Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes

Preoperative risk factors for early postoperative bleeding after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis

PURPOSE

Although bariatric surgery is an effective intervention for obesity, it comes with risks such as early postoperative bleeding (EPB). Identifying preoperative risk factors for this complication can help patients' risk stratification and optimization. We performed a systematic review and meta-analysis to find predictors for early postoperative bleeding after Roux-en-Y gastric bypass (RYGB).

METHODS

We conducted a systematic review, searching PubMed, Cochrane Library, and Web of Science until November 2023. We performed a random-effects meta-analysis to explore preoperative risk factors associated with early postoperative bleeding after RYGB. Sources of heterogeneity were explored by leave-one-out analyses.

RESULTS

23 studies were included, comprising 232,488 patients. Male gender (meta-analytical RR = 1.42, 95%CI = 1.21-1.66, I2 = 18%, Q Cochran test p-value = 0.29) and revisional surgery (meta-analytical RR = 1.35, 95%CI = 1.12-1.62, I2 = 22%, Q Cochran test p = 0.21) were associated with higher risk of EPB. On average, patients with EPB were older than the remainder (MD for the mean age = 2.82 years, 95%CI = 0.97-4.67, I2 = 0.00%, Q Cochran test p = 0.46). Except for hypertension (meta-analytical RR = 1.33, 95%CI = 1.02-1.73, I2 = 66%, Q Cochran test p < 0.0001), comorbidities were not associated with a higher risk of EPB.

CONCLUSION

Preoperative risk factors, including age, gender, hypertension, and revisional bariatric surgery, are associated with early postoperative bleeding after RYGB. Further primary studies, with higher methodological quality, are required to detail more risk factors.

Metabolic Bariatric surgery in People with Obesity aged ≥65 Years

Obesity management guidelines recommend metabolic bariatric surgery for individuals with body mass index (BMI) ≥35 kg/m2, regardless of the presence of any obesity-related comorbidity; and for individuals with BMI 30-34.9 kg/m2 with metabolic diseases. Older age is not in itself a contraindication for bariatric surgeries, which can be performed after careful selection and assessment, to decrease the risks of postoperative complications. An essential amount of data has accumulated about bariatric surgery results for persons aged ≥60 years; but data are limited though increasingly accumulating for the ≥65-year-old population. Laparoscopic Roux-en-Y-gastric bypass and sleeve gastrectomy have been the preferred bariatric procedures for older adults with obesity, as for younger patients. This review summarizes the safety and efficacy of bariatric surgery for individuals aged ≥65 years with obesity, and the efforts that have been invested to improve the perioperative and long-term consequences.

Bariatric Surgery and Vitamin D: Trends in Older Women and Association with Clinical Features and VDR Gene Polymorphisms

(1) Background: Obesity and its comorbidities can cause burdens and limitations. Bariatric surgery (BS) is indicated as a safe procedure to reduce body mass and improve present comorbidities. However, several complications were reported, such as vitamin D [25(OH)D] deficiency. We evaluated if 25(OH)D serum levels relate to clinical characteristics, symptoms, or habits in women after their BS, and whether the vitamin D receptor (VDR) gene's TaqI and FokI polymorphisms affected 25(OH)D levels and the total body bone mineral density (TBBMD). (2) Methods: This cohort cross-sectional comparative analytical prospective study consisted of 27 women, 61.6 ± 5.0 years, submitted to BS one year prior at a public reference hospital, DF-Brazil. All participants were asked to follow the physical and dietary activity recommendations and received vitamin D3 supplements. Their anthropometric, biochemical, and immunological measurements and blood samples were obtained. (3) Results: 73.3% of participants had low 25(OH)D levels, and their levels correlated positively with TBBMD and negatively with systolic pressure. VDR TaqI did not affect 25(OH)D levels, whereas VDR FokI's allele f presence correlated to a median rise in 25(OH)D levels. Neither polymorphism correlated to TBBMD. (4) Conclusions: 25(OH)D levels were positively correlated with TBBMD, negatively with systolic blood pressure, and were higher in those with the VDR FokI allele f.

Selection of Robotic Bariatric Surgery Candidates: a Nationwide Analysis

INTRODUCTION

This study aims to identify risk factors associated with 30-day major complications, readmission, and delayed discharge for patients undergoing robotic bariatric surgery.

METHODS

From the metabolic and bariatric surgery and accreditation quality improvement program (2015-2018) datasets, adult patients who underwent elective robotic bariatric operations were included. Predictors for 30-day major complications, readmission, and delayed discharge (hospital stay ≥ 3 days) were identified using univariable and multivariable analyses.

RESULTS

Major complications in patients undergoing robotic bariatric surgery were associated with both pre-operative and intraoperative factors including pre-existing cardiac morbidity (OR = 1.41, CI = [1.09-1.82]), gastroesophageal reflux disease [GERD] (OR = 1.23, CI = [1.11-1.38]), pulmonary embolism (OR = 1.51, CI = [1.02-2.22]), prior bariatric surgery (OR = 1.66, CI = [1.43-1.94]), increased operating time (OR = 1.003, CI = [1.002-1.004]), gastric bypass or duodenal switch (OR = 1.58, CI = [1.40-1.79]), and intraoperative drain placement (OR = 1.28, CI = [1.11-1.47]). With regard to 30-day readmission, non-white race (OR = 1.25, CI = [1.14-1.39]), preoperative hyperlipidemia (OR = 1.16, CI = [1.14-1.38]), DVT (OR = 1.48, CI = [1.10-1.99]), therapeutic anticoagulation (OR = 1.48, CI = [1.16-1.89]), limited ambulation (OR = 1.33, CI = [1.01-1.74]), and dialysis (OR = 2.14, CI = [1.13-4.09]) were significantly associated factors. Age ≥ 65 (OR = 1.18, CI = [1.04-1.34]), female gender (OR = 1.21, CI = [1.10-1.32]), hypertension (OR = 1.08, CI = [1.01-1.15]), renal insufficiency (OR = 2.32, CI = [1.69-3.17]), COPD (OR = 1.49, CI = [1.23-1.82]), sleep apnea (OR = 1.10, CI = [1.03-1.18]), oxygen dependence (OR = 1.47, CI = [1.10-2.0]), steroid use (OR = 1.26, CI = [1.02-1.55]), IVC filter (OR = 1.52, CI = [1.15-2.0]), and BMI ≥ 40 (OR = 1.12, CI = [1.04-1.21]) were risk factors associated with delayed discharge.

CONCLUSION

When selecting patients for bariatric surgery, surgeons early in their learning curve for utilizing robotics should avoid individuals with pre-existing cardiac or renal morbidities, venous thromboembolism, and limited functional status. Patients who have had previous bariatric surgery or require technically demanding operations are at higher risk for complications. An evidence-based approach in selecting bariatric candidates may potentially minimize the overall costs associated with adopting the technology.

One Anastomosis Gastric Bypass Compared with Sleeve Gastrectomy in Elderly Patients: Safety and Long-term Outcomes

BACKGROUND

As life expectancy increases, more elderly patients are being considered for metabolic bariatric surgery. We aimed to assess the safety and long-term effectiveness of one anastomosis gastric bypass (OAGB) compared to sleeve gastrectomy (SG).

METHODS

Single-center retrospective comparative study of OAGB and SG (2012-2019) in patients aged ≥ 65 years.

RESULTS

In all, 124 patients underwent OAGB (n = 41) and SG (n = 83). Mean age was 67.6 ± 2.8 and 67.6 ± 2.6 years (p = 0.89), respectively. Baseline characteristics were comparable, except lower rates of hypertension (HTN) and non-alcoholic fatty liver disease in OAGB than SG patients (43.9% vs. 74.6%; p < 0.001, and 39.0% vs. 89.1%; p < 0.001, respectively). Body mass index (BMI) of OAGB and SG patients decreased from 41.8 ± 7.8 and 43.3 ± 5.9 kg/m² (p = 0.25) to 28.6 ± 4.7 and 33.2 ± 5.3 (p < 0.001), at long-term follow-up, respectively. Excess weight loss (EWL) > 50% was achieved in 80.6% and 43.2% of OAGB and SG patients, with a mean EWL of 67.2% ± 22.3 and 45.8% ± 18.0 (p < 0.001) and a mean total weight loss (TWL) of 30.7% ± 10.4 and 21.9% ± 8.1 (p < 0.001), respectively. Resolution rates of obesity-associated medical problems were similar, except type 2 diabetes (T2D) and HTN, which were 86.6% and 73.3% in OAGB, compared with 29.7% and 36.3% in SG patients (p < 0.001 and p = 0.001), respectively. Major early complication rates were comparable (2.4% vs. 3.6%; p = 0.73, respectively). Revision for late complications was required in two OAGB patients.

CONCLUSIONS

OAGB in the elderly is safe and results in better long-term weight reduction and resolution of T2D and HTN than SG.

Current status of metabolic surgery in patients with type I diabetes mellitus and obesity: a nationwide multicenter study

PURPOSE

While obesity is prevalent among patients with type I diabetes mellitus (T1DM), the effects of metabolic surgery on patients with T1DM have not been adequately investigated. The study aims to investigate the perioperative outcomes and the improvement of comorbidity 1 year following metabolic surgery amongst this patient population.

METHODS

In this study, we evaluated the effects of sleeve gastrectomy (SG) and Roux-Y gastric bypass (RYGB) on patients with T1DM and insulin resistance.

RESULTS

One hundred forty-nine patients (SG n = 91 and RYGB n = 58) with obesity, T1DM, and insulin resistance were analyzed. There was no significant difference in BMI reduction and %EWL 1 year after surgery between the two groups. In the SG group, BMI reduction was 6.5 kg/m2 versus 5.9 kg/m2 in the RYGB group (p=0.406). The %EWL was 68.2 ± 25.2 in the RYGB group and 64.3 ± 21.5 in SG (p=0.332). There was also no significant difference in weight loss between the two groups (14.9 ± 5.4 kg in SG vs. 14.2 ± 7 kg in RYGB; p=0.548). In all patients, insulin requirements decreased after surgery, and in 22% of patients, insulin requirements were equivalent to those of normal-weight individuals. There was a significantly higher rate of remission of reflux in RYGB patients than in SG patients (94·44% vs 29·41; p<0.001).

CONCLUSION

Patients with obesity and T1DM may benefit from metabolic surgery. Both methods produce satisfactory results in this group of patients regarding daily insulin requirements and treatment of obesity-related diseases. However, the decision of which procedure should be carried out still depends on the patient's general condition and the surgeon's technical ability.