Is bariatric surgery a safe option in extremely high-risk morbidly obese patients?

Ali Aminian, MD, FICS, Esam Batayyah, MD, Hector Romero-Talamas, MD, Eric P Ahnfeldt, DO, FACS, Andrea Zelisko, MD, Tomasz Rogula, MD, PhD, Matthew D Kroh, MD, FACS, Bipan Chand, MD, FACS, Stacy A Brethauer, MD, FACS, Philip R Schauer, MD, FACS

Bariatric and Metabolic Institute, Cleveland Clinic, Ohio

Introduction: Advanced age, super-obesity, and cardiopulmonary co-morbidities are generally associated with increased surgical risk. The presence of multiple risk factors has been considered a relative contraindication for laparoscopic bariatric surgery (LBS). The aim of this study was to evaluate the outcomes following LBS in an extremely high-risk patient population.

Methods: Between 01/06 and 06/12, 3240 consecutive patients underwent LBS by one of five bariatric surgeons at a single institution. We defined extremely high-risk patients by age at the time of surgery ≥65 years, BMI ≥50 kg/m^2, and presence of at least 2 of 6 cardiopulmonary or vascular co-morbidities (hypertension, ischemic heart disease, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and past history of deep vein thrombosis or pulmonary embolism). Demographic data and medium-term postoperative outcomes were assessed.

Results: A total of 44 patients (1.4% of all patients) met our criteria. Patients had male to female ratio of 9:35, a mean age of 67.9±2.7 (range, 65-76) years, mean BMI of 54.8±5.5 (range, 50-82) kg/m^2, and median ASA score of 3 (range, 3-4). The median number of cardiopulmonary and all co-morbidities were 2 (range, 2-5) and 6 (range, 5-13), respectively. Surgical procedures included Roux-en-Y gastric bypass (RYGB, n=23), adjustable gastric banding (AGB, n=11), and sleeve gastrectomy (SG, n=10). One operation was revisional LBS and simultaneous hernia repair was performed in 4 cases (9%). There were no intraoperative complications and conversion to open technique. The mean operative time (OT) and length of hospital stay (LOS) were 170.9±56.9 (range, 54-246) minutes and 4.1±3.0 (range, 1-17) days, respectively. In total, thirteen (29.5%) 30-day postoperative complications occurred. Among them, six (13.6%) complications were major including leak of gastrojejunal anastomosis (n=1, 2.2%), adhesive obstruction (n=1), pulmonary embolism (n=1), myocardial infarction (n=1), atrial fibrillation (n=1), and respiratory failure (n=1). The 30-day postoperative re-admission, re-operation, and mortality rate were 15.9%, 2.2%, and zero, respectively. In the mean follow-up time of 20.5±15.6 (range, 1-54) months, the late morbidity and mortality rate were 20.4% and 2.2%, respectively. The median excess weight loss and BMI loss after one year were 34.1 (range, 13.3-97.6) and 37.1 (range, 15.3-98.8) percent, respectively. In subgroup analysis, AGB was associated with a significantly shorter OT and LOS, as compared with SG and RYGB. All of the major early complications except one (n=5) occurred after RYGB, however the difference among surgical groups did not reach statistical significance. Statistical analysis revealed no significant correlation between age, BMI, and number of cardiopulmonary and total co-morbidities with perioperative and long-term outcomes.

Conclusion: Extremely high-risk patients can be offered LBS without imposing significant risks in terms of intraoperative and postoperative outcomes. Preoperative optimization through comprehensive and multidisciplinary assessments and extensive surgical experience may have contributed to less-than-expected surgical risk of bariatric patients who are super-obese, of advanced age, and who have had severe cardiopulmonary co-morbidities. Those risk factors should not be the reason to exclude patients from consideration for LBS.

Session: Poster Presentation

Program Number: P460

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