Benefits and risks of bariatric surgery in patients aged more than 60 years.

BACKGROUND: The benefits and risks of bariatric surgery are debated in older patients. The objective of this study was to compare the weight changes and adverse outcomes in patients>60 years and in younger ones. METHODS: The French SOFFCO registry was screened for gastric bypass (RYGB), gastric banding (LAGB), or sleeve gastrectomy (SG) performed between 2007 and 2010. Adverse outcomes and weight changes (%) over 12 months were compared between patients<40 years (N = 1379), between 40-59 years (N = 1065), and>60 years (N = 164). RESULTS: After a RYGB surgical (12.3 versus 3.8%; P = .03) and nonsurgical (7.0% versus .8%; P = .01) complications were more prevalent in patients above 60 years than in those below 40. No increased prevalence of surgical and nonsurgical complications was seen after a LAGB or a SG. Weight loss (% of initial weight) was lower after a LAGB than after a RYGB or a SG. After LAGB weight loss (%) did not differ between patients above 60 years and those aged<40 (difference 1.7±1.5%, P = .26). After a RYGB weight loss (%) was lower in patients aged>60 years (-5.6±1.7%, P = .001) than in those aged<40 years. After a SG, weight loss (%) was lower in patients aged>60 years (-7.0±2.6%, P = .01) than in those aged<40 years. CONCLUSION: Bariatric surgery can be a short-term effective and safe therapeutic option in elderly patients. LAGB or SG appears to be an alternative strategy to RYGB, with lower adverse outcome rate.

The use of fibrin sealant to prevent major complications following laparoscopic gastric bypass: results of a multicenter, randomized trial.

BACKGROUND: Published interim results have shown that fibrin sealant (Tissucol/Tisseel Baxter AG, Vienna, Austria) may be effective in preventing anastomotic leaks and internal hernias following laparoscopic Roux-en-Y gastric bypass (LRYGBP). We report the final results of a multicenter, randomized clinical trial evaluating the use of fibrin sealant in LRYGBP. METHODS: Between January 2004 and December 2005, 340 patients aged 21-65 years with a body mass index (BMI) of 40-59 kg/m(2) undergoing LRYGBP were randomized (1:1) to two treatment groups: fibrin sealant group (applied to gastrojejunal and jejunojejunal anastomoses and over mesenteric openings), and control group (no fibrin sealant; suture of the mesenteric openings). Operative time, early and late complications, reinterventions, time to oral diet initiation, and length of stay were assessed. RESULTS: Overall, 320 patients were included into the study: 160 in the control group and 160 in the fibrin sealant group. All patients completed follow-up assessments at 6 and 12 months, and 60.9% completed assessments at 24 months. There were no significant differences between groups with respect to demographics, operative time, oral diet initiation, hospital stay, and BMI reduction at 6, 12, and 24 months. The incidence of anastomotic leak was numerically, but not significantly, greater in the control group. The overall reintervention rate for specific early complications (<30 days) was significantly higher in the control group (p = 0.016). No deaths or conversions to open laparotomy occurred. CONCLUSION: The use of fibrin sealant in laparoscopic RYGBP may be beneficial in reducing the reintervention rate for major perioperative (<30 days) complications. Larger studies are needed.

Long-term results of subtotal colectomy with cecorectal anastomosis for isolated colonic inertia.

AIM: To evaluate the results of sub total colectomy with cecorectal anastomosis (STC-CRA) for isolated colonic inertia (CI). METHODS: Fourteen patients (mean age 57.5 +/- 16.5 year) underwent surgery for isolated CI between January 1986 and December 2002. The mean frequency of bowel motions with the aid of laxatives was 1.2 +/- 0.6 per week. All subjects underwent colonoscopy, anorectal manometry, cinedefaecography and colonic transit time (CTT). CI was defined as diffuse markers delay on CTT without evidence of pelvic floor dysfunction. All patients underwent STC-CRA. Long-term follow-up was obtained prospectively by clinical visits between October 2005 and February 2006 at a mean of 10.5 +/- 3.6 years (range 5-16 years) during which we considered the number of stool emissions, the presence of abdominal pain or digitations, the use of pain killers, laxatives and/or fibers. Patients were also asked if they were satisfied with the surgery. RESULTS: There was no postoperative mortality. Postoperative complications occurred in 21.4% (3/14). At the end of follow-up, bowel frequency was significantly (P < 0.05) increased to a mean of 4.8 +/- 7.5 per day (range 1-30). One patient reported disabling diarrhea. Two patients used laxatives less than three times per month without complaining of what they called constipation. Overall, 78.5% of patients would have chosen surgery again if necessary. CONCLUSION: STC-CRA is feasible and safe in patients with CI achieving 79% of success at a mean follow-up of 10.5 years. A prospective controlled evaluation is warranted to verify the advantages of this surgical approach in patients with CI.

Cost-effectiveness and budget impact of obesity surgery in patients with type-2 diabetes in three European countries.

BACKGROUND: We aimed to establish a payer-perspective cost-effectiveness and budget impact (BI) model of adjustable gastric banding (AGB) and gastric bypass (GBP) vs conventional treatment (CT) in patients with BMI > or =35 kg/m(2) and type-2 diabetes T2DM, in Germany, UK and France. METHODS: Clinical evidence was obtained from literature and patient-reported EQ-5D scores given BMI and T2DM status from HODaR. Resource utilization data in AGB, GBP and CT were obtained from quoted publications so as to reflect practice in 2005. CT in each country was based on descriptions in HTA reports or based on co-authors' experience of current practice. Unit costs were obtained from published sources when available, or from co-authors' institutions. A deterministic algorithm with cost and utility discounting, enabled selection of inputs independently throughout the time scope for each of the 3 treatments, and included mean BMI, amounts of resources and unit costs. RESULTS: The base case time-scope was 5 years, and the annual discount rate for utilities and costs was 3.5%. Compared to CT, GBP yielded +80.8 kg/m(2).years, +2.6 T2DM-free-years and +1.34 QALYs. AGB yielded +57.8 kg/m(2).years, +2.5 T2DM-free-years and +1.03 QALYs. In Germany and France, both GBP and AGB yielded a cost decrease, and were thus dominant in terms of ICER compared to CT. In the UK, GBP and AGB yielded a cost increase, but were cost-effective. CONCLUSION: In patients with T2DM and BMI > or =35 kg/m(2), AGB and GBP are effective at 5-year follow-up in cost-saving in Germany and France, and are cost-effective in the UK with a moderate BI vs CT.

Long-term results of transperitoneal laparoscopic fenestration in the treatment of simple renal cysts.

The aim of this paper was to assess long-term results of transperitoneal laparoscopic fenestration in the treatment of symptomatic simple renal cysts. Fifteen consecutive patients (7 men, 8 women), with a mean age of 51 years (range, 36-79 years), underwent transperitoneal fenestration of simple renal cysts (SRC) at our institution from 1994 to 2001. Data were collected by reviewing patients' clinical files, conducting telephone interviews regarding symptoms, and followup renal ultrasonography (US). There were 15 symptomatic cysts (10 parenchymal, 5 peripelvic) ranging in diameter from 3.5 to 20 cm (mean, 8 cm). All patients had lumbar pain and in four (26.6%) the collecting system was compressed by the cysts. Fenestration was carried out laparoscopically in all patients. There was no mortality and no postoperative complications were recorded. No malignancies were detected at final histopathology. Mean length of stay was 2.5 days. All patients were available for long-term followup. At a mean of 60 months (range, 22-93 months) from surgery, three patients (20%) complained of slight discomfort in the lumbar area not requiring any analgesic. No recurrence of the cysts was seen on US. Two asymptomatic patients (13.3%) developed additional cysts originating from sites different than the one operated on. Laparoscopic fenestration of SRC is safe and effective in the long term to relieve patients from symptoms.