Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass in the Elderly: 1-Year Preliminary Outcomes in a Randomized Trial (BASE Trial)

Abstract

Dear Editor, We read with interest the paper by Pajecki et coll. reporting the preliminary outcomes of a randomized study involving 36 patients aged 65 years or more randomized to undergo either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with 12 months of follow-up [1]. Patients undergoing RYGB showed significantly higher excess weight loss (EWL), total weight loss (TWL), and better LDL control while no difference was observed in remission rate of the obesity-related comorbidities, e.g., hypertension, type 2 diabetes mellitus (T2DM), and dyslipidemia at 1 year. While we congratulate the authors for their interesting study which is the first randomized trial comparing RYGB and SG in elderly patients with obesity, we would like to point out some elements that need to be further discussed. The omission of information on postoperative course and intraoperative and postoperative complications is a major weakness. If on one side this remains quite surprising since surgical and clinical complications are reported among the primary outcome measures in the study protocol registered at ClinicalTrials.gov (NCT03339791), data on complications cannot be omitted to draw reliable (even though preliminary) conclusions when comparing two surgical procedures. The authors only focalize their report on the better results in terms of weight loss that RYGB provided in their study population compared to SG. This is not a new finding, since there is currently a large body of literature almost uniformly reporting that RYGB provides better weight loss than SG at short and long term [2, 3]. The difference between the two operations in terms of weight loss is well known and it has already been reported in elderly population, although not in randomized trials [4, 5]. This is why the results of the present study are in no way a novelty. Bariatric surgery in the elderly is challenging and needs a complex approach. Elderly patients, in fact, have a higher risk to develop postoperative complications after bariatric surgery compared to the younger counterpart. As a matter of fact, studies on the topic report a higher rate of adverse event, as well as a higher 30-daymortality rate in patients aged 65 years and more undergoing RYGB compared to younger patients [6–8]. One possible explanation may be identified in the fact that in this selected population comorbidities are more frequent and usually more severe and the functional reserve in case of complications is limited [9]. Furthermore, the few comparative studies available until now comparing different surgeries in the elderly population indicate that complication rate is higher after RYGB than after SG [4, 5]. This is a main point, since the outcomes of any bariatric procedure in terms of weight loss and comorbidities improvement must be weighed against the additional risk of morbidity and mortality. As this risk is increased in this selected population of patients, the choice of the procedure should be carefully chosen after multidisciplinary discussion and also considering patient’s wish. Another crucial aspect is that in the elderly population the expected weight loss is often lower, and its impact on the quality of life is variable and difficult to predict [9]. In this scenario, the main goal of bariatric and metabolic surgery should be to improve the quality of life as the effect on life expectancy does not seem to be affected [9–11]. Despite this, most studies indicate that bariatric surgery in elderly patients can provide the same results in terms of comorbidities improvement observed in younger patients [12–14]. * Enrico Facchiano [email protected]