Hindawi Journal of Obesity Volume 2020, Article ID 8783260, 6 pages https://doi.org/10.1155/2020/8783260 Research Article A Propensity Score Cohort Study on the Long-Term Safety and Efficacy of Sleeve Gastrectomy in Patients Older Than Age 60 Judith Molero,1 Romina Olbeyra,2 Josep Vidal,1,2,3 Ferran Torres,4 Silvia Cañizares,1,5 Alba Andreu,1 Ainitze Ibarzabal,6,7 Amanda Jiménez,1,2 Ana de Hollanda,1,2,8 Violeta Moizé,1 and Lilliam Flores 1,2,3 1 Endocrinology and Nutrition Department, Obesity Unit, Hospital Clinic, 170, Villarroel Street, Helios Office 9, Barcelona 08036, Spain 2 Institutd’Investigacions Biomèdiques August Pi Sunyer IDIBAPS, 180, Corcega Street, Barcelona 08036, Spain 3 Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain 4 Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Medical Statistics Core Facility, IDIBAPS, Hospital Clinic Barcelona, Barcelona 08036, Spain 5 Psychiatry and Psychology Department, Hospital Clinic, Department of Clinical Psychology and Psychobiosslogy, University of Barcelona, Barcelona 08036, Spain 6 Department of Surgery, ICMDM, Hospital Clinic of Barcelona, Barcelona, Spain 7 Gastrointestinal Surgery Department, Obesity Unit, Hospital Clı́nic de Barcelona, Barcelona, Spain 8 Centro de Investigación Biomédica en Red, Fisiopatologı́a de la Obesidad y Nutrición (CIBEROBN), Barcelona, Spain Correspondence should be addressed to Lilliam Flores; lflores@clinic.cat Received 6 May 2020; Accepted 8 July 2020; Published 1 August 2020 Academic Editor: Claire Stocker Copyright © 2020 Judith Molero et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Bariatric surgery (BS) in older obese subjects (>60 years of age) has risen in the past decade and will continue to rise in the coming years due to ageing of the population. Aim. To evaluate the short- (12 months) and long-term (60 months) results of laparoscopic sleeve gastroscopy (LSG) in patients older than age 60. Methods. We performed a retrospective review of patients prospectively included in a database from January 2007 to December 2013. All patients >60 [older group (OG)] who had undergone LSG were included. The control group (CG) included patients aged 50 to 59 years who had undergone LSG during the same period. Results. 116 (8.4 % of total surgery) and 145 patients were included in the OG and CG, respectively. BS in patients >60 years increased from 2.4% in 2003 to 14% in the last 2 years of the study. After inverse probability of treatment weighting (IPTW) analysis, all absolute standardized differences were <0.15. A 60-month follow-up was attained in 90% of patients in the OG and 74% in the CG. There were no significant differences in postoperative complications between the two groups. At 12 and 60 months after LSG, both groups achieved a similar body mass index. There was no statistical difference in the percentage of resolution of type 2 diabetes, hypertension, dyslipidemia, and SAHS between the two groups. In both groups, all the nutritional parameters evaluated remained within the normal range throughout the study. Conclusions. LSG provides acceptable outcomes and is safe in older adults indicating that age should not be a limitation to perform BS in this population. 1. Introduction age [2]. In 2017, 25.3% of the population in Spain was older than age 60, and this prevalence is projected to increase to The incidence of obesity continues to rise especially in older 41.9% by 2050 [3]. Bariatric surgery (BS) is currently the only adults (a population defined by the United Nations as adults effective treatment to achieve significant and sustained weight aged ≥60 years) [1]. In addition, the number of older adults has loss (WL) in patients with severe obesity [4]. considerably increased in developed countries and will likely The use of BS in older adults was initially limited due to a increase further as the baby boomer generation continues to greater inherent risk, the lack of evidence of long-term 2 Journal of Obesity impact of BS on weight control, remission, improvement of 1.5 g/kg of ideal body weight/day), vitamin, and mineral comorbidities, and nutritional level as well as the potential supplementation were prescribed. The exclusion criteria harmful effects of massive WL on muscle and bone mass were liver cirrhosis, chronic renal failure (creatinine ≥2 mg/ [5, 6]. Nonetheless, the use of BS in subjects >60 years has dl or glomerular filtration less than 40 ml/min), follow-up risen in the last decade, representing 10% of patients un- less than 1 year, or no information about the primary dergoing BS in the United States [7]. This increase coincides variable of the study. with the documented safety of BS due to the incorporation of The following variables of all the patients were obtained the laparoscopic approach and improvements in preoper- from the database: anthropometric data, age, body mass ative management in addition to the aforementioned ex- index (BMI), presurgical comorbidities (T2D, hypertension, ponential increase in obesity in this population group, dyslipidemia, and sleep apnea hypopnea syndrome (SAHS)). which, in the coming years, will lead to a greater number of Duration of follow-up, diagnosis, and resolution of obesity- older adults requiring BS. related comorbidities were defined according to the stan- Previous studies have compared the safety, WL, and dardized metabolic and BS outcomes of the American So- comorbidity resolution following laparoscopic BS in ciety for Metabolic and Bariatric Surgery (ASMBS) younger and older cohorts, and logically, these comparisons recommendations [9]. The operative variables collected are affected by significant bias due to the inherent differences included the type of surgery, American Society of Anes- in overall health, with, thus, a less favorable operative risk thesiologists Score (ASA), and postoperative complications profile in older aged subjects. In addition, studies on mid- at 30 days. The complications were classified according to the and long-term outcomes of BS in older adults using the Clavien-Dindo classification. Clavien-Dindo II-IIIa (adverse current surgical approaches are still scarce. Therefore, at events requiring medication or an intervention under local present, the major deficiencies in the knowledge about BS in anesthesia) were defined as significant, and Clavien-Dindo older adults do not allow firm conclusions to be drawn to IIIb-V (adverse events requiring an intervention under help guide clinical recommendations. general anesthesia) were defined as serious [10]. In addition, Taking all of the above into account, the aim of this study biochemical (hemoglobin, red blood cells, hematocrit, cre- was to evaluate both the short- (12 months) and long-term atinine, uric acid, total cholesterol, c-HDL, c-LDL, triglyc- (60 months) evolution of anthropometric measures, erides, alanine amino transferase (ALT), aspartate amino comorbidities, and nutritional parameters in patients older transferase (AST), gamma-glutamyl transferase (gGT), and than age 60 who had undergone LSG compared with in- albumin) and nutritional parameters (ferritin, transferrin, dividuals of age 50–59 who had also undergone LSG using prealbumin, folic acid, calcium, magnesium, phosphorus, an inverse probability of treatment weighting- (IPTW-) vitamin D3, PTH and vitamin B12) were registered. Finally, based analysis. This analysis reduces the impact of treat- absolute body weight lost (ABWL in kg) and total body ment-selection bias and the potential confounding factors weight lost (TBWL %) were calculated at 12 and 60 months inherent to an observational study, thereby facilitating ad- of follow-up [9]. Outcomes were assessed at the time of justed comparisons between the two groups. surgery, and at 12 months and 5 years after BS. Our hypothesis was that LSG would provide benefits Loss to follow-up was assessed as misses at scheduled without differences between the two groups, thereby sup- appointments and no attempt to contact was made. porting extension of the upper age limit for BS. The study was approved by the Ethics Review Board of our institution, and the need for informed consent was 2. Material and Methods waived due to the retrospective nature of the investigation (HCB/2019/0641). We performed a retrospective review of patients prospec- tively included in a database in our institution (university 3. Statistical Analysis hospital) from January 2007 to December 2013. All patients older than age 60 (older group (OG)) who had undergone A biostatistician (FT) was responsible for the statistical LSG as a stand-alone procedure with a follow-up of one to analyses. Categorial variables are described as frequencies five years were included in the study. In order to select an and percentages and continuous variables as mean (standard appropriate older control group (CG), we included patients deviation). We used standardized differences, defined as aged between 50 and 59 who had undergone LSG between differences between groups divided by pooled standard January 2007 and December 2013 to ensure a 5-year follow- deviation to assess heterogeneity between the two cohorts up. for baseline covariables. The IPTW approach [11] was used All patients met the standard eligibility for BS [4]. In our to create a pseudo-population in which the 2 surgery groups institution, the criteria to perform LSG are age >60 years, a were balanced across baseline covariates. The stabilized body mass index (BMI) > 50 kg/m2, and high surgical risk. weights were calculated using propensity scores [12] ob- On the other hand, laparoscopic gastric bypass (LGB) was tained from a logistic regression model aimed at minimizing performed in cases with a history of moderate to severe the between arms standardized differences [13]. The cova- gastroesophageal reflux disease. SG was performed as de- riates included in the final propensity score model were sex, scribed elsewhere [8]. The postoperative follow-up visits BMI, excess body weight (EBW), ASA, current smoking, were scheduled at 4 and 12 months during the first year and T2D, duration of type 2 DM, insulin treatment, hyperten- yearly thereafter, and protein (minimum 60 g/day and up to sion, duration of arterial hypertension AHT, hypotensive Journal of Obesity 3 treatment with more than 3 drugs, and dyslipidemia. analysis, all absolute standardized differences were <0.15. Postbaseline variables and outcomes were available only During follow-up, 11 and 12 patients in the OG and CG, after the definition of the final model for the IPTW. Co- respectively, underwent revisional surgery and were not variate balance was assessed using the standardized differ- included in the analysis at 60 months. A follow-up of 60 ences (STD) with the initial goal of achieving values <0.10 months was attained in 95/106 patients (90%) in the OG and using the IPTW to define insignificant differences in po- 98/133 (74%) in the CG. Table 1 shows the baseline char- tential confounders. For baseline comparisons, the cut-off acteristics of the raw and IPTW analyses in the two groups. target was achieved in all variables except for sex (STD: Table 2 shows the rates of operative and 30-day post- −0.13) and SAHS (STD � −0.12), although, for some authors, operative complications according to the Clavien-Dindo these values are acceptable because the STD is less than 0.2 classification. The groups did not differ in the rate of [14]. Baseline categorical variables were compared using the postoperative complications. The overall rate of complica- chi-square test, and continuous variables were compared tions was low (9,5%), with 5 complications being considered using ANOVA with rank-transformed data for both raw and as severe, precluding the need for statistical analysis. No IPTW analyses. The primary outcome was the comparison of surgical conversion from laparoscopic to open surgery was %TBWL between the OG and CG groups at the final time needed. There were no perioperative deaths. point. Secondary outcomes included the operative/30-day Table 3 summarizes the postoperative WL results and postoperative complication rate and remission and resolu- improvement of comorbidities in these patients. At 12 and tion of type 2 DM, arterial hypertension, dyslipidemia, and 60 months after LSG, both groups achieved a similar BMI. SAHS. However, OG patients had a significantly lower ABWL (kg) Continuous longitudinal data were analyzed using a and TBWL (%). There were no statistical differences in the restricted maximum likelihood- (REML-) based repeated percentage of resolution of T2D, hypertension, dyslipidemia, measures approach including the fixed, categorical effects of and SAHS between the two groups. Additionally, glycaemia, treatment, time, and treatment by time, setting the (co) A1c, creatinine, liver enzymes, total cholesterol, triglycer- variance structure to the compound symmetry type. Lon- ides, c-HDL, c-LDL, and uric acid levels were similar be- gitudinal binary data were analyzed using marginal models tween the 2 groups at both 12 and 60 months after LSG. including the same effects as for the continuous variables. Table 4 shows the nutritional status of the two study The models were IPTW weighted in both longitudinal groups. In both groups, all the parameters evaluated analyses. remained within the normal range throughout the study In addition, a post hoc ancillary analysis was conducted except for transferrin which significantly decreased at 12 to explore the covariate difference regardless of extreme age months after LSG in comparison to the pre-LSG value. categories: <60 years versus ≥65 years. In this case, we used Indeed these values were below normal at 12 months, but 1 : 2 matching to obtain patients with similar characteristics. they recovered to normal levels in the evaluation at 60 The statistical analyses were performed using SAS 9.4 months, being significantly lower in the OG. In addition, red (SAS Institute, Inc., Cary, NC, USA). blood cells, hemoglobin, and hematocrit levels remained within the normal range and were similar in both groups. 4. Results PTH significant decreased at 12 months after LSG but in- creased thereafter. While vitamin D levels were deficient in A total of 1,375 patients underwent BS during the study both groups prior to LSG, they significantly increased along period, with 128 (9.3 % of total BS) patients being older than the study period, reaching values close to normal ( >30 ng/ age 60 at the time of surgery (OG). LSG was performed in ml) at 12 and 60 months. 712 patients, 85 of whom were aged between 60 and 64, and In the additional subgroup analysis, patients ≥65 years 31 were more than age 65 (overall 116 patients). In addition, were compared with a matched 1 : 2 group of patients <60 during the study period 196 patients of 50–59 years un- years. This analysis showed similar outcomes in the rate of derwent LSG, 145 of whom met the study inclusion criteria complications, comorbidities, and even BMI (data not (CG). In our institution the percentage of BS in patients shown). older than age 60 increased from 2.4% in 2003 to 14% in the last 2 years of the study. 5. Discussion Based on a raw analysis, sex, current smoking, body weight (BW), EBW, and vitamin D levels were imbalanced The increasing prevalence of obesity in older adults illus- between the OG and the CG groups. On the other hand, the trates the combination of two of the main burdens to two groups were comparable in the ASA score, the preva- healthcare systems nowadays. In this study, we report the lence of hypertension, T2D, and SAHS, and there were no experience of a single university center in patients older than significant differences in the mean duration of T2D (9.38 age 60 who had undergone LSG and were followed for more (6.76) versus 8.25 (3.86) years, p 0.442) and the mean du- than 5 years. In contrast to the previous studies, we selected a ration of hypertension (11.18 (6.56) versus 9.87 (6.43) years, CG with preoperative medical comorbidities and surgical p 0.077) between the two groups. The adjusted IPTW risk similar to those of the OG to avoid the inherent risk resulted in well-balanced OG and CG cohorts, which were differences between the nonolder and older cohorts. similar in all the characteristics observed improving the Compared to the CG, the OG achieved less ABWL and covariate balance from the raw data cohorts. After IPTW TBWL; however, both groups obtained a similar BMI in the 4 Journal of Obesity Table 1: Baseline characteristics of the raw and IPTW analyses in older and control patients. Raw analysis IPTW analysis Variables Older Control group Older group Standardized Control Standardized P group P (CG) n:145 (OG) n: 116 difference group (CG) difference (OG) Age (year) 54.8 (2.6) 63.3 (2.5) <0.001 Sex (female %) 89 (61.4) 97 (83.6) <0.001 −0.514 103 (71.9) 86 (77.6) 0.294 −0.133 BMI (kg/m2) 47.1 (6.5) 45.3 (5.5) 0.055 −0.240 46.7 (6.0) 46.2 (5.9) 0.522 −0.081 EBW (kg) 58.6 (17.8) 50.0 (13.5) <0.001 −0.428 56.1 (15.8) 54.5 (15.4) 0.457 −0.090 ASA 2.4 (0.5) 2.5 (0.5) 0.377 0.110 2.50 (0.5) 2.4 (0.5) 0.669 −0.053 Current smoker (%) 29 (20.0) 4 (3.4) <0.001 0.532 18 (12.6) 8 (7.4) 0.181 −0.046 Type 2 DM (%) 63 (43.4) 62 (53.4) 0.108 0.201 69 (48.0) 51 (45.6) 0.711 −0.026 Duration DM (year) 8.2 (3.8) 9.3 (6.7) 0.442 0.094 8.9 (4.7) 8.7 (5.9) 0.609 −0.064 Insulin treatment (%) 3 (2.1) 8 (6.9) 0.053 0.234 5 (3.1) 5 (4.3) 0.624 0.061 AHT (%) 108 (74.5) 92 (79.3) 0.359 0.114 109 (76.1) 88 (79.0) 0.581 0.069 Duration AHT (year) 9.8 (6.4) 11.1(6.5) 0.077 0.221 10.7 (5.5) 10.7 (5.5) 0.872 0.020 Anti-AHT drugs: >3 28 (19.3) 19 (16.4) 0.540 −0.097 24 (16.8) 19 (17.3) 0.925 0.011 (%) Dyslipidemia (%) 68 (46.9) 62 (53.4) 0.292 0.131 70 (478.9) 55 (49.5) 0.918 0.012 SAHS (%) 59 (40.7) 40 (34.5) 0.304 −0.128 57 (39.6) 38 (34.0) 0.358 −0.116 Data are mean (SE); BMI: body mass index; EBW: excess body weight; ASA: American Society of Anesthesiologists Score; DM: diabetes mellitus; AHT: arterial hypertension; SAHS: sleep apnea hypopnea syndrome. Table 2: Operative and 30-day postoperative complications in the indication of BS in older adults. In this sense, in 2013, the two groups according to the Clavien-Dindo classification. European Guidelines for Metabolic and BS still stated that Grade Control group (CG) Older group (OG) proof of a favorable risk benefit must be demonstrated in I 4 0 elderly patients before surgery can be contemplated in these II 8 5 individuals [17], and in the NIH guidelines for BS, the upper IIIa 3 0 limit for BS continues to be 60 years [18]. However, in IIIb 1 4 contrast with these age restrictions, several scientific soci- IV 0 0 eties, such as the Italian Society for Bariatric and Metabolic V 0 0 Surgery (SICOB), have recently extended BS indications to Total 11% 8% elderly patients under the age of 70 [19], and the Federal Overall 9.5% Health Department in Brazil has authorized BS in indi- Grade I: any deviation from the normal postoperative; II: normal course viduals above 65 years without an upper age limit [20]. altered; III: complications that require intervention of various degrees; IIIa: Similar to our findings, previous studies have also re- complications that require an intervention performed under local anes- thesia; IIIb: interventions that require general or epidural anesthesia; IV: ported that older patients lose less weight. This fact might be life-threatening complications; V: death of a patient. a result of the aging process which affects their baseline physical condition, the presence of impaired muscle met- abolic capacity, and a greater presence of sarcopenia that can short and long term. The groups did not differ in the rate of be aggravated by the loss of lean body mass that follows after postoperative complications. Indeed, the overall 30-day BS (described in patients undergoing BS and ranging from surgical morbidity after LSG was low, with an acceptable 10% to 25%), all of which have been negatively correlated risk/benefit ratio in both groups. In addition, along the study with WL [16, 21, 22]. However, despite this lesser WL, the period, WL was associated with improvements in all the OG improved in all the comorbidities evaluated. comorbidities as well as nutritional status, which was similar Our findings show that chronological age alone should in both groups. not be an absolute contraindication for BS and confirm the Regarding older adult outcomes after LSG, there is a efficacy and safety of LSG in this population. Moreover, our paucity of well-reported studies. The main limitations of results support adjustment of the upper age limit and we previous studies were the differences in age in patients even suggest that it should not be a limitation because there considered as older adults, which varied from 50 to 70 years. are no contraindications per se for major surgery in older Moreover, most of the studies included less than 100 pa- adults. In older patients, the overall primary surgical goal tients, the subjects enrolled were mainly females, there was should be to slow the age-related decline in physical function an imbalance in comorbidities in the control groups, and and improve their quality of life, and, therefore, potential nutritional status reports were poor, all of which make it older surgical candidates who have disabling obesity that more challenging to achieve a favorable balance between can be ameliorated with WL should be considered. Not- benefit and risk for BS in older adults [15, 16]. All the withstanding, these candidates should be carefully evaluated methodological limitations of previous studies have con- (due to their specific needs) by a multidisciplinary team to tributed to the controversy still remaining in regard to the ensure that the risk of postoperative morbidity and mortality Journal of Obesity 5 Table 3: Evolution of anthropometric variables and comorbidities in the two groups at 12 and 60 months after bariatric surgery. Baseline 12 months 60 months Variables CG OG CG OG P CG OG P BW (kg) 121.18 (1.31) 119.18 (1.49) 82.89 (1.31) 84.80 (1.49) 0.334 88.48 (1.42) 90.06 (1,56) 0.455 BMI (kg/m2) 46.70 (0.43) 46.25 (0.49) 31.92 (0.43) 32.89 (0.49) 0.141 34.07 (0.48) 35.00 (0.52) 0.190 ABWL (kg) — — 38.28 (0.82) 34.39 (0.94) 0.002 32.79 (0.97) 28.67 (1.03) 0.003 TBWL (%) — — 31.42 (0.54) 28.61 (0.62) 0.001 26.79 (0.64) 23.66 (0.68) 0.001 Waist (cm) 131.92 (0.97) 129.76 (1.12) 103.62 (0.98) 103.22 (1.13) 0.790 107.44 (1.15) 109.99 (1.33) 0.148 DM2 (%) 48.0 45.6 25.9 23.1 0.660 26.7 29.8 0.666 HbA1c (%) 6.51 (0.10) 6.58 (0.11) 5.67 (0.10) 5.73 (0.11) 0.678 5.95 (0.11) 6.08 (0.12) 0.450 AHT (%) 76.1 79.0 46.1 43.0 0.613 47.7 57.1 0.671 SBP (mmHg) 137.76 (1.47) 133.85 (1.76) 124.54 (1.54) 132.57 (1.88) 0.001 136.00 (2.01) 134.55 (2.08) 0.616 DBP (mmHg) 82.44 (0.90) 80.63 (1.07) 74.57 (0.95) 76.43 (1.16) 0.217 77.07 (1.26) 76.16 (1.29) 0.614 Dyslipidemia (%) 48.9 49.5 27.4 29.8 0.931 42.1 41.8 0.724 SAHS (%) 39.6 34.0 20.3 15.5 0.401 11.3 8.7 0.557 Data are mean (SE); BW: body weight; BMI: body mass index; ABWL: absolute body weight loss; TBWL: total body weight loss; DM2: type 2 diabetes; AHT: arterial hypertension; SBP: systolic blood pressure; DBP: diastolic blood pressure; SAHS: sleep apnea hypopnea syndrome. Table 4: Biochemical and nutritional parameters in the two groups at 12 and 60 months after bariatric surgery. Baseline 12 months 60 months Variables CG OG CG OG P CG OG P Albumin (g/L) 43.37 (0.23) 43.25 (0.26) 42.46 (0.23) 42.52 (0.26) 0.867 42.57 (0.28) 42.03 (0.30) 0.197 Prealbumin (g/L) 0.25(0.01) 0.24 (0.01) 0.24 (0.01) 0.23 (0.01) 0.075 0.24 (0.01) 0.23 (0.01) 0.221 Calcium (mg/dl)∗ 9.56 (0.12) 10.01 (0.13) 9.67 (0.12) 9.75 (0.13) 0.651 9.51 (0.14) 9.48 (0.15) 0.870 Magnesium (mg/dl) 1.96 (0.01) 2.00 (0.02) 2.01 (0.01) 2.04 (0.01) 0.317 2.00 (0.02) 2.03 (0.02) 0.345 Phosphorous (mg/dl) 3.45 (0.04) 3.42 (0.04) 3.75 (0.04) 3.70 (0.04) 0.476 3.52 (0.05) 3.48 (0.05) 0.616 PTH (pg/ml) 86.43 (3.15) 88.74 (3.59) 62.07 (3.22) 60.34 (3.58) 0.720 83.71 (3.75) 80.24 (3.96) 0.524 25 (OH) VD (ng/mL) 15.23 (0.90) 15.31 (1.02) 27.39 (0.93) 27.47 (1.02) 0.949 25.71 (1.12) 27.47 (1.17) 0.280 Iron (mcg/dl) 72.06 (2.70) 72.34 (3.06) 90.00 (2.74) 92.94 (3.06) 0.476 92.24 (3.25) 86.28 (3.42) 0.280 Transferrin (g/L) 2.74 (0.03) 2.66 (0.04) 2.36 (0.03) 2.37 (0.04) 0.868 2.63 (0.04) 2.51 (0.04) 0.049 Vitamin B12 (pg/ml) 419.11 (30.11) 434.18 (34.23) 771.09 (30.87) 707 (34.15) 0.170 634.41 (36.35) 690.73 (38.14) 0.285 Folic acid (ng/dl) 414.76 (11.86) 392.69 (13.30) 429.36 (12.19) 450.27 (13.33) 0.247 513.79 (14.64) 516.04 (15.06) 0.914 Anemia (%)∗∗ 20.85 16.80 16.51 13.66 0.484 14.04 21.15 0.599 Data are mean (ES). Cut-off for deficiency: albumin: 31–48 g/L; pre-albumin: 0.200–0.400 g/L; ∗ corrected calcium: 8.5–10.5 mg/dL; magnesium: 1.8–2.6 mg/ dL; phosphorous: 2.3–4.3 mg/dL; PTH: 80 pg/mL; 25 (OH) VD: <30 ng/mL; Iron: 50–170 µg/dL; transferrin: 2.5–3.8 g/L; folic acid: >150 ng/mL. ∗∗ Anemia: hemoglobin in males<137 g/L; hemoglobin in females<122 g/L. is acceptable, and that they can gain the most benefits from <0.10, and only sex and SAHS were <0.15, which allowed this surgery. better assessment of the effectiveness and benefits of LSG in We acknowledge that the results of observational studies older adults. In addition, the sample size of both groups was are never definitive since potential confounding differences adequate and with a low attrition rate. between groups cannot be completely eliminated. Although In summary, LSG provides acceptable outcomes and is proof of the health impact of BS in older adults would re- safe in selected older adults. The results of the present study quire long-term randomized, controlled trials (RCTs), these indicate that age should not be a limitation to perform BS in are expensive, difficult to perform, and there are a number of this population. challenges regarding the feasibility of conducting large RCT in BS in older adults and comparing the results with non- Data Availability surgical treatment. However, an alternative to a large RCT is a pooled analysis of carefully designed observational studies Dataset generated during the study can be found using this with the use of robust statistical methodology. Although the hyperlink ../ederly_Journal_of_Obesity_05052020.sav. main limitation of the present study was its retrospective design, we followed a standardized protocol, and to ensure Conflicts of Interest accurate data collection, all variables were harmonized and collected prospectively. The strengths of this study were the The authors declare that they have no conflicts of interest. baseline similarities between the two study groups, including BMI and major obesity-related comorbidities after IPTW- Authors’ Contributions based analysis that equated the potential confounding fac- tors and thereby facilitated the outcome model. Indeed, the JM, RO, JV, and LF conceived the study, participated in majority of variables had absolute standardized differences collecting data, contributed to discussion, and wrote the 6 Journal of Obesity manuscript. FT performed statistical analysis. AI performed propensity-score matched samples,” Statistics in Medicine, most of the bariatric procedures. AJ, AA, AH, SC, and VM vol. 28, no. 25, pp. 3083–3107, 2009. participated in data collecting and contributed to the dis- [15] S. Susmallian, A. Raziel, R. Barnea, and H. Paran, “Bariatric cussion. All authors read and approved the final manuscript. surgery in older adults,” Medicine (Baltimore), vol. 98, no. 3, Article ID e13824, 2019. LF is the guarantor of this work. Judith Molero and Romina [16] E. Cazzo, M. A. Gestic, M. P. Utrini et al., “Bariatric surgery in Olbeyra both contributed equally to all aspects of this the elderly: a narrative review,” Revista da Associação Médica manuscript. Brasileira, vol. 63, no. 9, pp. 787–792, 2017. [17] M. Fried, V. Yumuk, J.-M. Oppert et al., “Interdisciplinary Acknowledgments European Guidelines on metabolic and bariatric surgery,” Gastroenterologie a Hepatologie, vol. 71, no. 6, pp. 487–500, This study was supported by a donation from the nonprofit 2017. Roviralta Foundation. [18] Panel CDC, “Gastrointestinal surgery for severe obesity,” Annals International Medicine [Internet, vol. 115, no. 12, pp. 956–961, 1991 Dec 15. References [19] SICOB, https://www.sicob.org/area_03_pazienti/chirurgia_ bariatrica/indicazioni.aspx. [1] World Health Organization, Elderly Population, World [20] A. Comunit, P. Vari, D. Federal, and P. Nacional, “Ministério Health Organization, Geneva, Switzerland, 2017, http://www. da Saúde,” 2018. searo.who.int/entity/health_situation_trends/data/chi/elderly- [21] J. A. Batsis and A. B. Zagaria, “Addressing obesity in aging population/en/#.XQ4QtZP522k.mendeley. patients,” Medical Clinical Northern America, vol. 102, no. 1, [2] 2019, http://www.euro.who.int/en/health-topics/ pp. 65–85, 2018. noncommunicable-diseases/obesity/data-and-statisticsWorld [22] S. Molino, M. Dossena, D. Buonocore, and M. Verri, “Sar- Health Organization. copenic obesity: an appraisal of the current status of [3] Nations U. World Population Ageing, 2017. knowledge and management in elderly people,” The Journal of [4] A. Jiménez, R. Casamitjana, L. Flores et al., “Long-term effects Nutrition, Health & Aging, vol. 20, no. 7, pp. 780–788, 2016. of sleeve gastrectomy and Roux-en-Y gastric bypass surgery on type 2 diabetes mellitus in morbidly obese subjects,” Annals of Surgery, vol. 256, no. 6, pp. 1023–1029, 2012. [5] S. Giordano and M. Victorzon, “Laparoscopic roux-en-Y gastric bypass in elderly patients (60 Years or older): a meta- analysis of comparative studies,” Scandinavian Journal of Surgery, vol. 107, no. 1, pp. 6–13, 2017. [6] M. Victorzon and S. Giordano, “Bariatric surgery in elderly patients: a systematic review,” Clinical Interventions in Aging, vol. 107, no. 1, pp. 6–13, 2015. [7] A. Gebhart, M. T. Young, and N. T. Nguyen, “Bariatric surgery in the elderly: 2009–2013,” Surgery for Obesity Related Diseases, vol. 11, no. 2, pp. 393–8, 2015. [8] E. Ortega, R. Morı, V. Moize, M. Rios, and A. M. Lacy, “Predictive factors of excess body weight loss 1 year after laparoscopic bariatric surgery,” 2012. [9] S. A. Brethauer, J. Kim, M. El Chaar et al., “Standardized outcomes reporting in metabolic and bariatric surgery,” Surgery for Obesity and Related Diseases, vol. 11, no. 3, pp. 489–506, 2015. [10] F. Experience, J. N. Vauthey, D. Dindo, R. D. Schulick, and E. D. Santiban, “The clavien-dindo classification of surgical complications,” Annals of Surgery, vol. 250, no. 2, pp. 187–196, 2009. [11] D’agostino RB, “Tutorial in biostatistics propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group,” Stat Med, vol. 17, pp. 2265–2281, 1998. [12] P. R. Rosenbaum and D. B. Rubin, “The central role of the propensity score in observational studies for causal effects published by: biometrika trust stable,” Biometrika, vol. 70, no. 1, pp. 41–55, 1983. [13] P. C. Austin, “An introduction to propensity score methods for reducing the effects of confounding in observational studies,” Multivariate Behavioral Research, vol. 46, no. 3, pp. 399–424, 2011. [14] P. C. Austin, “Balance diagnostics for comparing the distri- bution of baseline covariates between treatment groups in