: 956–61. [3] Gastrectomie Longitudinale [sleeve gastrectomy] pour obésité [monograph on the Internet]. Le Plaine, France: Haute Autorité de Santé; 2008. Available from: http://www.has-sante.fr/portail/upload/docs/ application/pdf/rapport_gastrectomie_longitudinale.pdf. [4] Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254: 410–20. [5] Péquignot A, Dhahri A, Verhaeghe P, Desailloud R, Lalau JD, Regimbeau JM. Efficiency of laparoscopic sleeve gastrectomy on metabolic syndrome disorders: two years results. J Visc Surg 2012;149:e350–5. [6] Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA 2014;149:275–87. [7] Brethauer SA, Aminian A, Romero-Talamás H, et al. Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Ann Surg 2013;258: 628–36. [8] Padwal R, Klarenbach S, Wiebe N, et al. Bariatric surgery: a systematic review of the clinical and economic evidence. J Gen Intern Med 2011;26:1183–94. [9] Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357: 741–52. [10] Han TS, Tajar A, Lean ME. Obesity and weight management in the elderly. Br Med Bull 2011;97:169–96. [11] Han TS, Wu FC, Lean ME. Obesity and weight management in the elderly: a focus on men. Best Pract Res Clin Endocrinol Metab 2013;27:509–25. [12] Flum DR, Salem L, Elrod JA, Dellinger EP, Cheadle A, Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294:1903–8. [13] Livingston EH, Langert J. The impact of age and Medicare status on bariatric surgical outcomes. Arch Surg 2006;141:1115–20. [14] Gebhart A, Young MT, Nguyen NT. Bariatric surgery in the elderly: 2009–2013. Surg Obes Relat Dis. Epub 2014 Apr 24.
[15] 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. [16] Soto FC, Gari V, de la Garza JR, Szomstein S, Rosenthal RJ. Sleeve gastrectomy in the elderly: a safe and effective procedure with minimal morbidity and mortality. Obes Surg 2013;23:1445–9. [17] Taylor CJ, Layani L. Laparoscopic adjustable gastric banding in patients Z60 years old. Obes Surg 2006;16:1579–83. [18] Kueper MA, Kramer KM, Kirschniak A, Königsrainer A, Pointner R, Granderath FA. Laparoscopic sleeve gastrectomy: standardized technique of a potential stand-alone bariatric procedure in morbidly obese patients. World J Surg 2008;32:1462–5. [19] Dhahri A, Verhaeghe P, Hajji H, et al. Sleeve gastrectomy: technique and results. J Visc Surg 2010;147:e39–46. [20] Billing PS, Crouthamel MR, Oling S, Landerholm RW. Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases. Surg Obes Relat Dis 2014;10:101–5. [21] Rebibo L, Blot C, Verhaeghe P, Cosse C, Dhahri A, Regimbeau JM. Effect of perioperative management on short-term outcomes after sleeve gastrectomy: a 600-patient single-center cohort study. Surg Obes Relat Dis 2014 Jan 9. (Epub). [22] Deguines JB, Verhaeghe P, Yzet T, Robert B, Cosse C, Regimbeau JM. Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure? Surg Obes Relat Dis 2013;9:660–6 [23] Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of The National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285:2486–97. [24] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. [25] Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States—no statistically significant chance since 2003–2004. NCHS Data Brief 2007;1:1–8. [26] Contreras JE, Santander C, Court I, Bravo J. Correlation between age and weight loss after bariatric surgery. Obes Surg 2013;23:1286–9. [27] 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. [28] Hazzan D, Chin EH, Steinhagen E, 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. [29] 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. [30] Fatima J, Houghton SG, Iqbal CW, et al. Bariatric surgery at the extremes of age. J Gastrointest Surg 2006;10:1392–6. [31] 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. [32] Ritz P, Topart P, Benchetrit S, et al. Benefits and risks of bariatric surgery in patients aged more than 60 years. Surg Obes Relat Dis Epub 2014 Jan 9.
