Bariatric Surgery Appears Safe for Selected Older Patients

CLEVELAND, June 18 -- Neither age nor Medicare status should be determinants for gastric bypass surgery, researchers here found.

No statistically significant differences in complications after surgery or in mortality were found between patients younger than 60 and those 60 and older, Peter T. Hallowell, M.D., of Case Western Reserve University here, and colleagues reported in the June issue of the Archives of Surgery.

The same held true for patients who had Medicare coverage (generally because of disabilities) and those covered by private insurance.

In a 1977 report of higher mortality rates for patients older than 50, researchers advised against bariatric surgery for these individuals, and the advice was followed by many surgeons for nearly two decades, Dr. Hallowell said.

To evaluate the experience at their own academic, tertiary care center, the researchers undertook a retrospective review of a prospectively maintained bariatric database.

The database included 892 consecutive patients who underwent gastric bypass from March 24, 1998, through May 31, 2006.

The review looked at the data first by age and then by Medicare status.

There were 46 patients ages 60 or older at the time of gastric bypass (range, 60 to 66 years) and 846 patients who were younger than 60 (range, 18 to 59 years).

Male-female ratios and body mass index (BMI) were similar between the two age groups. The average number of comorbidities was six for the older group and five for the younger.

Length of hospital stay was half a day longer for the older patients, but this difference was not statistically significant (P=0.40).

The operating room time for the older group was statistically significantly shorter, with a mean time 17 minutes less than that for the younger group.

The mean American Society of Anesthesiologists (ASA) scores for the older and younger patients were similar at 3 and 2.9, respectively.

No statistically significant difference was found between the two groups of patients for any postoperative complication or mortality.

A year out, there were no deaths among the older patients. Three deaths occurred within 30 days in the younger group with one additional death, a homicide, within a year.

The Medicare phase of the study compared non-Medicare patients with Medicare patients, both young and old, thereby diluting the age comparison.

Most of those insured by Medicare (31) qualified for coverage because of chronic disability (29), not age. The average number of comorbidities was six for the Medicare patients and five for those not on Medicare, the researchers said.

There were significant differences between these two groups:

• Medicare patients had a significantly greater mean BMI of 56 (P=0.001)
• Medicare patients had a significantly longer mean operating room time (P=0.03).
• ASA scores for the Medicare and non-Medicare groups were 3.1 and 2.8, respectively (P =0.01).

The difference in length of hospital stay was not statistically significant (P=0.07), nor were differences in postoperative complications and mortality, the researchers reported.

No deaths occurred at 30 days, 90 days, or one year among the Medicare patients. Among the non-Medicare patients, three deaths occurred within 30 days and there was one additional death within one year.

Possible explanations for the findings in the study include patient selection, surgeon experience, perioperative evaluation and management, preop and postop education, and program philosophies regarding smoking cessation, exercise, and preoperative weight management, the researchers said.

All patients had to be smoke-free for three months before surgery, were required to exercise at least four days a week (walking, swimming, or biking), and could not gain any weight between the initial visit and the surgery.

Despite evidence that the Medicare patients were sicker than the group as a whole, their outcomes were comparable, the researchers said.

In a discussion of the report in the same issue of the journal, three physicians asked questions that co-author Thomas A. Stellato, M.D., addressed.

Ravi Moonka, M.D., of the University of Washington in Seattle, called the study "invaluable" because, he said, it will help improve the outcomes for gastric bypass surgery.

It is really two studies in one, he said, and there is a lot of overlap between the groups. "If I were to quibble, he said, it would be with the relatively small number of patients in the study cohort.

He asked why patients were not excluded on the basis of body mass index, a well-established risk factor for mortality after bariatric surgery.

Dr. Stellato agreed with the limitation imposed by the small number of patients writing that "there is no question that the small numbers in this study are a liability."

He explained that the study used actual weight as the exclusion, a simple function of the operating room resources available at the hospital. Consequently, he said, they do not operate on patients who weigh more than 500 pounds.

A second discussant, Leah Anne Neumayer, M.D., of the University of Utah in Salt Lake City, asked whether perioperative processes changed when sleep apnea was identified.

Dr. Stellato noted that all such patients must be titrated with continuous positive pressure airway machines and must bring their machines to the hospital on the day of surgery. "If they haven't been titrated, he said, the surgery will be postponed until they actually receive CPAP."

Dr. Kenneth J. Printen of Wilmette, Ill., an early pioneer in bariatric surgery asked about differences in selection criteria between younger and older patients.

Dr. Stellato said that they do not operate on someone who is bedridden, and, if the patient is wheelchair-bound, he must be able to walk a few steps.

Otherwise, Dr. Stellato said, "I am not sure that the criteria are really any different in someone older than someone younger. We are going to be more aggressive in terms of pulmonary evaluation, and everyone is going to get a cardiology consult."