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Laparoscopic sleeve gastrectomy in patients over 60 years: Impact of age on weight loss and comorbidity improvement Carlos Rodríguez-Otero Luppi MD, Carmen Balagué MD PhD, Eduard M. Targarona MD PhD, Sorin Mocanu MD, Jesús Bollo MD, Carmen Martínez MD, Manel Trias MD PhD www.elsevier.com/locate/buildenv

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S1550-7289(14)00224-X http://dx.doi.org/10.1016/j.soard.2014.05.021 SOARD2019

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Surgery for Obesity and Related Diseases

Cite this article as: Carlos Rodríguez-Otero Luppi MD, Carmen Balagué MD PhD, Eduard M. Targarona MD PhD, Sorin Mocanu MD, Jesús Bollo MD, Carmen Martínez MD, Manel Trias MD PhD, Laparoscopic sleeve gastrectomy in patients over 60 years: Impact of age on weight loss and comorbidity improvement, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2014.05.021 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Laparoscopic sleeve gastrectomy in patients over 60 years: Impact of age on weight loss and comorbidity improvement

Carlos Rodríguez-Otero Luppi MD Carmen Balagué MD PhD Eduard M. Targarona MD PhD Sorin Mocanu MD Jesús Bollo MD Carmen Martínez MD Manel Trias MD PhD

General and Digestive Surgery Unit Hospital de la Santa Creu i Sant Pau Sant Antoni Maria Claret, 167 08025 Barcelona, Spain. Tel: + 34 93 291 90 00

Short Title: Laparoscopic sleeve gastrectomy in patients over 60 years

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Background: Advanced age has traditionally been considered a relative contraindication to bariatric surgery due to increased perioperative risk and less weight loss. However, it is now being reconsidered in older patients following encouraging results in recent series and the increasing life expectancy.

Objective: We compared operative and postoperative outcomes of laparoscopic sleeve gastrectomy in patients over 60 years with outcomes in younger patients. We also, analyzed the impact of bariatric surgery on improvement and resolution of comorbidities in the older group.

Setting: Hospital, Spain

Methods: From November 2008 to November 2013, 130 patients underwent laparoscopic sleeve gastrectomy. Of these, 28 patients (21.5%) were 60 years or older. Outcomes in terms of perioperative complications, short-term and medium-term weight loss, remission or improvement of comorbidities and medication requirements were extracted from our prospective database.

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Results: Short-term mortality was 0% and thirty-day complication rate was similar in both groups (17.9% vs 17.6% according to Clavien-Dindo classification). At 12 months post-surgery, older patients had lost 49% percent of excess weight compared to 60% in the younger group (p=0.012). At 2 years the results were 45% vs 60% respectively with p=0.015. At least one major comorbidity improved in 65.2% of older patients. Before surgery, the older group took an average of 4.3 medications compared to 2.7 at 1 year after surgery (p 35 kg/m2 and less than 50% of excess weight loss at 1 and 2 years after surgery)[9].

Before and after surgery, we analyze the four most commonly studied obesity-related comorbidities: hypertension, adult onset diabetes, hyperlipidemia and sleep apnea. These comorbidities were confirmed by the corresponding clinical specialist. Each comorbidity, was recorded as present or absent before surgery and unchanged, improved or reduced after surgery. Remission of diabetes was defined as suspension of anti-diabetic medications by the endocrinologist, HbA1c levels less than 6.5% and fasting blood glucose below 126 mg/dl. Remission of hypertension was defined as blood pressure of at least 140/90 mm Hg with cessation of antihypertensive drugs by the primary care physician. Remission of 6

hyperlipidemia was considered when LDL cholesterol levels were below 160 mg/dL and triglycerides below 200 mg/dl without medication. Remission of sleep apnea was defined as the discontinued need for continuous positive airway pressure (CPAP) confirmed with polysomnography. The number of medications (including need for CPAP) used to treat these four specific conditions was also recorded before and after surgery.

Statistical analysis: Using a cohort analysis, we compared two groups: one consisting of patients aged under 60 years, and the other with patients of 60 years and older. Chi-square tests were used to compare categorical data, and T-tests were used to compare continuous variables between groups. Statistical calculations were performed with SPSS® (v 17.0, SPSS Inc, Chicago, IL, USA). A p value less than 0.05 was considered statistically significant.

RESULTS

A total of 130 patients were identified, 28 (21.5%) of whom were 60 years or older. All interventions were attempted and completed laparoscopically. Patients´ characteristics are shown in Table 1. The average age of patients in the younger group was 45.2 years (range 21-59) compared to 63.2 years (range 60-68). There were no significant differences between sexes in either groups. There was more females in each group. 7

Operative mortality was 0% and the 30-day complication rate was similar in both groups (17.9% vs 17.6%, according to Clavien-Dindo classification) without significant differences (Table 2). The most serious complications were 2 hemoperitoneum and 2 staple line leaks, all requiring surgical reintervention. Of these four reoperations (3.1% of the total), only one patient - a 65-year-old male who was hemodynamically unstable because of a massive hemoperitoneum - required a laparotomy. The other three reinterventions (all patients in the younger group) were approached laparoscopically. The remaining significant complications were a surgical site infection that was favorably treated percutaneously (a patient from the younger group) and two perigastric hematomas (one from each group). Three patients (two in the younger group and one older patient) developed pulmonary complications (pneumonia). There were no differences in operative time (109.2 minutes vs 98.4 minutes; p=0.588). Median length of stay (LOS) was 2 days (2-8 days) in the older group vs 2 days (2-67 days) in the younger group. Average LOS was 2.8 +/- 1.4 days in the older group vs 3.5 +/- 6.6 days in the younger group (p=0.421). The longer average LOS in the younger group could be explained by the need of hospitalization of 67 days in one of the younger patients who had staple line leak. As seen in Table 3, preoperative differences were observed in total weight between groups (113.2 kg in older patients vs 126 kg in younger patients, p=0.002), BMI (43.3 vs 45.8 kg/m2, p=0.049) and overweight (56.7 vs 60.5 kg, p=0.001). At 12 months postsurgery, we observed that patients aged 60 or more had a percent excess weight loss (%EWL) of 49% compared with 60% of those younger (p=0,012). Mean BMI value was 32,8

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kg/m2 vs 31,5 kg/m2 respectively (p=0.338). At 2 years the results were similar (45% vs 60% with p=0,015, and BMI 33,2 vs 31,5, p=0.277). In terms of failure of the procedure (according to Reinhold score) 7 patients in the older group (30%) at 1 year did not attain the objectives compared with 11 (14%) in the younger group (p

Laparoscopic sleeve gastrectomy in patients over 60 years: impact of age on weight loss and co-morbidity improvement.

Advanced age has traditionally been considered a relative contraindication to bariatric surgery due to increased perioperative risk and less weight lo...
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