Laparoscopic Sleeve Gastrectomy in Patients Over 60 Years Old: A Long-Term Follow-Up

Abstract

Purpose:

This study analyzed the safety and effectiveness of laparoscopic sleeve gastrectomy (LSG) in patients over 60 years old, in a long-term follow-up, in a high-volume bariatric center.

Methods:

We retrospectively analyzed all patients older than 60 years who underwent LSG in our center from January 2009 to December 2018. A prospectively collected database of 4991 consecutive LSG cases was reviewed.

Results:

One hundred seventy-nine sleeve gastrectomy procedures were performed in patients older than 60 years, 135 were aged 60–65 years (group A) and 44 were older than 65 years (group B). We reported five cases (2.7%) of early complications: three postoperative hemorrhages, one cardial leakage, and one perigastric abscess. No thromboembolic events or mortality rates were reported. The mean follow-up period was 5.5 years (66 months). The follow-up loss rate was about 29%. At last follow-up, the mean body–mass index/body mass/percentage of excess weight loss values were, respectively, 33.7 ± 7/86.1 ± 21/60.4 ± 28.6 in group A and 32.4 ± 6.4/82.6 ± 18/61.8 ± 33 in group B. We reported 5 (4.0%) trocar site hernias, 1 (0.8%) cardial junction stenosis, and 22 (18%) new outbreaks of gastroesophageal reflux (GERD). There were 7 reinterventions (5.7%): 5 for weight regain and 2 for GERD not responding to medical therapy. There were no statistically significant differences between the two age groups.

Conclusions:

LSG is a safe and effective treatment for severe obesity in people over 60 years old. There are no differences in results of patients over 65 years and between 60 and 65 years old. Scales that include associated medical problems and the patient's general condition must be considered.

Introduction

The World Health Organization (WHO) has estimated a 10%–30% prevalence of obesity in the European adult population. It has been reported that severe obesity shortens life expectancy and decreases quality of life.^1–3 With global aging, obesity will increasingly affect the elderly population with increased risk of morbidity and mortality. Furthermore, aging increases the risk of complications of obesity, including cardiovascular disease, sleep apnea, and diabetes mellitus.⁴

Bariatric surgery is considered in the literature to be the most effective treatment modality with long-lasting effects, remission of associated disease processes, improved quality of life, and longevity.⁵ Despite this, advanced age (>65 years) has been widely considered a relative contraindication to laparoscopic sleeve gastrectomy (LSG) and other bariatric surgery procedures. This is due to concerns of increased perioperative risk and decreased efficacy in weight control.⁶

There are already other studies that have addressed this issue, but few have been conducted on patients over 60 years of age with long follow-ups and have focused on LSG.^7–11 Therefore, we designed this study to analyze the feasibility, safety, and efficacy of LSG in patients over 60 years and older than 65 years.

Methods

We retrospectively analyzed our prospectively collected database of patients undergoing LSG in our Department of General Surgery from January 2009 to December 2018. All patients over 60 years old who underwent LSG were included in the final study group. All patients over 65 years were assessed preoperatively by a multidisciplinary team, including preoperative behavioral management, psychological screening, and evaluation of medical comorbidities.

The inclusion criteria were the same as proposed by the International Federation for the Surgery of Obesity (IFSO), which are body–mass index (BMI) higher than 40 kg/m² or higher than 35 kg/m², severe associated medical problems (such as type 2 diabetes, hypertension (HT), obstructive sleep apnea syndrome [OSAS], or affected joints), and previous ineffective attempts at losing weight.

The exclusion criteria were severe eating disorders, severe psychiatric disorders, alcoholism, and anesthesiologic contraindications. Collected data included age, gender, BMI, excess weight, prior bariatric interventions, associated medical problems, and perioperative complications. Informed consent was obtained from all patients.

Data on the rate of weight loss, time for weight loss, remission of associated medical problems, revision of LSG, and complications were collected during clinic visits or with telephone surveys during the long-term follow-up. Outcomes of weight control were evaluated as change in BMI and percentage of excess weight loss (EW%L). EWL was calculated from the initial weight (global EWL).

Surgical technique

All procedures were performed by surgeons with a complete learning curve for bariatric surgery or under the supervision of an expert bariatric surgeon. Pneumoperitoneum was induced through a Veress needle placed in the left subcostal space. In all cases, sleeve gastrectomy (SG) was performed using 4 trocars, with the camera placed in the left subcostal space. The dissection started at a distance >3 cm from the pylorus. The great curvature was dissected and isolated from the gastrocolic ligament through an ultrasonic device or a radiofrequency sealer device.

The fundus and the esophagogastric junction were freed from the left pillar. If present, hiatal hernia was reduced and, eventually, hiatoplasty was performed. The gastric section was performed, starting a few millimeters away from a 38Fr orogastric bougie to avoid tissue stretching and incomplete closure of the stapler.

The choice of cartridges depended on the thickness of the tissue, according to the intraoperative perception and experience of the surgeon, because we know from anatomical studies that gastric thickness decreases from the bottom to the top and from the medial to lateral position.

Statistical analyses

Categorical variables have been described as counts and percentages and their sample distributions were compared with the chi-square test or Fisher's exact test. Continuous variables have been described as means and standard deviations (SDs) or medians and interquartile ranges. Their distribution within the groups was evaluated with the t-test or Wilcoxon rank sum test, according to the hypothesized distribution in the population.

Statistical significance was determined by considering a P value less than or equal to .05. All statistical analyses were performed using STATA15 software (Stata Corp LP, College Station, TX).

Results

From January 2009 to December 2018, 179 patients older than 60 years underwent LSG in our Department of General Surgery, of which 135 were aged between 60 and 65 years (group A) and 44 were aged 65 years and older (group B). Table 1 summarizes the preoperative characteristics of patients: the mean age was 62 years in group A and 67.5 years in group B (range 66–72 years) and mean preoperative BMI (±SD) was 44.9 ± 7.6 in group A and 42.2 ± 5.7 in group B. Four patients had undergone previous laparoscopic adjustable gastric banding, which was removed before LSG for weight regain.

Table 1.

Main Preoperative Characteristics

	Group A (60–65 years—n 135)	Group B (>65 years—n 44)	P
Sex (male/female)	31/104	12/32	.561^a
Age^b	62 ± 1.6	67.5 ± 2.2
Height^b	1.61 ± 0.09	1.60 ± 0.09	.89^c
Body mass^b	116.9 ± 24.5	109.4 ± 18.5	.07^c
BMI^b	44.9 ± 7.6	42.2 ± 5.7	.03^c
Osteoarticular diseases	60/135	21/44	.704^a
Obstructive sleep apnea syndrome	54/135	17/44	.213^a
HT	90/135	46/44	.817^a
Diabetes	36/35	23/44	.197^a
Drugs^d	3 (2)	4 (6)	.28^e
Previous LAGB	3/135	1/44	>.99^f

Chi-square test.

Values are mean ± SD.

Unpaired t-test.

Values are median (interquartile range).

Wilcoxon rank sum test.

Fisher's exact test.

BMI, body–mass index; HT, hypertension; LAGB, laparoscopic adjustable gastric banding; SD, standard deviation.

Early complications are shown in Table 2. Overall, we had five cases (2.7%) of early complications. Conversion to open surgery has never been necessary. We encountered 3 (1.6%) postoperative hemorrhages: 1 patient (group A) needed relaparoscopy and 2 patients were managed conservatively (1 in group A and 1 in group B).

Table 2.

Early Complications

	Group A (60–65 years—n = 135)	Group B (>65 years—n = 44)	P
Early complications	4/135 (3.7%)	1/44 (2%)	.99^a
Bleeding treated conservatively	1/135	1/44
Bleeding requiring surgical reintervention	1/135	0/44
Cardial leakage	1/135	0/44
Intra-abdominal abscess	1/135	0/44
Deaths	0/135	0/44
Thromboembolic events	0/135	0/44

Fisher's exact test.

We reported one cardial leakage (0.55%) treated with laparoscopic drainage and endoscopic placement of a self-expandable metal stent (SEMS) and one perigastric abscess (0.55%) treated with drainage surgery (both in group A). No thromboembolic events or mortality rates were reported.

Five patients died at least 2 years after surgery, from causes not attributable to the SG performed (3 in group A and 2 in group B): 2 patients died from cancer, 1 from respiratory failure after COVID-related interstitial pneumonia, and 2 from heart attack. A total of 52 patients were lost to follow-up (29%), these were lost because they did not attend their scheduled postoperative visits after the first year or mainly due to lack of telephone availability.

The mean follow-up period was 5.5 years (66 months); follow-up was over 5 years for 44 patients (48%) in group A and 18 patients (58%) in group B. Table 3 shows that at the last follow-up, the mean BMI/body mass/EW%L (±SD) values were, respectively, 33.7 ± 7/86.1 ± 21/60.4 ± 28.6 in group A and 32.4 ± 6.4/82.6 ± 18/61.8 ± 33 in group B, without statistically significant differences between the two age groups. Related diseases and the number of drugs taken at the last follow-up are shown in Table 3, without significant differences.

Table 3.

Follow-Up

	Group A (60–65 years—n 91)	Group B (>65 years—n 31)	P
Follow-up time,^a months	67 ± 28	64.6 ± 21	.66^b
Body mass^a	86.1 ± 21	82.6 ± 18	.41^b
BMI^a	33.7 ± 7	32.4 ± 6.4	.36^b
EW%L^a	60.4 ± 28.6	61.8 ± 33	.82^b
Osteoarticular diseases	35/91	17/31	.73^c
Obstructive sleep apnea syndrome	9/91	5/31	.56^d
HT	43/91	23/31	.30^c
Diabetes	17/91	9/31	.64^d
Drugs^e	2 (3)	3 (4)	.73^f
Time to lose weight,^e months	10.9 ± 6.2	13.1 ± 6.8	.12^b
Late complication	5/91	1/31	.33^d
Esophageal stricture	1/91	0/31
Incisional hernia	4/91	1/31
New GE reflux	18/91	4/31	.589^d
Resurgery^g	6/91	1/31	.667^d
Due to GE reflux	2/91	0/31
Due to weight regain	5/91	1/31
Gastric bypass	2/91	0/31
Resleeve gastrectomy	5/91	1/31

Values are mean ± SD.

Unpaired t-test.

Chi-square test.

Fisher's exact test.

Values are median (interquartile range).

Wilcoxon rank sum test.

A patient first underwent a resleeve procedure for weight recovery and then a gastric bypass for GE reflux.

BMI, body–mass index; EW%L, percentage of excess weight loss; GE, gastroesophageal.

We observed that 57% of the patients analyzed in the follow-up had a reduction in the number of related diseases, 38% maintained the same amount, and only 5% had an increase in their count. Time to reach minimum BMI was longer in the older group (13.1 ± 6.8 versus 10.9 ± 6.2 months).

Five patients (4.0%) developed trocar site hernias (4 in group A and 1 in group B), 1 patient developed a cardial junction stenosis complicated with esophageal candidiasis and was treated with medical therapy and endoscopic placement of SEMS. One patient of group A underwent total gastrectomy after finding gastric carcinoma, which was not present in preoperative checks. In our follow-up, 22 new outbreaks of gastroesophageal reflux (GERD) were detected (18%): 18 in group A and 4 in group B (P = .58).

During the follow-up, 7 patients (5.7%) required revisional surgery: 6 in group A and 1 in group B (P = .667). Six patients (5 in group A and 1 in group B) underwent re-SG for weight regain and one of them required a new revisional surgery (conversion to Roux-en-Y gastric bypass [RYGB]) for development of GERD not responding to medical therapy. One other patient underwent RYGB for the presence of GERD not responding to medical therapy.

We conducted subanalyses to see if there were any conditions associated with reduced weight loss. We verified that patients older than 65 years (group B), with BMI greater than 45, and with diabetes had a statistically significant (P = .0098 with rank sum test) reduced weight loss compared with the remaining patients in group B.

Discussion

Obesity in the elderly is increasing in incidence and is linked to an increase in comorbidities and reduction in life expectancy. It has been reported that between the ages of 65 and 75 years, 33% of men and 39% of women are affected by obesity.¹² International guidelines describe an upper limit of 65 years with the possibility of exceptions only in selected cases. The aim of this study is to demonstrate the safety and effectiveness of SG in patients over 60 years old.

In our Department of General Surgery, 4991 LSG procedures were done from January 2009 to December 2018, of these, 179 patients were over 60 years of age. There were 44 patients aged over 65 years; before surgery, all patients underwent meticulous evaluation by a multidisciplinary team. We therefore considered group A with patients between the ages of 60 and 65 years and group B with patients aged older than 65 years.

Even if the two groups differed in terms of BMI with statistical significance, the slight entity could be considered with clinically irrelevant impact. It also emerged that the older population took more medications than the younger population (on average one more), probably because age is directly related to increased comorbidities and the need for drug therapy. The average follow-up was greater than 5 years, which is a long time compared with other studies in the literature on the subject, and the rate of loss to follow-up was around 29%.

Our results show a body mass reduction with an average BMI of less than 35 and excess weight loss (EW%L) of more than 60% in the two age groups. The intervention was effective in reducing comorbidities, also in the group over 65 years of age, with no significant differences with the other group. The reduction in comorbidities is also supported by reduction in the number of drugs, defined as the number of different drugs.

Our analysis agrees with other studies in the literature. Vallois et al. published a meta-analysis on bariatric surgery in patients over 60 years old⁷ and they showed improvement in comorbidities (diabetes, HT, OSAS, and hyperlipidemia) in patients over 60 years of age and in those younger, with no significant differences. Caceres et al. found the same result and concluded that obesity surgery has a positive effect on the quality of life of elderly patients because obesity surgery can provide treatment for comorbidities.¹³

Prasad et al. published a propensity-matched cohort study that demonstrated significant weight loss and diabetes resolution in patients over 60 years old undergoing bariatric surgery compared with those treated medically. This means a higher rate of long-term survival in surgically treated patients compared with medical management.¹⁴

Giordano S and Salminen P, in a recent meta-analysis, found no significant differences in remission of diabetes, HT, and hyperlipidemia between age groups, while they found a significantly higher remission/improvement rate of OSAS in younger patients.¹¹ Andrés Navarrete, in his study, also showed no statistical difference in the resolution of all comorbidities, except for OSAS in the younger group.¹⁵

Our results show that patients over 60 years of age reached the minimum body mass after 1 year in most cases. We identified only a small difference between the two groups considered, observing that patients older than 65 years reached their minimum body mass 2 months later than patients between 60 and 65 years of age. This follows the literature according to which older patients have a lower tendency to lose weight.^11,16

Carlos Rodriguez-Otero Luppi, in his study, reported that at 12 months after surgery, older patients (over 60 years) had lost 49% of excess weight compared with 60% in the younger group, whereas at 2 years, the results were 45% versus 60%, respectively.¹⁷

Natalia Dowgiałło-Wnukiewicz et al., in a 2020 study, matched 89 patients older than 60 years undergoing LSG with 89 younger patients (aged 18–40 years) according to BMI and comorbidities. They found no differences in the resolution of comorbidities, but showed better weight loss results in younger patients than in older ones.¹⁸

Aurelien Pequignot et al., in a similar case-matched study with 24 months of follow-up, compared 42 patients older than 60 years with 84 younger patients and found the same result.¹⁹

Vallois et al. reported that the EWL at 1 year and the EBMIL at 2 years were significantly reduced in patients older than 60 years.⁷ Vallois et al. explained in their meta-analysis that patients over 60 years of age may have a lower tendency to lose weight due to lower physical activity and slower metabolism, although this has not been clarified at present.

Nevertheless, it has been reported that obesity-related comorbidities can be reversed even with modest weight loss of 5%–10%.^20,21 Thus, despite less weight loss, there is a strong reduction in comorbidities leading to longer life expectancy.

In another study by Garofalo et al., it was observed that a BMI >45 kg/m² associated with type 2 diabetes mellitus leads to insufficient weight loss or weight regain in patients aged ≥65 years.²²

In our study, we verified that patients older than 65 years (group B) with BMI greater than 45 and with diabetes had a statistically significant (P = .0098 with the rank sum test) weight loss compared with the remaining patients in group B. These results suggest that SG for these patients is not the best choice and that better results could be achieved with Roux-en-Y Gastric Bypass (RYGBP).

Possible postoperative complications after LSG are anastomotic leakage, intra-abdominal abscess, and thromboembolic and hemorrhagic events. Our data showed a low incidence of these early complications, with no significant differences between patients older than 65 years and those aged 60–65 years.^23,24 None of our patients died in the first year after surgery.

Vallois et al. showed a 1-year mortality of 0.2% in all age groups. Their leak rate was 0.6% in patients over 60 years of age, which is in agreement with our study (1 leak in 179 patients, 0.56%). The intra-abdominal abscess rate was 0.47% in patients over 60 years old, as in our study where it is 0.6%. The bleeding rate is 0.88%, while in our study it is higher (1.7%).⁷ After bariatric surgery, long-term complications such as malnutrition, GERD, laparoceles, cholelithiasis, and intestinal obstructions may occur.

In the literature, many studies discuss these complications and have shown a comparison of possible bariatric surgery techniques.^25–27 We chose to investigate SG in detail. However, elderly populations deserve higher attention, and further research is encouraged to compare the possible bariatric procedures and options, with specific attention to the connected postoperative complications.

In our study, we found a low rate of long-term complications. A higher incidence of trocar site hernia was observed for patients between the ages of 60 and 65 years, probably related to the greater physical activity of these patients compared with the elderly. GERD remains the most frequent long-term complication in the elderly population, but required revisional surgery only in rare cases.

Hajer et al., in 2018, compared two age categories (19,786 patients younger than 60 years and 1771 patients older than 60 years) after LSG and found no difference in short-term mortality and intraoperative complications; however, they found that patients aged 60 years had a greater statistically significant difference in general postoperative complications than younger patients. They associated this difference with the greater number of comorbidities present in the older population.²⁸

Mizrahi et al. also reported a higher rate of early complications in patients over 60 years of age, highlighting cases of pulmonary embolism, surgical site infection, urinary tract infection, hemorrhage, and arrhythmia.²⁹

Leivonen et al. reported a higher complication rate in elderly patients (> 59 years), while younger patients (<59 years) showed a higher rate of late complications.³⁰ Instead, Benotti writes that although elderly people have more comorbidities associated with being overweight, and thus are suspected to be at higher surgical risk, there is no link between age and complication rates.³¹

In contrast to these studies, an analysis by Giordano et al. of patients over 60 years of age was able to show that surgery is not associated with increased mortality or higher risk of complications compared with younger patients.³² The same conclusions were drawn by Dorman in a study that analyzed data from 48,378 patients (older than 65 years and with a BMI of 35 kg/m²) between 2005 and 2009.³³

As can be deduced from these studies, there is no common agreement on the possible difference in complications between the young and elderly population. Our study, in agreement with that of van Rutte, concludes that complications do not vary between the age group of 60–65 years and age group older than 65 years.³⁴

For these analyses, it is necessary to consider the hospital where the operations are performed; a center with little experience in bariatric surgery may have a higher complication rate for the elderly population than for the young. SG has increased in popularity due to its proven effectiveness in achieving considerable weight loss and comorbidity resolution without increasing the risk of complications.

There are some studies that have compared LSG with RYGB in the elderly population.^35,36 Abbas et al. evaluated the effectiveness of the 2 surgical procedures in 83 patients over the age of 60 over a period of 4 years and found no significant differences in the incidence of early complications and mortality between the 2 groups.³⁷ Spaniolas et al. and Thaher et al. suggested the same in their studies.^38,39

Omer Thaher, in his study, analyzed data from 3561 patients over 60 years of age who underwent LSG (1970 patients) and RYGB (1591 patients); he concluded that the 2 surgical procedures did not show significant differences in terms of postoperative pulmonary, renal, and cardiac complications and in terms of 30-day mortality.³⁹

In opposition to these studies, a recent meta-analysis by Xu et al., including 19 studies, suggested that LSG is a preferable surgical alternative to RYGB for patients over 60 years of age as early and late complication rates after RYGB were much higher than those after SG. However, there may be bias due to inclusion of both laparoscopic and open surgery. They showed that weight loss at 1 year would be better after RYGB than SG in patients over 60 years of age, but the results become similar at 2 and 3 years.⁴⁰ Soto et al. also recommended LSG for its lower overall complication rate (8.4% versus 20.4% for gastric bypass).⁴¹

Some limits should be taken into account for further consideration. Retrospective data collection may have introduced some biases and the single-centre nature of our study prevents generalisation of results to other Centres. Moreover, our loss to follow-up (29%) may have led to other biases. Finally, the modest sample size included requires confirmation in larger cohorts, especially in consideration of some less frequent complications that were not detected by our study.

However, this study has the value of considering a long follow-up period and of having been conducted in a reference center for bariatric surgery with high quality standards.

Our study suggests that age limit alone cannot negate bariatric surgery; for patients over 60 years of age, scales based on specific comorbidities and preoperative functional status should be considered for better patient management. Gondal et al., in an observational study, suggested the use of a frailty index score, especially in patients older than 60 years, because it correlated with adverse outcomes at 30 days after bariatric surgery.⁴²

Conclusions

LSG can be used as a safe and effective surgical method in patients aged 60 years or older than 65 years. According to our data, there is no difference between LSG patients aged between 60 and 65 years and those over 65 years; instead, studies should be conducted to identify indication scales for patients over 60 years of age, which include patients' comorbidities and general condition.

Footnotes

Authors' Contributions

A.D., A.A.G.Z., F.C., and S.O. were involved in conception and design. A.D., A.A.G.Z., F.C., A.O., R.V., and S.O. were involved in analysis and interpretation. A.D., A.A.G.Z., F.C., A.O., R.V., and S.O. were involved in data collection. A.D., A.A.G.Z., C.A., and S.O. were involved in writing the article. A.D., A.A.G.Z., C.A., and S.O. were involved in critical revision of the article. A.D., A.A.G.Z., F.C., A.O., R.V., C.A., and S.O. were involved in final approval of the article. C.A. was involved in statistical analysis.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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