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The increasing prevalence of obesity and rising life expectancy have led to a growing need for metabolic bariatric surgery (MBS) in older patients. While short-term outcomes are well documented, there is limited data on long-term outcomes comparing younger and older patients. This study aims to analyze 10-year outcomes after primary bariatric surgery in patients under 30 and over 60 years of age.
Materials and Methods
A retrospective, multicenter analysis was conducted as part of the BARI-10-POL project, including patients who underwent laparoscopic MBS in Poland between 2008 and 2014. Inclusion criteria were age under 30 or over 60 years at the time of surgery and at least 10 years of follow-up.
Results
A total of 49 younger and 46 older patients were included. The most common procedure in both groups was sleeve gastrectomy. The percentage of excess weight loss (%EWL) was 59.3% in the younger group and 60.2% in the older group (p = 0.671), with percentage of total weight loss (%TWL) of 21.6% and 20.5% (p = 0.726), respectively. Older patients had a higher prevalence of type 2 diabetes and hypertension, with remission rates of 52.8% and 40.5%, respectively, compared to 42.9% and 62.5% in younger patients (p = 0.302; p = 0.303). Complication rates were 2.0% in younger and 4.3% in the older group (p = 0.517), with no mortality observed in either group.
Conclusions
MBS seems to be effective and safe in long-term follow-up across different age groups. There were no statistical differences in weight loss or metabolic outcomes between younger and older patients.
• Long-term weight loss outcomes after bariatric surgery are comparable in patients under 30 and over 60 years of age.
• Metabolic effects after bariatric surgery do not differ significantly between younger and older patients in long-term follow-up.
• Complication rates after bariatric surgery are similar in younger and older patients over a 10-year follow-up.
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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
The number of patients undergoing metabolic bariatric surgery (MBS) is steadily increasing [1]. Recent data show that the number of bariatric surgeries in Poland has increased sixfold, rising from 1500 in 2014 to over 9000 in 2021 [2, 3]. The average age of the population is also rising, so we can expect a growing need for MBS in older patients [4, 5].
In the early stages of MBS worldwide, there was caution regarding surgeries in older patients. Polish recommendations suggested surgery up to the age of 65, with careful analysis of indications for patients over this age [6]. Over time and with ongoing research, the scientific community has understood that MBS is not reserved solely for younger individuals, but also for older patients [7, 8]. The literature has repeatedly shown that MBS is safe for older individuals, and patients meeting criteria should be considered for surgery [9].
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There are many reports in the literature regarding short-term follow-ups after bariatric surgeries, but there are few studies with follow-up periods longer than 10 years [10, 11]. This is due to significant challenges in conducting long-term observations. It is difficult to find studies that compare outcomes in patients across different age groups with such a long follow-up period. This has created a gap in the literature on this topic.
Aims
This study aims to analyze the outcomes of MBS in patients under 30 years of age and over 60 years of age. The primary objective is to determine differences in weight loss 10 years after surgery in these age groups. Secondary objectives include evaluating the remission of obesity-related diseases and complications after the surgery.
Material and Methods
Study Design and Settings
This study is a retrospective, multicenter analysis based on a database of patients who underwent laparoscopic MBS in Poland between 2008 and 2014. It is part of the Bariatric Ten Years Outcomes in Poland (BARI-10-POL) project. Data were collected from five centers. The study was conducted under the patronage of the Metabolic and Bariatric Surgery Chapter.
Population
The inclusion criteria were being under 30 or over 60 years of age at the time of surgery, meeting the eligibility requirements for MBS, and having at least 10 years of follow-up data. Patients with a history of previous bariatric procedures, missing or inconsistent records were excluded. The database included demographic data: sex, age, and preoperative body mass index (BMI). The database also included information on obesity-related diseases, including type 2 diabetes (T2D) and hypertension (HT). Additionally, surgical details were recorded, including the type and length of the procedure, length of hospital stay, and any complications.
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Surgical Techniques and Perioperative Care
The procedures performed were: sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one-anastomosis gastric bypass (OAGB). All surgeries were performed following standard guidelines [12]. During SG, a 36 F bougie was used, with gastric resection starting 4–6 cm from the pylorus. In RYGB, the gastric pouch measured approximately 30 ml and 5–7 cm in length; the biliopancreatic limb was about 100 cm, and the alimentary limb about 150 cm. For OAGB, the gastric pouch was about 15–20 cm in length with an estimated volume of 100 ml, the biliopancreatic limb extended roughly 200 cm from the ligament of Treitz. Each participating center adhered to standardized preoperative, intraoperative, and postoperative protocols.
Outcomes
MBS treatment outcomes were assessed based on standardized reporting guidelines according to ASMBS criteria [13]. T2D remission was defined as the normalization of glucose metabolism (HbA1c < 6.4%, fasting blood glucose < 125 mg/dL) without the use of antidiabetic medications. HT remission was defined as maintaining normotension (BP < 140/90 mmHg) without antihypertensive treatment. Weight loss outcomes were expressed as the percentage of excess weight loss (%EWL), and total weight loss (%TWL). %EWL was calculated using the ideal body weight corresponding to a BMI of 25 kg/m2. All reported results correspond to the follow-up period.
Statistical Analysis
A descriptive statistical analysis was conducted. All data were analyzed using StataNow 18.5 (TX, USA). The normal distribution was checked using the Shapiro–Wilk test. Due to the lack of a normal distribution, continuous values were presented as medians with interquartile ranges. The Mann–Whitney U test was applied for continuous variables to compare two groups of patients. Categorical variables were compared using the chi-square test or Fisher’s exact test when appropriate. P values ≤ 0.05 were considered statistically significant.
The power of this study was set at 80%, with a significance level of α = 0.05. Based on the sample size calculation, a total of 96 patients, 48 per arm, was required to detect a statistically significant difference in weight loss outcomes between younger and older patients. The estimated effect size (Cohen’s d) was approximately 0.58, indicating a moderate effect, which aligns with findings from previous literature on weight loss differences across age groups [14].
Ethical Considerations
The data were anonymized. The study was conducted in accordance with the ethical standards.
of the 1964 Declaration of Helsinki and its subsequent amendments. The study was approved by the Bioethics Committee of the University of Warmia and Mazury in Olsztyn (10/2024).
Results
A total of 1703 patients were included in the initial cohort. Due to missing data and loss to follow-up, a total of 485 patients were included in the BARI-10-POL. Among them, there were 49 patients under 30 years old and 46 patients over 60 years old (Fig. 1).
In the younger group, there were 49 patients, and in the older group there were 46 patients. The patients did not differ statistically in terms of gender and preoperative BMI. The most commonly performed surgery was SG in both groups (Table 1).
Table 1
Characteristics of patients. (young patients younger than 30 years of age; old patients older than 60 years of age; BMI body mass index, IQR interquartile range, SG sleeve gastrectomy, RYGB Roux-en-Y gastric bypass, OAGB one anastomosis gastric bypass)
Young n = 49
Old n = 46
p value
Age, years (IQR)
26 (24–28)
64 (62–67)
< 0.001
Gender, female (%)
40 (81.6)
30 (65.2)
0.069
Preoperative BMI [kg/m2], median (IQR)
43.8 (38.9–46.6)
40.6 (35.8–45.3)
0.069
Type of surgery
SG, n (%)
41 (83.7)
24 (52.2)
0.001
RYGB, n (%)
6 (12.2)
8 (17.4)
OAGB, n (%)
2 (4.1)
14 (30.4)
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Outcomes
A decrease in BMI was observed in both groups after the surgery (Fig. 2). The %EWL was 59.3% in the younger group and 60.2% in the older group. The %TWL was 21.6% and 20.5% respectively. There was no statistically significant difference (Table 2).
Fig. 2
BMI changes in old and young patients. (Old patients older than 60 years of age, young patients younger than 30 years of age)
Patients’ outcomes. (young patients younger than 30 years of age; old patients older than 60 years of age; BMI body mass index, IQR interquartile range, %EWL percentage of excess weight loss, %TWL percentage of total weight loss, T2D type 2 diabetes, HT hypertension)
Young n = 49
Old n = 46
p value
Postoperative BMI [kg/m2], median (IQR)
32.7 (28.7–39.8)
30.9 (28.2–36.8)
0.415
%EWL, % (IQR)
59.3 (25.4–79.1)
60.2 (41.2–76.3)
0.671
%TWL, % (IQR)
21.6 (11.3–34.3)
20.5 (14.9–28.8)
0.726
T2D, n (% of all cases)
7 (14.3)
36 (78.3)
Remission, n (%)
3 (42.9)
19 (52.8)
0.320
Improvement, n (%)
3 (42.9)
6 (16.7)
HT, n (% of all cases)
16 (32.7)
37 (80.4)
Remission, n (%)
10 (62.5)
15 (40.5)
0.303
Improvement, n (%)
3 (18.8)
11 (29.7)
Among older patients, T2D and HT were more prevalent compared to younger patients (Table 2). T2D remission occurred in 42.9% of younger patients and 52.8% of older patients, while HT remission was observed in 62.5% and 40.5% of patients, respectively. No statistically significant differences were observed in terms of remission rates.
When comparing outcomes across surgical procedures, no statistically significant differences were observed in %TWL, HT remission, or T2D remission (all p > 0.05) (Table 3).
Table 3
P values for differences in %TWL, hypertension remission, and type 2 diabetes remission across procedures. (young patients younger than 30 years of age; old patients older than 60 years of age; %TWL percentage of total weight loss, T2D type 2 diabetes, HT hypertension)
%TWL
HT remission
T2D remission
All
0.103
0.114
0.322
Young
0.116
0.328
0.810
Old
0.593
0.074
0.221
Complications
In the younger group, there was one case (2.0%) of Clavien-Dindo III complication, while in the older group, there were two (4.3%), p = 0.517. In the younger group, the complication was a leak, whereas in the older group, there were two cases of postoperative bleeding. All complications occurred after SG. Additionally, in the older group, there were two cases of iatrogenic bowel injury, both of which were managed intraoperatively. There was no mortality.
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in both groups.
Discussion
Our study is a 10-year follow-up of bariatric surgery outcomes in patients under 30 years of age compared to those over 60 years of age. This is part of the multicenter BARI-10-POL project, which analyzes 10-year outcomes of MBS in Poland. To our knowledge, this is the first analysis comparing younger and older patients in such a long follow-up period.
There is a lack of data in the literature on follow-ups exceeding 10 years comparing younger and older patients. However, an increasing number of reports focus on long-term outcomes after various bariatric procedures. Salminen et al. compared SG and RYGB in their randomized control trial [15]. The median %EWL was 43.5% after LSG and 50.7% after LRYGB, regardless of patient age. In our study, younger patients achieved 59.3%, and older patients 60.2%, regardless of the surgery performed. Our study indicates better results in long-term follow-up. We attribute this to the low follow-up rate, which could introduce some bias into the results. However, another randomized trial comparing RYGB to duodenal switch by Salte et al. showed that in a 10-year follow-up, %TWL after RYGB was 20% [16]. In our study, for all surgeries, %TWL was 21.6% in younger patients and 20.5% in older patients, which is similar to the results of these authors. The meta-analysis by O’Brien et al. showed 56.7% EWL after RYGB and 58.3% after SG in 10 years follow up [17]. Other observational studies have reported similar outcomes, regardless of patient age [18‐20]. Despite the limitations, our results do not differ significantly from other reports.
The data comparing patients in the two age groups pertain to shorter follow-up periods than those presented in our study. Wang et al. conducted a meta-analysis comparing younger and older patients after SG [14]. It was shown that younger patients have better weight loss expressed in %EWL, but no differences were found in the resolution of comorbidities or the risk of complications. The analysis was based on studies with a short follow-up period. On the other hand, Keren et al. analyzed outcomes after SG with a 5-year follow-up [21]. In their report, it was shown that patients over 55 years old had better weight loss compared to younger age groups (p < 0.01). The reasons for this are attributed to more mature decision-making and better compliance among older patients. In the literature, there are also studies where weight loss outcomes after SG do not differ in short-term follow-ups, regardless of patient age [22‐25].
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In our study, the majority of older patients had T2D and HT, whereas the prevalence was lower in the younger group. The remission rate of T2D was close to 50% in both age groups. Although HT remission did not differ statistically, there was a slight trend favoring younger patients. We attribute this to the likely longer duration of HT in older patients [24]. Previous studies have reported similar remission rates for T2D and HT in 10-year follow-ups [17‐19]. The 5-year STAMPEDE trial, a prospective randomized study, demonstrated that patients with T2D who underwent gastric bypass achieved a remission rate of 30.6% for RYGB and 30.4% for SG at 5 years [25]. However, this study focused on patients with newly diagnosed T2D, where remission rates were much lower than those reported in our study. We believe that the retrospective nature of our study may introduce some bias, as patients with better compliance are more likely to remain in long-term follow-up, potentially leading to an overestimation of positive outcomes.
A meta-analysis by Vallois et al. found that the overall morbidity rate in short-term follow-up was significantly higher in patients over 60years old compared to younger individuals (8.98% vs. 6.2%) [26]. However, the incidence of severe complications classified as Clavien-Dindo III or higher was comparable between groups, occurring in 4.6% of older patients and 5.5% of younger patients, with no statistically significant difference. Severe complications occurred in 2.0% of younger patients and 4.3% of older patients in our study. However, it is important to note that the sample size in the meta-analysis was substantially larger than in our study. Nevertheless, other studies also confirmed the safety of MBS in older patients [27, 28].
Previous studies have highlighted the importance of body composition changes after MBS in elderly patients. Ponce de León-Ballesteros et al. demonstrated that patients > 60 years undergoing RYGB had lower fat-free mass at baseline, but the decrease in fat-free mass after surgery was similar to that observed in younger patients [29]. In our study, body composition was not assessed. Including such data would provide valuable insights, particularly regarding long-term outcomes in elderly patients.
The study’s limitations include its retrospective nature and low follow-up rate over time. Achieving a high patient follow-up rate becomes increasingly challenging over time, which may introduce a risk of bias in the reported data. Additionally, our analysis does not include interim data, as all outcomes refer solely to the 10-year follow-up. Our outcomes did not differ significantly between procedures. However, these findings should be interpreted with caution due to the relatively small sample sizes and the marked differences in the number of patients across different procedures. Another limitation is the lack of detailed data on obesity-related diseases, including medication use and disease duration. Despite these limitations, the novelty of this study, which compares younger and older patients over such an extended observation period, makes its findings a valuable contribution to the field.
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Conclusions
This study provides a 10-year follow-up comparison of MBS outcomes in patients under 30 years of age and over 60 years of age. Both groups achieved comparable weight loss, with no significant differences in %EWL or %TWL. Older patients had a higher prevalence of T2D and HT preoperatively, with similar remission rates postoperatively compared to younger patients. These results suggest that operating on older patients is worthwhile, as their outcomes are comparable to those of younger patients.
Acknowledgements
The study was conducted as part of The Harvard Medical School’s Polish Clinical Scholars Research Training project organized by Medical Research Agency (granted to NDG). BARI-10-POL Collaborative Study Group: 1. Paula Franczak, PhD, MD Department of General and Oncological Surgery, Ceynowa Hospital, 84-200 Wejherowo, Poland 2. Anna Kloczkowska, MD Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, 80-214 Gdańsk, Poland 3. Paweł Lech, PhD, MD Department of General, Minimally Invasive and Elderly Surgery, Collegium Medicum, University of Warmia and Mazury, 10-045 Olsztyn, Poland 4. Michał Orłowski, PhD, MD Department of General and Oncological Surgery, Ceynowa Hospital, 84-200 Wejherowo, Poland 5. Monika Proczko-Stepaniak, Prof. PhD, MD Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, 80-214 Gdańsk, Poland
Declarations
Ethics Approval
The study was conducted according to the guidelines of the Declaration of Helsinki.
Consent to Participate
Informed consent was obtained from all participants included in the study.
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Competing Interests
The authors declare no competing interests.
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