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weight loss in older patients undergoing bariatric surgery. In 1977, Printen and
Mason reported an 8% mortality rate in patients older than 50 years, compared
with a 2.8% mortality rate in patients younger than 50 years and recommended
against surgery above 50 years [24]. In 1985 the NIH Consensus Conference on
Obesity [25], and in 1987, a study by Grace, regarded age greater than 50 years
as a potential contraindication to bariatric surgery [26]. Livingston et al. in 2002
recommended against bariatric surgery for those aged 55 years or older due to
threefold-higher mortality rate relative to younger patients [27]. Flum et al. in
2005 reported a mortality rate of 11.1% at 1 year for patients aged > 65 and recommended against it in elderly [28].
With the advent of laparoscopy and the improvement in pre, peri and postoperative care, surgical morbidity and mortality in elderly from bariatric surgery
improved and bariatric surgery was increasingly accepted as a treatment of obesity
in the elderly.
From 1999 to 2005 2.7% of all bariatric surgeries were performed in elderly
subjects. This number increased to 10% from 2009 to 2013 [29]. Sosa et al. in
2004 reported that patients > 60 years of age undergoing laparoscopic bariatric surgery have higher but acceptable levels of morbidity and mortality and
significant improvement in co-morbidities, and recommended it in elderly
[30]. Papasavas et al. in 2004 showed that laparoscopic bariatric surgery is
a safe and well tolerated surgical option for the treatment of morbid obesity in
patients > 55 years [31].
2 Sleeve Gastrectomy: Procedure of Choice
The popularity of bariatric surgery in the elderly population increased exponentially with the advent of laparoscopic sleeve gastrectomy (LSG) as a stand-alone
procedure in 2004. LSG with its technical simplicity, shorter operative time, and
acceptable rate of co-morbidities improvement and weight loss is currently the
surgery of choice for elderly obese patients worldwide. This has been recognized
in the 2016 International Consensus Conference on Sleeve Gastrectomy [32].
Early studies by Van Rute et al. [33] and Leivonen et al. [34] that compared LSG
in elderly with younger patients reported similar complications rate and acceptable
reduction in weight and improvement in co-morbidities. The additional increase
in popularity of LSG among elderly patients was also attributed to recognition of
LSG by Medicare in the US in 2012 [35].
LSG can be performed safely in the elderly with an acceptable low rate of complications. These complications can be reduced further by careful patient selection
[36]. The reduction of complications is also related to the performance of such
procedures by an experienced surgeon within a Center of Excellence with appropriate resources, and with the availability of a multidisciplinary team.
K. Saeed et al.350
Patient characteristics considered high risk for bariatric surgery are highly variable. In a group of 381 patients undergoing LSG Husain et al. found that male sex,
preoperative BMI ≥ 60 kg/m2, smoker within the last year, deep vein thrombosis,
therapeutic anticoagulation, and abnormal serum albumin < 3.5 g/dL are risk factors associated with severe complications [37]. Also attempts were made to stratify
the patient population risk by using standardized scoring systems. The obesity surgery mortality risk score (OS-MRS), proposed by De Maria et al. was used and
validated in patients undergoing gastric bypass surgery [38]. More recent studies
doubted the ability of such scores to accurately predict risk of postoperative complications in LSG [39, 40].
A bariatric specific score risk calculator was recently developed by the
Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
(MBSAQIP). This calculator uses 20 patient predictors, such as age, American
Society of Anesthesiologists Physical Status classification, and preoperative body
mass index (BMI) to predict the likelihood that patients will experience any of
nine different outcomes within the first 30 days after an operation [41].
Optimization of co-morbidities before LSG can further reduce complications.
It is highly important that all elderly individuals should have a comprehensive
geriatric preoperative assessment before undergoing bariatric surgery in order to
identify any potential risks and address accordingly. Batsis et al. detailed the ways
to assess elderly individuals undergoing bariatric surgery and listed the characteristics of ideal candidates for bariatric surgery, which is beyond the scope of this
chapter [42].
2.1 Intraoperative Difference in Elderly
No significant intraoperative differences have been described between elderly
patients undergoing LSG and younger individuals. In fact, both young and older
individuals undergoing bariatric surgery have similar length of operative procedure
time [43]. Due to increase in tissue friability, decrease in physiologic reserves,
and increased chances of adhesion formation in the elderly, operative time can be
expected to be longer, but no differences were observed. Bartosiak et al. reported
a mean operative time of 82.1 min for the elderly and 77 minutes for younger
patients undergoing LSG [43].
The only exception pertains to the presence of a hiatal hernia, which could
be more common in the elderly. In one study, 46.7% of older patients required
hiatal hernia repair versus 8.3% in younger counterparts [44, 45]. Also, the intraoperative complications are comparable between the two populations [43]. There
is, however, in some studies a potential but non-statistically significant trend of
increased intraoperative complications in septuagenarians [45].
Elderly High Risk Patients …
351
3 Postoperative Care in the Elderly
Based on the different physiologic needs and higher prevalence of comorbidities, the postoperative care of the elderly bariatric patient may differ. Among
the different levels of care, likely more ICU admissions can be expected. ICU
admission in general has been linked to both preoperative and perioperative
factors. Older age, male gender, higher BMI, OSA and open surgery are at
increased risk of requiring ICU admission. Less important is the type of procedure, as no difference was observed between LSG and gastric bypass in terms
of need for ICU admission postoperatively [46, 47]. In a study by Khidir et al.,
the number of comorbidities, a diagnosis of OSA, and ASA score were found to
predict the need for post-LSG ICU admission [48].
On the other end, ERAS protocol after bariatric surgery is associated with
decreased length of stay, and cost reduction without increase in perioperative morbidity or readmission rates [49, 50]. Though ERAS has not been studied exclusively in elderly obese undergoing SG, its implementation in other laparoscopic
gastrointestinal surgeries has been proven beneficial in older patients [51]. Given
the simplicity of LSG, ERAS can be safely implemented in elderly patients undergoing LSG. Length of stay after LSG in elderly does not appear to be different as
compared to the younger population. In fact, depending on institution protocols, it
varies from 1 to 4 days [52, 53, 54, 55].
4 Postoperative Mortality and Morbidity
LSG in carefully selected patients in elderly is a very safe procedure. With
increase in age, it is expected that complications and mortality rate will also
increase [56]. However, multiple studies have demonstrated the safety of LSG in
the elderly and a comparable rate of complications and mortality to the younger
population.
Early 30-day mortality after LSG has remained very low and approaches zero
[43]. Goldberg et al. reported a slightly higher rate of mortality in elderly, but the
absolute increase is very small, much less than 1% [57, 58, 59].
Early complications remain a serious concern when operating on elderly
patients. Increasing age is associated with increase in morbidity following LSG
[60, 61]. Though increase is present, it is within the acceptable range and comparable to younger patients undergoing LSG. Early 30-day morbidity has been
reported to be around 8 to 12% [45, 59, 55, 43, 62]. The increase is seen mainly
in medical complications as opposed to surgical complications [61]. Susmallian
et al. reported a total number of complications of 8.86% but among those, 3.10%
were in relation to aggravation of previous medical diseases [63]. Also in a study
K. Saeed et al.352
by Charles et al., surgical complications in patients undergoing LSG less than
65 years and greater than 65 years of age were 1.4% and 1.3%, respectively, while
medical complications increased from 3.10 to 6.60% as patients age moved above
65 years [61]. Among medical complications, cardiac, pulmonary, and renal are
significantly more in elderly [59]. A recent study from Poland showed an early
morbidity rate of 8.9% for elderly and 6.7% for younger patients, and the most
common was bleeding in both groups [64].
Similar to early complications, late complications also occur at an acceptable
rate in the elderly. GERD is one of the most common mid and long term complications of LSG. Due to an increased incidence of hiatal hernias in the elderly,
it is expected to have more incidence of GERD in the elderly, but studies have
shown comparable rates to younger patients [55]. Due to a decreased tendency in
tissue healing abilities [65], higher BMI [66], loss of muscle mass [67] and high
prevalence of comorbidities that increase intra-abdominal pressure, there is in general a higher prevalence of incisional hernias in the elderly [68]. But as with other
laparoscopic procedures, LSG does not have an increased incidence of ventral hernia compared to younger individuals. Similarly the rate of dysphagia and stricture
were not different between the elderly and the younger population [53].
Nevo et al. compared early versus late morbidity between elderly and younger
patients undergoing LSG and showed similar rates of complications. Early morbidity rate was 10.6% among the elderly and 10.7% in younger patients with similar rate of leaks, re-bleeding and re-operation. Late complications (i.e. GERD,
stricture, ventral hernia) were also similar [53].
Increased incidence of osteoporotic fractures has been reported after bariatric
surgery. In general, this risk is less after LSG than after gastric bypass. Although
this particular complication has not been directly studied in the elderly cohort,
extrapolating from the results on a younger population, the risk of osteoporotic fractures should be lower in patients undergoing LSG compared to gastric
bypass [69].
Elderly subjects are expected to be at higher risk of malnutrition [70], especially of micronutrients after bariatric surgery. However, close monitoring and
proper supplementation can prevent and treat the above-mentioned deficiencies.
In a recent study, there was no difference in micronutrient deficiencies between
groups [71].
5 Postoperative Outcomes
5.1 Excess Body Weight Loss
The percentage of excess body weight loss (%EBWL) tends to be less after LSG
in elderly as compared to younger patients [72]. %EBWL ranges from 50 to 70%
at 12-month follow-up, which is statistically less than that in younger patients [43,
64, 63].
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353
Although the weight loss tends to be inferior in the elderly, the amount of
weight loss achieved and the consequent comorbidity resolution is still quite significant [73]. Several mechanisms have been offered to explain the more modest weight loss in the elderly. First of all, the increasing age is associated with
decrease in body muscle mass and increase in fat mass, referred to as sarcopenic
obesity [67]. Loss of muscle mass along with certain other factors [7, 8] results
in decrease in resting metabolic rate. In addition, due to physical decline, active
energy expenditure decreases rapidly with age and contributes significantly
to overall decrease in energy expenditure [7]. Also, the ability of the body to
mobilize fat decreases in the elderly and thus leads to accumulation of fat [74].
Hormonal alterations in females after menopause have been associated with an
increase in abdominal adiposity and thus less %EBWL, as evidenced by greater
%EBWL in premenopausal women compared to menopausal women after bariatric surgery [75]. All these factors are postulated to contribute to less %EBWL
in the elderly but further studies need to be done to determine other factors and
mechanisms that lead to less %EBWL in the elderly after bariatric surgery compared to younger counterparts.
5.2 Comorbidities Improvement
The positive metabolic effects of LSG have been well described in the elderly
population. This improvement is more significant for elderly as they have more
burden of co-morbidities and have much significant impact on quality of life
compared to younger patients. Even in some elderly, individual reduction in the
amount of medication used postoperatively is significantly higher compared to
young patients [76]. Despite significant reduction in the severity of comorbidities, the total resolution of comorbidities have been reported to be less in elderly.
This can be attributed to more permanent organ damage in elderly due gradual
decline in physiological reserve with aging [77]. and presence of comorbidities
for a longer time.
Arterial hypertension improvement has been reported in the range of 50 to
80% [78, 45, 55]. Interestingly, some studies reported a more significant improvement than in younger patients, based on the more significant reduction of HTN
medications in the elderly [79]. In a recent study, HTN improvement for elderly
was 73.1% for older and 69.2% for younger patients [64]. In another recent study
72.5% of older individuals showed improvement in HTN [58]. Froylich et al.
reported a decrease in anti-hypertensive medication on average from 1.6 to 1.0
[52, 80].
Similarly to HTN, the use of diabetic medications decreases substantially in the
elderly after LSG. Although compared to younger patients, the complete resolution of DM is less, the relative improvement of the disease is more substantial as
the elderly have a more severe burden of disease itself. The improvement has been
K. Saeed et al.354
reported in the range of 30 to 80% [64, 55, 45]. In a study by Danan et al. 65% of
older individuals reported improvement of diabetes [58], and 50% improvement
by Bianco et al. [80].
As for other comorbidities, the elderly population presents an improvement in obstructive sleep apnea (OSA) to a less significant degree as compared
to younger patients. Burchett et al. reported that 27% of elderly patients showed
improvement or resolution compared to 37% of the younger group after LSG [55].
Navarrete et al. showed significantly higher improvement or resolution of OSA
(60.8% of elderly) but still statistically lower than in younger patients (76%) [62].
Hyperlipidemia also follows the same pattern of improvement of HTN and DM
after bariatric surgery [55, 53]. Danan et al. showed 47.1 improvement in hyperlipidemia in older individuals [58].
Elderly at baseline have more severe arthritis compared to younger patients.
Complete resolution is less compared to younger patients, but the amount of
improvement is greater in the elderly. In one recent study, improvement was seen
in 27% of older and 34% of younger patients [55].
5.3 Quality of Life Improvement
Compared to in the younger population, obesity has more quality limiting effects
on the elderly due to age-related frailty and burden of comorbidities. In a study by
Lainas et al., using the SF-36 Questionnaire, significant improvement was seen in
physical health and mental health scores [81]. As LSG is a safer bariatric procedure in elderly, it can lead to significant improvement in quality of life [82, 83].
With significant improvement in co-morbidities, it is expected that bariatric surgery will improve life expectancy in the elderly compared to non-surgical weight
loss measures. However, more studies are needed before drawing definitive conclusions on the life expectancy of elderly patients after bariatric surgery.
6 LSG in Septuagenarians and Elderly Super Obese
Septuagenarians have higher baseline comorbidities; consequently, there is a
potential for higher complication rate in such patients undergoing LSG as compared to those less than 70. This difference, however, is still within acceptable
range, and the benefits of bariatric surgery are still present. As previously mentioned, the longer operative time reported was due to the higher incidence of hiatal
hernia requiring concomitant repair. Also, the planned post-procedure ICU admission incidence increased in septuagenarians.
In a study by our institution, bariatric surgery in those age > 70 years was
associated with a slightly higher but acceptable rate of complications [84, 85].
Pechman et al has reported that LSG in age > 70 years was associated with
increased length of stay, slight increase in morbidity, unplanned or prolonged
Elderly High Risk Patients …
355
intubation, progressive renal insufficiency, and increased transfusion requirement [86]. Smith et al. showed that although the overall complications are more
as compared to patients less than 69 years of age, the rate of severe complications
is still less than 5% [87].
Weight loss and remission of comorbidities is modest but comparable to those
less < 70 years of age [45]. A study from our institution evaluating LSG in a population of age > 75 reported a %EBWL of 56%, 50.9%, and 43.9% at 1– 2–, and
3–5 year follow-up, respectively. These weight loss results are slightly less than
those in patients less than 70 years, but still significant [36, 85].
In conjunction with older age, a higher BMI is associated with higher complication rates [88]. Minhem et al. showed that complication rates were higher in
older super obese patients (10%) compared to younger super obese patients (7%)
[89]. In spite of these higher expected complications rates, the weight loss results
are still significant. Daigle et al. reported EBWL of 48.3% after 37 months [90].
7 LSG Compared to Gastric Bypass in Elderly
Before the widespread use of LSG, laparoscopic Roux-en-Y gastric bypass
(LRYGB) and laparoscopic adjustable gastric band (LAGB) were the most common procedures performed in the elderly. Similar to younger counterparts, the
overall complications of the LRYGB in elderly present higher morbidity compared
to LSG [61]. With the LAGB having fallen out of favor and the increased morbidity of the LRYGB, LSG has become the procedure of choice in the elderly.
In general, there is higher weight loss after LRYGB [91] and higher resolution
of comorbidities compared to LSG, but at the cost of higher mortality and morbidity [92, 93, 94, 95].
A study by Janik et al. of 3371 matched patients showed that LRYGB compared to LSG in the elderly presents a higher leak rate (0.33 vs. 0.12%), 30 day
readmission (6.08 vs. 3.74%), 30 day re-operation (2.49 vs. 0.89%), longer hospital stay (2.3 vs. 1.9%), increased operative time (122 vs. 84%) and increased rate
of SSI (0.8 vs. 0.24) [96]. Similarly, Xu et al. reported that risk of both early and
late complications are increased in the elderly. In this study, the elderly undergoing LRYGB are 1.75 and 1.63 times more prone to early and late complications as
compared to the elderly undergoing LSG [97].
As previously reported, the %EBWL was less with LSG, but comparable
to LRYGB. In a study by Moon et al., the elderly undergoing SG had a 60.8%
EBWL after 24 months while those undergoing LRYGB had %EBWL of 67%
after 24 months [95]. Regarding comorbidities improvement, RYGB has higher
remission of type 2 diabetes mellitus (DM) and improvement in hyperlipidemia
compared to LSG [98, 99]. Nevertheless, the ratio risk benefit with the SG remains
superior to the LRYGB.
K. Saeed et al.356
8 Conclusions
In conclusion, LSG in the elderly population seems safe and effective. Patient
selection is paramount to reduce the morbidity of a population already at higher
risk. Larger and longer studies are necessary to assess the benefits of bariatric surgery in terms of life expectancy.
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