Obesity Surgery

, Volume 21, Issue 8, pp 1180–1187

Laparoscopic Sleeve Gastrectomy in Patients over 59 Years: Early Recovery and 12-Month Follow-Up

Authors

    • Department of SurgeryHelsinki University Central Hospital
    • HUCHPeijas Hospital
  • Anne Juuti
    • Department of SurgeryHelsinki University Central Hospital
    • HUCHPeijas Hospital
  • Nabil Jaser
    • Department of SurgeryHelsinki University Central Hospital
    • HUCHPeijas Hospital
  • Harri Mustonen
    • Department of SurgeryHelsinki University Central Hospital
    • HUCHMeilahti Hospital
Clinical Research

DOI: 10.1007/s11695-011-0454-6

Cite this article as:
Leivonen, M.K., Juuti, A., Jaser, N. et al. OBES SURG (2011) 21: 1180. doi:10.1007/s11695-011-0454-6

Abstract

Background

Bariatric surgery has shown to be safe for patients over 60 years with good results especially considering resolving of comorbidities. Sleeve gastrectomy is considered to be safer than gastric bypass (GBP) and more effective than gastric banding with less adverse symptoms. Weight loss may be more modest than after GBP, but the effect on vitamins may also be milder.

Methods

Since 2007, we collected prospectively 12-month follow-up data from 55 sleeve gastrectomy patients of whom 12 were over 59 years of age. Vitamin and calcium supplements were used postoperatively. The recovery from the operation was recorded during hospital stay, at 1- and 12-month follow-up visits using a standard protocol including laboratory tests. The results between patients over and under 59 years were compared.

Results

The preoperative weight and weight loss were comparable between the groups. Operation time was shorter and hospital stay was longer for older patients, p = ns. There was no operative mortality. Early major complications were seen more often in the older age group, 42% vs 9% (p = 0.02), but late complications were more common in younger patients, 17% vs 44%, p = ns. Early complications were mostly bleedings, which did not lengthen the hospital stay, neither were re-operations nor endoscopic procedures needed. Excess weight loss and resolving of comorbidities after 12 months was comparable between the groups. However, vitamin deficiencies and hypoalbuminemia were more common in the older age group, 42% and 23% for vitamins and 44% and 29% for proteins, p = ns. The older patients had more adverse effects related to surgery, 25% vs 9%, and younger had more adverse psychiatric effects, p = ns.

Conclusions

Sleeve gastrectomy is effective and safe for older bariatric patients. Weight loss is comparable to younger patients and enough to resolve the comorbidities in most of the patients. With standardized nutritional supplementation, the older patients had more often vitamin deficiencies and hypoalbuminemia. Although operative treatment of older bariatric patients is safe, their postoperative care is demanding considering vitamins and protein.

Keywords

Sleeve gastrectomyBariatric surgeryElderly age groupsVitamin deficiency

Introduction

Bariatric surgery has during recent years shown to be safe for patients over 60 years and older with good results especially considering resolving of comorbidities [15]. The recovery after the operation has been comparable with younger patients in these studies. Although weight loss has been more modest, 49 and 59 percent excess weight loss (EWL%) at 5 years in the study of Sugermans et al. [1], resolving of comorbidities has been as good in all of these studies. Thus, bariatric surgery has been recommended also for older patients. The results have also been good when comparing laparoscopic adjustable gastric banding and laparoscopic gastric bypass for the elderly [6].

Sleeve gastrectomy is a new method and long-term follow-up studies are still lacking. In a study by Lakdawala et al. [7], sleeve gastrectomy (SG) was as safe as gastric bypass with no mortality, but more comparative studies are needed. The mortality rate for sleeve gastrectomy has been 0–3.2% [811], and the complication rate has described to be 4.8–10%, including mainly leaks and hemorrhages [913]. Sleeve gastrectomy has shown to be more effective than gastric banding with less adverse symptoms [14]. The effect on weight loss may be more modest than after gastric bypass, but the effect on vitamin deficiencies may also be milder [15].

In our new bariatric unit, there were certain patient groups that were more suitable for sleeve gastrectomy than for gastric bypass. Among those patients, there were older patients who had been waiting to be operated on for many years. We were interested to see whether these older patients would have as good results as younger sleeve gastrectomy patients regarding recovery, weight loss, and vitamin status after 12-month follow-up. We started to collect data from the beginning and after 12 months the data were analyzed.

Patients and Methods

We started bariatric operations in our new unit in December 2007. Since then we have operated in total 490 bariatric patients (February 2011). Of these, 152 were laparoscopic sleeve gastrectomies. The operation type was based on patients’ characteristics. SG was chosen for patients who had poor respiratory condition, Mb Crohn, liver cirrhosis, age over 60 years, coagulopathy, BMI over 60, or patients’ preference. Until this date, we were able to collect complete 12-month follow-up data from 55 sleeve gastrectomy patients of whom 12 were over 59 years of age.

Patients were on an average 48.5 (SD ±10.5) years old. Preoperative weight was 142.1 kg (SD ±32.0), BMI was 49.5 (SD ±8.1) and preoperative weight loss was 4.7 kg (SD ±6.0) (Table 1).
Table 1

Patient characteristics, operation time, and hospital stay

 

Male

Age <59

13

Female

Age <59

30

p

Age 59+

4

Age 59+

8

Mean

SD

Median

Minimum

Maximum

N

Age

 

48.5

10.5

49.0

24.0

67.0

55

 

Weight

All

142.1

32.0

140.0

92.0

220.0

55

 

Age <59

143.0

33.4

136.0

92.0

220.0

43

 

Age 59+

138.9

27.7

140.5

109.0

190.0

12

0.79

BMI

All

49.5

8.1

47.1

37.7

67.9

55

 

Age <59

49.6

8.5

48.0

37.7

67.9

43

 

Age 59+

48.9

6.5

45.7

41.8

60.5

12

0.9

Weight at operation

All

137.3

32.0

132.0

83.0

223.0

55

 

Age <59

139.0

33.8

136.0

83.0

223.0

43

 

Age 59+

131.4

24.8

129.0

104.0

190.0

12

0.6

BMI at operation

All

47.8

8.4

45.1

34.5

68.8

55

 

Age <59

48.2

8.9

46.1

34.5

68.8

43

 

Age 59+

46.4

6.5

44.0

40.0

58.6

12

0.6

Preoperative weight loss

All

4.7

6.0

4.0

−5.0

36.0

55

 

Age <59

4.0

4.0

4.0

−5.0

16.0

43

 

Age 59+

7.5

10.1

5.0

−2.0

36.0

12

0.4

Operation time

All

93.5

29.8

86.0

50.0

185.0

55

 

Age <59

95.7

28.5

88.0

50.0

185.0

43

 

Age 59+

85.3

34.1

72.5

54.0

172.0

12

0.08

Hospital stay

All

5.6

4.4

5.0

4.0

36.0

54

 

Age <59

5.6

4.9

5.0

4.0

36.0

42

 

Age 59+

5.8

1.4

5.0

4.0

8.0

12

0.05

At the operation, stapler lines were enhanced by patches and fibrin glue. Methylene blue test was used to check the seam line and an intra-abdominal drain was used until discharge. Our routine postoperative therapy was single antibiotic prophylaxis during the hospital stay, intermittent CPAP therapy, early mobilization, enoxaparin 40 mg as antithrombotic medication twice a day except in the morning of the operation day for 2 weeks, pantoprazol 40 mg twice a day for 3 months, and permanent vitamin and calcium supplementation including calcium 1 g and cholecalciferol (D3) 800 IU per day starting immediately after surgery.

The patient data were collected prospectively. Primary weight, preoperative weight loss, comorbidities, and medication were recorded. The recovery from the operation, complications and symptoms delaying recovery, operation time, and length of hospital stay were recorded. Also the symptoms and findings during the first 1-month follow-up visit were recorded. Complications were classified according to the Bariatric Analysis and Reporting Outcome System (BAROS) [16] as major surgical, when a re-operation or an endoscopic procedure was performed, bleeding requiring transfusion, or an event resulting a hospital stay over 7 days; and minor surgical, when there was an operation-related morbidity, which did not lengthen the hospital stay over 1 week. Late surgical complications were minor, if the patient had symptoms related to the operation that delayed normal recovery and prohibited normal daily activity. In a routine 1-year follow-up visit, wide laboratory tests were taken, weight was measured, medication was checked, and the general well-being and physical status were recorded. Resolving of comorbidities was based on diminishing or discontinuing medication for diabetes, hypertension, or hyperlipidemia due to normalization of laboratory values (HbA1c in diabetes) or blood pressure. The results of patients 59 years or older were compared with the results of patients 58 years or younger.

Statistical Analysis

Continuous variables are presented as mean ± standard deviation (SD) and as median (range). Discrete variables are presented as number of patients or percentage. Non-parametric Wilcoxon–Mann–Whitney test was used to compare continuous variables and Fisher’s exact test was used for unordered categorical variables. Statistical calculations were performed either with SPSS (v 15.0, SPSS Inc, Chicago, IL, USA) or with Stat Exact (v.4.0, Cytel Software Corporation, Cambridge, MA, USA). A p value less than 0.05 was considered statistically significant.

Results

Seventeen patients were males and four men were 59 years or older. Mean age was 48.5 ± 10.5 years. Patient characteristics, operation time, and hospital stay are provided in Table 1. Mean operation time for younger patients was 96 min and for older 85 min (p = ns). There were no conversions to open surgery. Older patients stayed 5.8 days and younger patients 5.6 days at the hospital (p = 0.05). Other parameters did not significantly differ between the age groups. All patients had one or more comorbidities (Table 2). Hypertension was more common among older patients (p = 0.01), but psychiatric disorders were more common in younger patients (p = 0.05). Also older patients had more often hyperlipidemia, but not significantly. Sleep apnea and joint disorders were common in both groups. Older patients had more often several comorbidities than younger patients (p = 0.04).
Table 2

Comorbidities

 

<59

<59 (%)

59+

59+ (%)

Total

p

T2DM

16

37

6

50

22

0.51

Hypertension

26

60

12

100

38

0.01

Hyperlipidemia

13

30

5

42

18

0.5

Sleep apnea

16

37

4

33

20

1.0

Joint disorders

24

56

6

50

30

0.75

Psychiatric

12

28

0

0

12

0.05

Asthma

3

7

0

0

3

1.0

Others

19

40

9

73

28

0.05

Total

129

 

42

 

171

 
Complications are shown in Table 3. Early major complications were more common in older patients (p = 0.02). Late complications were more often seen in younger patients, but the difference was not significant. Bleeding from stapler line was common though only one patient had high doses of LMWH for atrial fibrillation. Bleeding was categorized as complication, when blood transfusion, usually 1–3 units, was required. There were no major bleedings, no re-operations, nor endoscopic procedures needed neither did hospital stay lengthen due to bleeding. There were no thromboembolic complications or mortality among these patients. One re-operation for leak was performed and this patient stayed 36 days at the hospital.
Table 3

Early and late complications

 

<59

59+

Total

<59 (%)

59+ (%)

p

Early

None

25

6

31

58

50

0.75

Major surgicala

4

5

9

9

42

0.02

Minor surgicalb

2

0

2

5

0

1.0

Otherc

15

1

16

35

8

0.15

Total complications

21

6

27

   

Late

None

25

10

35

58

83

0.180

Major surgical

0

0

0

   

Minor surgicald

9

1

10

21

8

0.4

Othere

10

1

11

23

8

0.42

Total complications

19

2

21

   

Early complications were recorded on ward, and late complications occurred during the first month after leaving the hospital. The BAROS criteria were used [16]. One patient can have more than one complication

aMajor: 1 leakage <59, 8 bleeding from stapler line or subcutaneously, 1–3 units blood transfusion

bMinor: intensive pain, nerve entrapment

cOther: pneumonia, migraine, diarrhea, urinary tract infection, infection of unknown origin

dMinor: ulcer in stapler line, stricture, wound infection, nerve entrapment, dehydration, vomiting, reflux, dumping

eOther: necrosis of previous scar, headache, obstipation, diarrhea, yeast

EWL% was slightly better in younger patients, but not significantly. BMI after 12 months was the same in both groups, 38.2 ± 8.7 for younger and 38.5 ± 7.9 for older patients (Table 4).
Table 4

Twelve-month follow-up

 

Mean

SD

Median

Minimum

Maximum

Number

p

EWL%

All

49.2

21.7

48.5

4.2

96.5

50

 

Age <59

50.3

22.3

48.4

4.2

96.5

38

 

Age 59+

45.6

20.5

48.5

11.6

80.3

12

0.6

EWLkg

All

32.7

13.9

32.5

2.0

61.3

50

 

Age <59

33.5

13.5

33.5

2.0

61.3

38

 

Age 59+

30.0

15.7

26.5

10.3

61.0

12

0.36

BMI

All

38.2

8.4

36.1

25.7

61.7

50

 

Age <59

38.2

8.7

36.1

25.7

61.7

38

 

Age 59+

38.5

7.9

36.5

30.9

56.4

12

0.87

Resolving of type 2 diabetes mellitus (T2DM) was good in both age groups, 75% for younger and 83% for older patients, and the same was with hypertension, 50% for younger and 58% for older patients (Table 5). The difference between the age groups was not statistically significant.
Table 5

Resolving of comorbidities, 12-month follow-up

 

<59

59+

Total

<59 (%)

59+ (%)

p

T2DM

No

4

1

5

25

17

 

Yes

12

5

17

75

83

1.00

Total

 

16

6

22

   

Hypertension

No

13

5

18

50

42

 

Yes

13

7

20

50

58

0.73

Total

 

26

12

38

   

Hyperlipidemia

No

10

5

15

77

100

 

Yes

3

0

3

23

0

0.52

Total

 

13

5

18

   
There were no differences in the laboratory parameters at 12 months (Table 6). Profile of lipids was slightly better in the older age group. Vitamin D deficiency was common, 7 (19%) in younger and 3 (25%) in older patients (p = ns). Twenty-nine percent of younger and 44% of older patients had hypoalbuminemia, but the difference was not significant. Total 8/9 (89%) of older and 11/23 (48%) of younger patients had some nutritional deficiency in the 12-month follow-up, p = 0.05. Twelve percent of younger patients had mental problems 12 months after the operation, and two of five had no previous history of mental problems. None of the older patients had reported mental problems. Older patients had adverse effects related to the operation in 25% of the patients compared to 9% in younger patients. However, the difference was not significant (Table 7). Six of the patients had an unrelated operation during the follow-up.
Table 6

Laboratory parameters after 12-month follow-up

 

Mean

SD

Median

Minimum

Maximum

Number

p

Hemoglobin (women 117–155, men 134–167)

Age <59

138.6

9.7

136.5

118.0

161.0

38

 

Age 59+

135.3

9.7

135.5

119.0

148.0

12

0.5

Mean cell volume (82–98)

Age <59

89.9

4.0

89.0

83.0

100.0

38

 

Age 59+

91.2

3.7

90.0

87.0

98.0

12

0.3

Kreatinin (women 50–90, men 60–100)

Age <59

62.2

12.2

61.0

42.0

101.0

37

 

Age 59+

62.4

13.6

59.0

45.0

87.0

11

0.9

Cholesterol (<5.0)

Age <59

4.7

1.0

4.5

3.0

7.2

27

 

Age 59+

4.3

0.8

4.1

3.3

5.8

10

0.3

LD lipoprotein (<3.0)

Age <59

3.0

1.0

2.8

1.4

5.6

27

 

Age 59+

2.4

0.8

2.0

1.5

3.6

9

0.09

HD lipoprotein (>1.0)

Age <59

1.3

0.3

1.2

0.9

2.3

27

 

Age 59+

1.4

0.2

1.4

1.0

1.8

9

0.3

Triglycerides (<2.0)

Age <59

1.4

0.4

1.4

0.8

2.0

27

 

Age 59+

1.1

0.3

1.1

0.7

1.6

10

0.03

D25 vitamin (>40)

Age <59

61.4

22.6

63.0

20.0

104.0

36

 

Age 59+

57.8

19.8

52.5

28.0

97.0

12

0.7

B12 vitamin (140–540)

Age <59

314.2

144.6

287.0

121.0

799.0

37

 

Age 59+

336.1

160.8

300.0

156.0

722.0

12

0.8

Hemoglobin A1C (4.0–6.0)

Age <59

6.0

0.7

5.8

5.2

8.6

22

 

Age 59+

6.0

0.7

5.8

5.5

8.1

11

0.8

Albumin (36–45)

Age <59

37.9

3.9

38.0

30.0

44.0

24

 

Age 59+

37.2

2.1

36.6

35.0

41.0

9

0.5

Ca-ion (1.16–1.3)

Age <59

1.2

0.0

1.2

1.2

1.3

22

 

Age 59+

1.2

0.0

1.2

1.2

1.3

5

0.4

Table 7

Adverse effects after 12-month follow-up

 

<59

59+

Total

<59 (%)

59+ (%)

p

None

30

7

37

70

58

0.5

Psychological

5

0

5

12

0

0.57

Related to operationa

4

3

7

9

25

0.17

Othersb

4

2

6

9

17

0.6

Total adverse

13

5

18

   

Vitamin deficiencies: D25, B12, Fe+

None

27

7

34

77

58

 

Yes

8

5

13

23

42

0.27

Total

35

12

47

   

Hypoalbuminemia

None

17

5

22

71

56

 

Yes

7

4

11

29

44

0.44

Total

24

9

33

   

aRelated to operation: reflux—3 patients <59, abdominal pain, dysphagia, anorexy, gout, increase of T2DM medication

bOthers: multiple infections, primary hyperaldosteronism, brain stroke, disk prolapse, hyperplasia of prostate, chronic leg ulcers

Discussion

There are several studies on gastric banding and gastric bypass showing that bariatric surgery is as safe for older patients as it is for younger ones [2, 3, 5, 6, 1719]. Morbidity after laparoscopic gastric bypass has described to be 11.7–15% for patients over 60 years [3, 5], pulmonary complications and bleeding being the most common [3]. Patients aged 65 years or older have a substantially higher risk of death within the early postoperative period than younger patients [2, 20, 21]. However, bariatric surgery in the elderly is considered as safe as other gastrointestinal procedures because the observed mortality is better than the expected (risk-adjusted) mortality [3]. Although weight loss is not as good in older patients as in younger age groups, resolving of comorbidities has been satisfactory [1, 17].

We adopted sleeve gastrectomy as a single-stage procedure in our new bariatric clinic in addition with Roux-en-Y gastric bypass. Sleeve gastrectomy has shown to be in short-term follow-up safe and effective single-stage bariatric procedure [810, 12, 13, 22]. It is suitable for revisions for failed gastric banding or gastroplasty [2325], but prone to more complications compared to an initial laparoscopic sleeve gastrectomy (LSG) without a prior bariatric procedure [26]. The mortality rate for sleeve gastrectomy has been 0–3.2% [811], and the complication rate has described to be 4.8–10% including mainly leaks and hemorrhages [913]. In a study by Daskalakis et al. [13], early complication rate was 10% and the use of buttress material was associated with improved perioperative outcome, not the surgeons’ experience. In our study, the major surgical morbidity was 9% for the younger patients and 42% for the older patients. There was one leakage in the younger age group, but morbidity due to bleeding from the stapler line was high. Bleeding from the stapler line was modest, and patients required 1 to 3 units of blood transfusion. There were no re-operations nor endoscopic procedures due to bleedings nor did the hospital stay lengthen. Therefore, we did not consider bleeding as a serious complication. We adopted first antithrombotic prophylaxis twice daily also during the operation day, but after several bleedings, we stopped giving the morning dose, which improved the situation. The high bleeding morbidity may also be due to several comorbidities these patients had. They had very often low dose acetylsalicylic acid as a prophylactic medicine. However, there were no thromboembolic complications. There was only one re-operation and it was due to leakage from the stapler line. There was no mortality.

In a study by Menenakos et al. [11] with 261 patients, the 12-month EWL% after sleeve gastrectomy was 65.7% and the overall success rate after the first year was 74.3% when accounted for EWL% > 50 and 81.7% for BMI < 35 kg/m2. The median preoperative BMI was 45.2 and the median age was 37 years. In a study by Frezza et al. [12], mean excess weight loss was at 12 and 18 months 52.2% and 59.2%, respectively; in the studies by Jacobs et al. [9] and Nocca et al. [10] EWL% at 24 months was 75% and 61.5%, respectively; and in a study by Bohdjalian et al. [27], it was 55% at 60 months. In our study, patients in the older age group were able to lose weight before the operation more than the younger ones. Despite this, the younger patients lost more weight in 12 months, although these differences were not significant. The EWL% was 50.3% for younger and 45.6% for older patients, which was more modest than in the literature [912, 27]. The median preoperative BMI of our patients was 47.1 and the median age was 49 years.

Resolving of comorbidities is the most important effect of bariatric surgery and it has also economic benefits [28]. In a study by Lakdawala et al. [7], the percentage of EWL and the resolution of comorbidities were comparable after sleeve gastrectomy and gastric bypass at the end of 12 months. Both procedures, LSG and LRYGBP, markedly improved glucose homeostasis in a randomized study by Peterli et al. [29] and also in a study by Vidal et al. [30]. In a study by Wittgrove and Martinez [5], resolution of comorbidities after gastric bypass in patients over 60 years was for diabetes mellitus 75% and hypertension 88%, sleep apnea 94%, and hypercholesterolemia 83% in the 12-month follow-up. In a study comparing gastric bypass, sleeve gastrectomy, and gastric banding in the age groups, resolving of T2DM has been comparable in study groups, with gastric banding being the least effective [31]. Resolving of comorbidities, diabetes mellitus, and hypertension were comparable also between the two patient groups in our study, 75% and 50% for younger and 83% and 58% for older patients, respectively.

It has been shown in several studies that vitamin deficiencies are common in bariatric patients already before the operation [32, 33], but especially they are known to be related to bariatric procedures [3437]. It is strongly recommended to use vitamin supplements after bariatric procedures. In a recent study by Gehrer et al. [15], it was shown that deficiencies after the operation became significantly more often after gastric bypass than after sleeve gastrectomy. In the sleeve gastrectomy group, vitamin D deficiency was seen in 23% of the patients, vitamin B12 deficiency in 18% of the patients, and mild protein deficiency in 4% of the patients. In our study with standardized vitamin supplementation, there was no significant difference in laboratory parameters in patients under and over 59 years of age at the end of 12 months. But 19% of younger and 25% of older patients had D25 vitamin deficiency. If all vitamin deficiencies were summarized, 23% of younger and 42% of older patients had deficiencies, but the difference was not significant. Hypoalbuminemia was especially common in the older age group, 44%, and it shows an obvious failure of dieticians’ support. The weakness of this study was that we had no preoperative values of vitamins and proteins. Despite this, the values at 12 months were surprisingly low. Perhaps, one should measure the values prior to surgery and correct the deficiencies. In particular, older patients seem to need intensive support and follow-up by an internist and a dietician.

General recovery was excellent in both age groups in our study. In a study by Himpens et al. [38], 23% of sleeve gastrectomy patients suffered from gastroesophageal reflux and 18% from vomiting 6 years postoperatively. In a study by Bohdjalian et al. [27], 15.4% of the patients were converted to gastric bypass due to severe reflux and weight loss failure in a 5-year follow-up. In a study by Nocca et al. [10], 11.8% of the patients had reflux symptoms 2 years after the operation. In our study, 12 months after the bariatric operation, adverse effects related to operation were seen in 25% of the older patients and 9% of the younger patients, with three reflux complaints in younger patients. The difference was not significant. Psychiatric problems were seen in 12% of the younger patients. Other adverse events were seen in 17% of the older patients and in 9% of the younger patients. Six of our patients had an unrelated operation during the follow-up. These data are descriptive to these patients with multiple comorbidities. It has to be noticed that our patients were selected patients, i.e., patients with BMI > 60, with liver cirrhosis, etc., and thus, patients were at higher risk for morbidity when compared to more healthy morbidly obese patients.

Conclusion

Sleeve gastrectomy is effective and relatively safe for older bariatric patients in a 12-month follow-up. Weight loss is comparable to younger patients and enough to resolve the comorbidities in most of the patients. With standardized calcium and vitamin supplementation, the older patients had more often D25 vitamin deficiency than younger patients. Also older patients were more often hypoalbuminemic. Although operative treatment of older bariatric patients is safe, their postoperative care is demanding considering vitamins and protein.

Conflict of Interest

The authors declare that they have no conflict of interest.

Copyright information

© Springer Science + Business Media, LLC 2011