Laparoscopic Gastric Banding in Over 60s
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- Clough, A., Layani, L., Shah, A. et al. OBES SURG (2011) 21: 10. doi:10.1007/s11695-010-0158-3
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The aggressive pursuit of weight loss in the elderly remains a controversial objective. In this series of 113 patients over 60 years of age who underwent laparoscopic gastric banding surgery, we report on complications, co-morbidity change, quality-of-life improvement and changes in medication use over a median follow-up period of 25.5 months.
A prospectively kept database was reviewed from January 1999 to September 2008 identifying patients over 60 who underwent gastric banding surgery. Baseline and follow-up SF-36® survey scores were compared longitudinally. Co-morbidity change and medication use were assessed by questionnaire and electronic record review.
Major complications were experienced by 7.1% over the follow-up period with a re-operation rate of 15.0%. Excess BMI loss was 44.1% after 5 years and combined mean SF-36® quality-of-life scores (out of 100) improved 22.1 points, achieving parity with age-matched norms for the general population. Diabetes improved in 74.2% with hypertension, hyperlipidaemia and depression improving in 57.1, 51.1 and 35.9% of cases. A significant drop in medication use was not seen, and cancer was responsible for three deaths over the follow-up period. No surgical mortality was incurred.
Laparoscopic gastric banding can markedly improve quality of life for morbidly obese over 60s. Health gains are significant, but medication use is not substantially altered. Gastric banding is an ideal weight loss operation for this age group due to its safety and efficacy, and the primary goal should be quality-of-life improvement.
KeywordsGastric bandingLongevityObesityObeseElderlyOver 60Weight lossQuality of lifeBariatric surgery
Over 20% of Australians aged over 60 are obese  (body mass index (BMI) ≥ 30 kg/m2), and in the United States this figure has been quoted at over 35% . These numbers are likely to rise in the foreseeable future  as will the proportion of the population over 65 in these countries and many others . Obesity is a major contributor to the metabolic syndrome, obstructive sleep apnoea, arthritis, psychosocial dysfunction, urinary incontinence and several types of cancer .
Whilst surgery for weight loss is an accepted intervention for selected individuals, it remains a controversial area for the elderly with goals less easily defined than those of younger patients. Weight loss can be associated with decreased lean body mass and bone demineralisation, which may predispose to hip fracture in older patients . A high BMI may even be protective in some patients, for example, those with congestive heart failure according to recent publications . McTigue et al.  are of the opinion that no amount of weight loss will allow older patients to forgo all pharmacotherapy for their cardiovascular risk factors.
But many overweight elderly have trouble performing basic personal activities such as bending over, managing stairs, carrying groceries, showering and maintaining personal hygiene. Obesity accelerates lower limb arthritis , which impacts on flexibility and general mobility. These physical impediments threaten independence and effective social functioning.
Whilst a number of studies demonstrate significant quality-of-life (QOL) improvements in younger cohorts after laparoscopic gastric banding (LGB) surgery [8–14], there is less information available on QOL changes specific to elderly patients after this operation. It would be useful to know that QOL gains and co-morbidity improvements can still be achieved in elderly patients with LGB, who are likely to lose less excess weight from surgery than their younger counterparts [3, 15–17].
This study updates our previous series of patients over 60 undergoing LGB surgery  and is one of the largest published series to date looking at bariatric surgery in this age group.
A single surgeon’s (Dr Layani) clinic and hospital records were examined between 1999 and 2008 to identify any patient who had received LGB surgery over 60 years of age. As well as these records, the LapBase® (Accessmed, Melbourne) bariatric database was searched. A subject was included in the banded group if they were over 60 years of age at the time of LGB surgery and had at least 3 months follow-up since the time of operation.
We collected information on demographics, baseline co-morbidities, hospital and ICU stay, BMI and medications. Early and late complications were assessed from clinic records, hospital charts, questionnaire and interview in some cases. A baseline SF-36® QOL questionnaire was available for all subjects attending the clinic from 2003 onwards.
Gastric banding was performed laparoscopically in every case, and the pars flaccida technique was used. Both the Lap-Band System (Inamed/Allergan, Irvine, CA) and the Swedish adjustable gastric band (SAGB®, Obtech, Ethicon Endo-Surgery) were used in about equal proportions, with the SAGB® system in use almost exclusively during the last 2 years of the study. Patients who had bands removed at a later date were not excluded for the purpose of statistical analysis.
All patients were sent a follow-up SF-36® QOL questionnaire and a purpose-designed Wellbeing Questionnaire to document co-morbidity changes, medications, weight and questions relating to success of the band. Co-morbidity improvement or decline was assessed by self-report and by change in medication use. SF-36® QOL scores for eight categories were compared against published norms in the non-obese, well population of similar age. Subjects failing to return questionnaires were contacted by phone where possible and invited to complete the questionnaires verbally. The Registries of Births, Deaths and Marriages in the states of Queensland and New South Wales performed death record searches for all un-contactable patients.
SF-36® response variables were not normally distributed, and the Wilcoxon signed-rank test for dependent samples was utilised to compare baseline to follow-up values. All statistical analyses and graphs were produced using Microsoft® Office Excel® 2007 with the add-in software WinSTAT® for Microsoft Excel®. All analyses were performed at a significance level of p = 0.05.
Mean age (years)
Mean weight (kg)
Mean BMI (kg/m2)
Median follow-up (months)
Meds taken per patienta
Baseline co-morbidity details available
Diabetics (all type II)
Diabetics on insulin
Suffer back pain
Suffer hip/knee pain
Complete follow-up surveys were obtained from 85/113 (75.2%) subjects, 6/113 (5.3%) declined to respond, leaving 22/113 (19.5%) un-contactable for follow-up.
Early and Late Complications
Complications from gastric banding surgery
Subjects with at least one complication
Complications per subject affected
Slipped band—re-operation (2)
Gastric obstruction—re-operation (2)
Acute gastric dilatation
Cardiac arrhythmia—ablation procedure
Recurrent aspiration pneumonia
All port-related complications
All infectious complications
Total re-operations related to banding
Over the follow-up period, 7/113 (6.2%) patients had their band removed. Of these, five removals were for general band intolerance without a specific reversible complication. There was no early mortality.
Two scored SF-36® categories refer to mental and emotional health. “Role-Emotional” demonstrated a particularly large improvement with mean scores moving from 58.5 to 89.6 (population norm 80.3) at follow-up. “Mental Health” scores also increased above published norms.
A healthy improvement is likewise seen in the one scored parameter related to “Social Functioning”.
Back and lower limb pain were common ailments in this group, affecting approximately two thirds of the baseline cohort. Back pain was “Better” or “Much Better” in 42.0% of the band group on follow-up and hip/knee pain improved in 34.0%.
Self-reported change in co-morbidities and medication use with time
Less medsa (%)
More medsb (%)
Mean number of medsc
Apart from diabetics, in whom 43.8% of patients reported using less medication (and 18.8% more medication), there was not a marked drop in medication use in either group. When assessed quantitatively, the mean number of medications per patient for diabetes used actually increased from 0.35 to 0.43, although drug dosages were not taken into account, and the difference was not statistically significant.
Over the follow-up period three patients died, all due to cancer.
This is a case series produced from prospectively kept records and a bariatric database with longitudinal follow-up. Good quality baseline information was available including SF-36® QOL surveys on each patient since 2003.
Quality of Life
Marked improvement in QOL after LGB surgery in the obese elderly is the key positive finding of this study.
QOL gains were seen in all eight categories of the SF-36® with banded patients achieving parity with published population norms for non-obese individuals . These marked QOL gains were seen in this elderly cohort group despite achieving EBMIL of less than 50%. The effect of LGB on reducing depression and improving self-esteem has been well documented [20–22], and this effect holds true in the elderly according to our data. Back and lower limb pain, common maladies in this age group, improved significantly.
Weight Loss and Health
It is not surprising that excess weight loss after bariatric surgery in the elderly is less than in younger cohorts [20, 23]. These patients are usually retired from work and frequently have lower limb arthritis or medical problems which preclude heavy exercise. At least one patient in this study was confined to a wheelchair. Those patients admitting to Hip/Knee pain at baseline appeared to lose less weight than those free of pain (mean %EBMIL of 42.5 vs. 52.5%, p = 0.064).
Co-morbidity change is in line with previous studies showing significant improvements in diabetes, hypertension, hyperlipidaemia and sleep apnoea after LGB [8, 15, 20]. However, there did not appear to be a substantial decrease in medication use after surgical intervention. It is difficult to know how to interpret this in light of considerable self-reported improvements. Despite losing weight after surgery, patients continue to age and we presume that it is more difficult to dispense with medications as the seventh and eight decades are reached. Many elderly patients with normal BMIs take numerous tablets.
Safety and Complications
In this elderly group, despite high levels of co-morbidity, medical complications were uncommon (4.4%). ICU stay was short when required, and overall hospital stay averaged less than 2 days.
Reported complications after gastric banding surgery in the elderly
Age studied (years)
Nehoda et al. 
Silecchia et al. 
Varela et al. 
Taylor et al. d
Busetto et al. e
Mittermair et al. 
Clough et al. (this study)
A similar number of reports are available looking at Roux-en-Y Gastric Bypass (RYGB) in the elderly including case series with n < 100 [3, 16, 27, 28] and two nationwide reviews [29, 30] both with n > 1,300. In the smaller series, early and late major complications range from 6.1% to over 15% and mortality of 0 to 1.6%. In the larger reviews, bariatric surgery was considered as a whole with the majority of cases RYGB. Mortality for the elderly ranges from 0.7 to 4.8%, although a subset of 300 RYGB performed between 2004 and 2005 produced 0% mortality.
Given the impressive QOL improvements from LGB demonstrated in this paper, any further benefits bestowed by more complex operations may be offset by the surgical risk faced by this age group. Aggressively pursuing greater degrees of weight loss in this demographic is unlikely to translate into improvements in longevity and may not decrease the need for medication as much as in younger groups.
Elderly patients seeking weight loss surgery are different from younger patients, with higher rates of co-morbidities, reduced exercise potential and less prospective life span. The decision to offer bariatric surgery in these patients is complicated by findings in several studies of a possible protective role of excess fat in some demographics. Weight loss is associated with a decrease in lean body mass and may decrease bone mineralisation and predispose patients to fracture. We recommend that any elderly patient choosing to undergo bariatric surgery do so only after careful discussion and incorporation of a tailored diet and exercise programme with a primary focus on quality-of-life improvement.
Laparoscopic gastric banding in appropriately selected obese patients over 60 years of age can markedly improve quality of life in each of physical, mental, emotional and social contexts. The procedure is safe and well tolerated in this age group and leads to improvements in medical co-morbidities, although significant medication reduction was not shown in this study. We believe that laparoscopic gastric banding is the most appropriate bariatric procedure for this age group due to its inherent safety and proven efficacy.
Conflicts of Interest