DDW 2011: Should Old Age Disqualify Patients from Receiving Weight Loss Surgery?

Age is less important than BMI, cardiovascular health, diabetes, and other considerations when evaluating elderly patients for bariatric surgery.

Although bariatric surgeons “should continue to proceed with caution in older patients, age greater than 65 is not an absolute contraindication for weight loss surgery,” said Robert B. Dorman, MD, PhD, a general surgery resident at the University of Minnesota Medical School. Dorman’s study showed, in an oral presentation and press conference at Digestive Disease Week 2011, that when body mass index and medical conditions such as cardiovascular disease and diabetes are taken into account, age becomes a less significant issue.

Dorman noted that previous research has linked age to increased morbidity and mortality following bariatric surgery. Specifically, a 2005 study by David R. Flum published in 2005 in JAMA showed a 30-day mortality rate of 1.7% among patients <65 years and 4.8% for those 65 or older. Based on other research findings, however, Dorman hypothesized that age ≥65 years will not predict adverse outcomes following bariatric surgery. His study objective, based on data from 48,378 bariatric procedure patients in the American College of Surgeons National Surgical Quality Improvement Program multi-hospital database (2005-2009), was to determine prevalence of bariatric operations by age, and to determine if age is a risk factor for mortality, major events, and prolonged length of stay (PLOS). The assessment encompassed a range of procedures (open and laparoscopic Roux-en-Y gastric bypass, duodenal switch, laparoscopic adjustable gastric band and vertical banded gastroplasty).

Analysis showed that over the course of five years, the percentage of older patients undergoing bariatric surgery increased from 1.92% in 2005 to 4.77% in 2009 (p < 0.001). The laparoscopic adjustable gastric band approach was used significantly more often than the Roux-en-Y gastric bypass (P<0.001) in patients 65 years and older. Only 72 deaths were reported throughout the entire study period, 8 of which were in the ≥ 65 years cohort. The incidence of 30-day mortality in those 35-49, 50-64 and ≥ 65 years was 0.12%, 0.21% and 0.40%, respectively. Adjusting for confounders, multivariate regression analysis did show higher mortality with advancing age, but the increase was non-significant. The odds ratio for 30-day mortality in patients with diabetes was 1.8 with open and 2.4 with laparoscopic procedures. Age ≥ 65 was a significant predictor of PLOS for both open and laparoscopic procedures. For those who underwent laparoscopic procedures, odds ratios were similar for PLOS for the 50-64 years and ≥ 65 years cohorts. Major adverse events were not predicted by age ≥ 65 for either open or laparoscopic procedures. BMI ≥ 55 kg/m², however, and severe ASA [American Society of Anesthesiologists] score, cardiac co-morbidities, albumin < 3 and creatinine > 1.5, were all predictors of major adverse events.

Dorman concluded that bariatric surgery in the elderly population is increasing and leads to no significant increases in mortality or major adverse events in both open and laparoscopic procedures. “These data demonstrate that age should not serve as a sole deterrent for elderly patients undergoing bariatric surgery,” he said.

Commenting on the findings at the DDW press conference, John Morton, MD, associate professor and director of bariatric medicine at Stanford University said, “The benefit is clearly there. The groups of older patients who benefit most are those with diabetes—because they get such quick resolution of their symptoms, with 82% going off medication within a couple of weeks&mdash;and those with bad joint disease, because orthopedists aren’t always able to put total joint replacements in patients who carry weight.”