Revisional Bariatric Surgery (RBS) in elderly patients (over 65 years old) is effective and with a reasonable complication rate and with long-lasting weight loss and improvements in obesity associated medical problems, according to researchers from Tel Aviv University, Tel Aviv, Israel.
The authors stated that RBS currently accounts for 9–18% of all bariatric procedures and the main indications for revisional surgery are weight regain (WR) or insufficient weight loss (IWL) and previous studies estimate 10–50% of patients with a previous restrictive procedure may require a secondary procedure. They highlight that the main cause WR or IWL can vary and may be related to technical factors of the procedure performed but in general, are more commonly encountered in patients undergoing restrictive bariatric procedures in their background. The objective of their study is to show the outcomes of patients aged ≥ 65 years old undergoing RBS due to IWR or WR after restrictive bariatric procedures.
In total, 40 patients were included in the study and the indication for surgery were due to IWL or WR after a previous restrictive procedure. Patients were compared according to their previous restrictive procedure: 23 patients (57.5%) after laparoscopic adjustable gastric band (LAGB) and 16 patients (40%) after sleeve gastrectomy (SG). One patient (2.5%) who had a siliastic ring vertical gastroplasty was not included in the analysis.
All surgical procedures were performed by the same surgical team with a standardised approach. Conversion from LAGB was preceded by removal of the band unless previously performed. Conversion from SG was initiated with transection of the SG at the level of the crow’s foot, with trimming of the sleeve when indicated.
Conversion to laparoscopic one anastomosis gastric bypass (OAGB) was performed in 22 patients (55%), SG was performed in eight patients and Roux-en-Y gastric bypass (RYGB) was performed in nine patients (n=30).
Outcomes
The mean age of patients was 67.2±2.8 years old (range 65–74) with no significant difference between groups. A majority (61.5%) of the patients were female and the mean BMI was comparable between groups at 38.3±7.4kg/m2. There was no significant difference in associated medical problems including T2D, hypertension, hyperlipidaemia, OSA, osteoarthritis and MAFLD. There was a significantly higher rate of patients with GERD in SG patients (68% vs 13%; p<0.001). The mean time interval between surgeries was 8.7±5.1 years and was comparable between groups.
The postoperative (30-day) surgical complications of leaks, bleeding, obstruction and fluid collections was comparable between groups. The rate of 30-day readmission was significantly higher in SG patients (18.7% vs 0%; p=0.03).
A comparative analysis regarding the type of RBS performed revealed there were no significant difference in surgical complications, reoperations, readmissions and mortality. The length of hospital stay was significantly higher in patients undergoing RYGB when compared to SG and OAGB (8.5 days vs 3.7 days and 4.7 days, respectively; p=0.03).
Thirty-six patients were available to mid-term follow-up (10% loss to follow-up) and the mean BMI and TWL at last follow-up was 29.2 kg/m2 and 20.3%, respectively, with no significant difference between groups. The rate of patients with obesity associated medical problems was significantly reduced and comparable between groups, at last follow-up. In regards to poor clinical response, 12 patients (≈ 30%) did not reach the TWL of at least 20%.
Additional revisional surgery due to complications during the follow-up was required in five patients (12.5%) - one patient was converted from SG to OAGB due to sleeve stenosis, two patients after OAGB underwent laparoscopic exploration with omental patch due to marginal ulcer perforation, of which one required an additional revision due to small-bowel obstruction due to internal hernia which required reduction of hernia content and closure of the mesenteric defect. Finally, one patient had an OAGB anastomotic stricture which was treated with endoscopic dilatation which was complicated with a perforation that required surgical exploration and closure of the perforation.
“In our opinion, age by itself should not define the patients’ physiologic and clinical status,” they write. “However, it is naturally more common to encounter elderly patients with significant chronic medical conditions and frailty which might require a more careful, evaluation, optimisation of chronic medical diseases, and careful patient selection.”
OAGB was shown to have significantly lower BMI (27.8 kg/m2) and higher TWL (26%) when compared to SG (34.4 kg/m2, 11.8%, respectively) and RYGB (29.1 kg/m2, 16.7%, respectively) (p<0.05). There was no significant difference in rates of T2D, hypertension and hyperlipidaemia at last follow-up.
“Careful patient selection is mandatory to keep complication rate low and to ensure a true improvement in physical wellness and quality of life,” they concluded. “Prospective, larger scale studies are necessary to further evaluate thus sub-group of patients as we are likely to encounter more of them with the increase in life expectancy.”
The findings were reported in the paper, ‘Revision of restrictive bariatric procedures in elderly patients: results at a 5-year follow-up’, published in Updates in Surgery. To access this paper, please click here