Comparative Study between the Outcomes of Laparoscopic Sleeve Gastrectomy in Middle Aged and Elderly Obese Patients

DISCUSSION

In the current study, we found more decrease in BMI and higher Wight loss in 2 respectively  and after 18 month was  82.20±8.04 kg and 28.50±0.68 kg/m² respectively in group 2 pre-operative weight was  115.40±10.90 kg and BMI was 39.48±1.41 kg/m² and after 18 month weight loss was 77.70±8.001kg and BMI was 26.58±1.20 kg/m², But statistically insignificant difference of mean weight and BMI was found between two groups of the study.

The postoperative losing weight and Mass index decrease are more substantial in the younger group, as per Nevo et al.⁷ research, which is also confirmed by Wang et al.⁸ meta-analytical review. In a small case-control study, Luppi et al.⁹ reported no significant variation in BMI among the older and younger groups at two years (33.2 vs. 31.5 kg/m2), but a substantial change in percentage EWL favouring the youngers (45 percent 9 vs. percent) (n=28).

Our findings are also consistent with those of the Bartosiak et al.¹⁰  study, in that the elderly cohort lost less weight than the control group. However, we disagree with them because the study group's mean postoperative BMI was considerably higher (12 months after surgery) (36.38 kg/m3 7.07 vs 33.10 kg/m3 5.65).

In the current study, the difference in mean hospital stay (days) between group 1 (3.4 days) and group 2 (2 days) is statistically insignificant (P.>0.05).

There are no highly relevant variations in outcomes seen between two age groups, according to the findings of the Burchett et al.¹¹ analysis. The mean hospital LOS was two or three days following SG in all age groups and 5.8 days in elderly patients, which was smaller than the two or three days documented in past research in all age groups and 5.8 days in senior patients.

Nor Hanipah et al.¹²group, who studied a total of 19 participants aged seventy five and over who had laparoscopic bariatric surgery involving GS, found that the median hospital stay was two days. On the other hand, Gebhart et al.¹³ found that the average length of hospital stay in old patients over sixty years was substantially greater (2.6 vs. 2.3 days) than in non-elderly patients.

In terms of intraoperative complications, 40% of group 1 required blood transfusions, which was statistically significantly greater than group 2 (0 percent ). In addition, 60% of group 1 had adhesions, which is statistically significantly greater than group 2 (0 percent). In terms of operating time, group 1 (85 minutes) has a statistically significant longer operative duration than group 2. (50 minutes).

According to numerous researches, such as Mizrahi et al.⁴, the elderly group had a longer operating time, and the operating time increment in their report was significantly longer compared to the other findings; Luppi et al.⁹, Leivonen et al.¹⁴, and Pequignot et al.¹⁵. Mizrahi et al.⁴ observed a greater rate of hiatal hernia, which was identified during surgical operations, with no statistically significant difference in terms of adhesion.

The longer operating time and surgical skills were linked to a greater incidence rate of problems in the elderly, according to a meta-analysis by Wang et al.⁸. Turrentine et al.¹⁶ discovered that when operating times lengthened, side effects such as cardiovascular events, pulmonary dysfunction, wound infections, and other problems occurred more often in the elderly. Meanwhile, they observed that the complexity of surgery had a factor in operation mortality in patients over 60. Aust et al.¹⁷ demonstrated this by looking at the impact of surgical complexity on patient risk variables and found that it had a significant contribution. As a consequence, decreasing the time of operations and simplifying processes may be beneficial in minimising the rate of difficulties.

One of the most significant outcomes of bariatric surgery is the resolution of comorbidities, which improves not only quality of life but also life expectancy. In our study, all of the controls received surgical correction for reproduction function abnormalities and osteoarthritis, which was statistically significantly greater than the old group (0 percent , 60 percent respectively). All participants in both groups improved their dyslipidemia and NAFLD grade 1; OSA was treated in 100% of the elderly group and 90% of the control group; and gout was corrected in 40% and 70% of the elderly group and control group, respectively.

Our results are similar to those of St Peter et al.¹⁸ and Dunkle-Blatter et al.^19, who showed that younger patients lost more weight but required less medication, with the same complication rates and mortality rates in both groups. The incidence of comorbidity remission after twelve months was equivalent in both older and younger subjects, according to a research by Leivonen et al.^14. The favourable benefits of bariatric surgery on the development of comorbidities seem to be unchanged by age, and the major benefit of bariatric surgery for elderly patients should be comorbidity management. In our research, COPD affects 40% of the elderly, which is statistically considerably greater than the control group.

At a twelve - month follow-up, Giordano and Victorzon²⁰ observed 54.5 percent remission of diabetic patients, 42.5 percent remission of hypertension, and 41 percent remission of dyslipidemia in a complete review of bariatric surgery in the elderly. Hutter et al.²¹ also published the first American College of Surgeons research on SG outcomes in the general population (n=944) in 2011. After a year of follow-up, diabetes remission or recovery rates were 79 percent, hypertension 81 percent, and OSA and dyslipidemia 74 percent.

In the Navarrete et al.²² series, there was no significant difference in remission or improvement of comorbidities between older and younger patients in diabetes (77.2 percent vs. 82.7 percent), hypertension (62.2 percent vs. 78.7%), or dyslipidemia (34.9 percent vs. 33.3). OSA remission was the only comorbidity with a significant difference favouring the younger group (60.8 percent vs. 76 percent, p= 0.02).

Identical outcomes with a 24-month follow-up, Pequignot et al.¹⁵  were able to achieve 87 percent diabetic remission, 81 percent hypertension remission, and 94 percent dyslipidemia remission in the elderly, with no difference when compared to the control group. This disparity is likely affected by the fact that elderly individuals have greater chronic respiratory changes over time as a result of variables such as smoke or environmental factors.

The Burchett et al.¹¹ study found that SG is safe and beneficial in elderly obese individuals, with no significant differences in results between patients having SG at age

Wang et al.⁸ meta-analysis considered that the higher incidence rate of complications in the old patients was related to the longer operating time and surgical skills, as Turrentine et al.¹⁶ found that an increase of operating duration would increase the occurrences of adverse events, such as cardiovascular events, respiratory dysfunction, wound infections, and other complications for the old patients. Meanwhile, he also found that operation complexity contributed to operation mortality in patients older than age 60. It was proven by Aust et al.¹⁷ who studied the impact of operative complexity on patient risk factors and finally emphasized that operation complexity played a major role. Thus, simplifying procedures and shortening operation time could be effective to reduce incidence rate of complications

Resolution of comorbidities is one of the most important outcome metrics of bariatric surgery because not only does it improve quality of life, but also life expectancy. Regarding postoperative correction of comorbidities in our study, all of control group had correction for reproduction function abnormalities and osteoarthritis, statistically significant higher than elderly group (0%, 60% respectively).  Dyslipidemia and NAFLD grade 1 were improved in all participants in both groups, OSA was corrected in 100% in elderly group and 90 % in control group and gout was corrected in 40% and 70% of elderly group and control group respectively

Our findings are in correlation with the studies by St Peter et al.¹⁸ and Dunkle-Blatter et al.¹⁹ who showed greater weight loss in younger patients, but a greater reduction in medication use in older patients, with similar complication rate and mortality in both groups. A report by Leivonen et al.¹⁴ showed that comorbidity remission rate after 12 months was similar in older and younger patients. Positive influence of bariatric surgery on the course of the comorbidities seems not to be affected by age and comorbidity improvement should be considered as the major benefit from bariatric surgery for the elderly patients. As in our study with 40% of elderly have COPD, statistically significant higher than control group.

Furthermore, the authors feel that perioperative risk is determined more by the number and severity of comorbidities than by age. Clearly, medical optimization and continued attentiveness are critical variables in ensuring that older obese patients have a safe and effective outcome.⁸

CONCLUSION

We concluded that the relatively low major complication rate along with excellent weight reduction and comorbidity improvement make the LSG a reasonable effective and safe surgical option for the elderly.