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High-risk patients

Bariatric surgery can be performed safely in severe high-risk patients

LRYGB can be performed safely in the patients with liver cirrhosis or other severe comorbidities in selected cases, while LSG is a safe option in patients who are severely obese

Bariatric surgery for severe high-risk patients can be performed safely in high-volume centres following standardised procedures, according to researchers from the University of Leipzig and the Integrated Treatment and Research Centre (IFB) for Obesity Diseases, Leipzig, Germany. They note that laparoscopic Roux-en-Y gastric bypass (LRYGB) can be performed safely in the patients with liver cirrhosis or other severe comorbidities in selected cases, while laparoscopic sleeve gastrectomy (LSG) is a safe option in patients who are severely obese (BMI≥70). The paper, ‘Feasibility and Safety of Bariatric Surgery in High-Risk Patients: A Single-Center Experience’, was published in the Journal of Obesity.

Although bariatric surgery has been deemed safe in low-risk patients, high-risk patients with vast obesity and severe comorbidities still demonstrate relatively high perioperative morbidity and mortality rates. This unique group of patients represent a particular challenge even for highly-experienced surgeons, with mortality in obese patients with high risk is 17-fold greater compared to no-risk patients. Therefore, the study researchers sought to identify the factors to form a profile of high-risk bariatric patients.

The researchers retrospectively analysed high-risk patients undergoing bariatric surgery at their centre, who had one of the risk factors (summarised in Table 1) and at least two of obesity-associated comorbidities such as T2DM, arterial hypertension, OSA, or chronic obstructive pulmonary disease (COPD)/asthma.

Table 1: Definition of high risks

The morbidity and mortality rates were analysed for a period of 30 days postoperatively and all patients had an outpatient visit after 12 and 48 days postoperatively. The severity of the postoperative complications was categorized according to the Clavien–Dindo classification.

Outcomes

Between May 2012 and December 2016, a total of 25 high-risk patients undergoing bariatric surgery were identified (Figure 1). Among the 25 patients, there were 11 (44%) females and the mean age was 50.9±13.8 years. LSG was performed in 14 patients (56%) and LRYGB in 11 patients (44%). The median duration of the surgery was 152 min (range 79 to 310 min) and was analogous to the no-risk group (median 160min).

Figure 1: The number of patients in each high-risk subgroup (%)

The characteristics of the study cohort and the incidence of additional comorbidities such as diabetes mellitus, hypertension, gastroesophageal reflux disease, OSA, and COPD are summarised in Table 2.

Table 2: Baseline of study cohort. Entries are medians (range) or numbers (%); LRYGB = laparoscopic Roux-en-Y gastric bypass; LSG = laparoscopic sleeve gastrectomy; BMI = body mass index; GERD = gastroesophageal reflux disease; DVT = deep vein thrombosis

The length of stay at hospital was in mean 4.4 ± 1.4 days. Twenty-three patients (92%) could be discharged at the fourth day postoperatively, as scheduled via standards. One patient was discharged two days later due to unclear high inflammatory laboratory values. One patient had a stapler line leak two days after LSG and underwent revision by relaparoscopy on the same day. The leak was closed with a running suture. The rate of the major complications, Grade IIIb, was 4%. The distribution of the postoperative complications within the first postoperative month (according to the Clavien–Dindo classification). There were no instances of postoperative bleeding, acute renal failure, pneumonia, vein thrombosis, respiratory failure, acute liver failure, and pulmonary thrombosis within the first 30 days following the operation, and the mortality rate was 0%.

In the subgroup of patients with BMI≥70, LSG was performed in the majority of the patients (90%, n=9/10). In three patients of this subgroup, a previous endoscopic therapy (1x EndoBarrier Therapy, 2x gastric balloon) had failed. One patient underwent a LRYGB without postoperative complications and was discharged on the 4th postoperative day as planned. For BMI≥70 patients undergoing LSG, their mean weight was 217kg (range 189–249kg) and the mean operative time was 137min (range 79–310min).

Nine patients (2%) had liver cirrhosis, which was was unknown before surgery in six patients (1.3%) and was confirmed through a simultaneous biopsy during the operation. One patient with known liver cirrhosis preoperatively suffered from Child B cirrhosis and the other two from Child A. LRYGB was performed in six patients and LSG in three patients out of the cirrhosis subgroup. No bleeding or liver decompensation was observed postoperatively.

Although the patient’s number with BMI≥70 was low in this cohort, LSG appears as a safe primary procedure for handling patients with extremely high BMI, the researchers noted, and despite the limited number of patients, this study confirms that even LRYGB can be done safely in selected cases.

“Our data suggest that standardized bariatric surgery in high-volume centres can be performed safely in advanced high-risk patients,” the researchers conclude. “Regarding the procedure, LRYGB can be done safely in the patients with liver cirrhosis or other severe comorbidities in selected cases, while LSG is a safe option in patients who are super-super obese.”

To access this paper, please click here

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