We are often asked if somebody is too young or too old for bariatric surgery because of concerns about fairly major surgery for themselves or their family members if they are they are below 20 or above age 65. When somebody presents with a weight problem at the extremes of age it is very important to individualise their care and make very considered decisions. Below I will discuss some of the issues we examine while making management decisions for these patients.
Bariatric Surgery for patients under the age of 20
There are very few topics that create more controversy than the prospect of weight loss surgery in young people. In general, in order to make decisions easier, we break young people into 3 different groups because each of these groups has their own issues.
Group 1 – young adults
These are young people who have left childhood and adolescence behind and have often taken on a lot of adult achievements including having left school, going to University or getting a job. While they have entered adulthood they still may not have achieved their full growth and body development. There are also concerns about future potential problems such as vitamin deficiencies or the effect of pregnancy on somebody who has had bariatric surgery that needs to be taken into consideration. The total number of people in this age group seeking weight loss surgery is fairly small, mainly because the majority of young people with excess weight are too young to have suffered irreversible musculoskeletal injuries that come with many years of carrying excess kilograms. There are some young people whoever, who are badly affected by adult diseases such as sleep apnoea, arthritis and diabetes who will seek surgery and, in these situations, we treat them in the same way that we would any other patient. Younger patients do need to be aware of the requirement for longer-term follow-up especially to reduce the risks of weight regain which would clearly be a disappointment for anyone but especially so in a younger person.
Group 2 – Adolescents
An adolescent is a young person who is not a child but is also not an adult. Their issues need to be taken into consideration given this is a time of rapid development with hormonal changes and the individual becoming more affected by their interactions with their friends and peers and less under the direct day to day control of their parents and very close family. The number of adolescents with obesity severe enough to benefit from consideration of surgery or other fairly aggressive weight management treatments is very low. If, however, somebody is overweight enough so that they are disabled and unable to function or they have particularly aggressive diabetes or sleep apnoea then occasionally these types of procedures will be considered. In reality surgery in the 12 to 17 age group is very uncommon but we do know for patients afflicted with severe obesity in this age their quality of life is worse than the quality of life of adolescents undergoing chemotherapy for cancer. The teenage years are tough on all of us and they are especially tough on very overweight kids who feel discrimination and social isolation far more acutely than adults do because they haven’t yet developed the life skills to manage themselves in difficult social circumstances. While the number of people in this situation is thankfully small it is very good to know that the published results from this type of surgery are very good as long as the individual is appropriately supported by a range of specialists before and after the procedure including paediatricians, endocrinologists, psychologists and dietitians. In general patients of this age having surgery should be under the care of a paediatrician before considering this option.
Group 3 – Childhood obesity surgery
It seems that there is nothing media likes more than the spectre of children having obesity surgery. This type of option is very uncommonly considered and only as part of a multidisciplinary specialist management plan. The rare children who do end up being considered for this surgery usually have marked biologically based abnormalities in their growth, sometimes with genetic conditions that predispose them to obesity. While the numbers of surgery in this age group worldwide are very low the results once again seem sufficiently safe to be a valid option for this rare group of patients.
Bariatric Surgery for patients over the age of 65
People tend to accumulate weight problems and medical conditions associated with their weight as they get older. Unfortunately, as people get older their mobility and general health can become pretty poor if they’ve been carrying extra weight for many years. For this reason, older Australians who feel their mobility, quality of life and overall health are very compromised will sometimes elect to consider weight loss surgery as a treatment option.
There are a couple of extra issues when considering weight loss surgery in people over the age of 65 compared with younger patients. One issue is that many of the diseases associated with severe obesity in younger patients will reverse with surgical treatment and this will lead to a significant prolongation of that individual’s life expectancy. If, however, you treat somebody after many years of suffering diabetes or other diseases a degree of damage has already been done so life expectancy increases are not as likely to occur. Older patients will still find that uncontrollable conditions can be bought under control with a 20 to 40 kg weight loss.
In general people over the age of 65 who seek weight loss surgery have very specific goals they wish to achieve, usually involving increasing their ability to undertake normal day to day tasks and maintain their independence as they get older.
There are always concerns about medical fitness for surgery in people over the age of 65. Cardiology and lung assessments will usually determine if an individual is a high risk or not. Putting things in perspective our weight loss operations are less likely to lead to a complication leading to either death or a major injury than knee or hip replacement, hysterectomy or other reasonably routine procedures such as angiography. Because weight loss surgery is elective surgery, we are able to take the time to identify and correct any risk factors that might be at increased risk of harm in somebody having surgery.
At St George Hospital we’ve looked at the safety profile of over 400 patients who have had bariatric surgery aged over 65 and haven’t had an increase in complication or re-admission compared with the younger patients.
The weight loss goals we have for older patients are a little different than younger patients, in this group we are not aiming to get people down to an ideal body weight of BMI 25 but prefer them to get down closer to a BMI of 30 so they have a couple of extra kilograms in reserve. There is a concern that excessive weight loss in older people can lead to loss of bone and muscle tissue which is very important for maintaining mobility, day to day activities and immunity.
Surgery between the ages of 65 and 70 is reasonably common however it is uncommon for patients over the age of 70 to consider this as an option for them however there is no doubt that the rare individual may consider this as a reasonable option even out up to the age of 80.
Weight loss and metabolic surgery in younger and older Australians are appropriately less commonly performed than in patients in the middle years of their life. By carefully selecting patients who are heavy enough to benefit but well enough and supported enough to have the procedure safely we can ensure that benefits from surgery outweigh any risks.