本帖最後由 lsc0019 於 2009-7-15 00:21 編輯
作者：Louise Gagnon
出處：WebMD醫學新聞
June 29, 2009(德州達拉斯) — 一篇發表於美國代謝與減重手術協會第26屆年會的研究顯示，65歲以上病患從減重手術獲得的幫助與年輕人無異，研究認為年紀大並非減重手術的併發症或死亡率的風險因素。
根據德州Baylor大學醫學中心外科臨床研究主任Joseph Kuhn醫師表示，此發現駁斥了之前資料所認為的，年長者於胃繞道手術後死亡率較高的發現。
本研究的主要作者Kuhn醫師解釋，數年前發表的一些報告顯示，65歲以上病患進行這類手術有比較高的死亡率。這些手術多數為開腹式胃繞道手術，只有少數幾人為腹腔鏡手術，且多數屬於學習曲線中。而現代的腹腔鏡手術，多數病患可以在隔天返家，即使患者年紀超過65歲。
Kuhn醫師與研究夥伴前溯追蹤1,753名於2005年1月至2008年7月間，在他們醫院接受減重手術的病患，且至少有6週的術後追蹤資料。
有153名病患年紀超過65歲。相較於1,600名同樣進行追蹤的年輕病患，他們的手術風險資料比較不佳。特別的是，較年長病患的睡眠呼吸中止發生率增加(46% vs 33%)、糖尿病(62% vs 31%)和高血壓(83% vs 57%)也都增加。這些年長病患的年紀從65至77歲，平均身體質量指數45 kg/m2，年輕組病患的年紀為18至64歲，平均身體質量指數47 kg/m2。
儘管健康狀態比較不佳，65歲以上病患的手術結果與65歲以下者相當。手術時間為70分鐘相較於65分鐘、住院天數為1.6天和1.3天，30天時的緩解率為5.2%與7.0%。
再者，年長與年輕兩組之間的併發症比率並無顯著差異。年長者之中，術後出血的病患有0.6%，肺部併發症有1.9%、心臟併發症有1.9%、傷口併發症有1.9%、狹窄部位併發症有1.2%；沒有死亡。
在年長組與年輕組之間，胃繞道手術病患的過重體重減輕百分比(% EBWL))，在12個月時並無顯著差異(60.4% EBWL vs 71.9% EBWL)。
接受胃束帶手術的病患中，年長組與年輕組之間減輕的體重，在12個月(29.9% EBWL vs 35.8% EBWL)與24個月(45.3% EBWL vs 33.4% EBWL)時均相當。
Kuhn醫師表示，相較於每年在65歲以上者進行的其他無數的手術，如髖關節置換術、各種癌症手術、肝臟與肺臟切除術，身為醫師的我們一般對進行這些手術不會猶豫。
Kuhn醫師表示，阻礙之一在於對認知風險的焦慮；病患需要減重大約100磅。他們是病患，有許多共病症。
波特蘭奧勒岡健康與科學大學外科教授、美國代謝與減重手術協會執行委員Bruce Wolfe醫師表示同意，在以前的分析中，年長被視為胃繞道手術與其他減重手術後不佳結果的風險因素之一。
Wolfe醫師表示，那指出手術不應被經常進行，若有必要，在年長、嚴重肥胖病患得有一些依據。重點在於目前的手術狀況。各類資料庫均顯示，目前的減重手術結果有諸多改善，也未發現年長（65歲以上）是術後不佳結果的風險因素。
Wolfe醫師表示，該研究的發現顯示，須重新檢討不鼓勵65歲以上病患手術的觀念，本研究的研究限制為，研究中最年長的病患只有77歲。他表示，65歲以上病患的手術顯示是安全的，但是70多歲將近80歲者的安全性並未提及。
Kuhn醫師宣告沒有相關財務關係。Wolfe醫師擔任Ethicon Endo-Surger公司和Allergan公司的顧問，同時也是EnteroMedics公司的研究人員。美國代謝與減重手術協會第26屆年會：摘要PL-207。發表於2009年6月25日。
ASMBS 2009: Elderly Obese Patients Benefit From Weight Loss Surgery
By Louise Gagnon
Medscape Medical News
June 29, 2009 (Dallas, Texas) — Patients who are older than 65 years fare no differently from their younger counterparts after weight loss surgery, suggesting older age is not a risk factor for complications or mortality in bariatric surgery, a study presented here at the American Society for Metabolic and Bariatric Surgery 26th Annual Meeting shows.
The findings refute previous data that indicated mortality was greater in the elderly after gastric bypass surgery, according to Joseph Kuhn, MD, director of clinical research, Department of Surgery, Baylor University Medical Center, Dallas, Texas.
"A few reports that were released years ago had shown a higher mortality rate occurring with this surgery in patients over 65 [years old]," explained Dr. Kuhn, the study's principal investigator. "Most of those procedures were open gastric bypass surgeries...only a smattering of them were laparoscop[ic], and most of those were in the learning curve. Modern programs in laparoscopic surgery mean most patients go home the very next day, even with patients who are older than 65."
Dr. Kuhn and coinvestigators prospectively followed 1753 patients who underwent bariatric surgery between January 2005 and July 2008 at their center and who had at least 6 weeks of postoperative follow-up data.
There were 153 patients who were older than 65 years. They had a less favorable operative risk profile compared with 1600 younger patients who also were followed up. Specifically, older patients had an increased incidence of sleep apnea (46% vs 33%), diabetes mellitus (62% vs 31%), and hypertension (83% vs 57%). The older patients ranged in age from 65 to 77 years and had a mean body mass index of 45 kg/m2, whereas younger patients ranged in age from 18 to 64 years and had a mean body mass index of 47 kg/m2.
Despite their poorer health status, operative outcomes for patients older than 65 years were similar to those for patients younger than 65 years. Operative time was 70 minutes vs 65 minutes, length of stay was 1.6 days vs 1.3 days, and the 30-day readmission rate was 5.2% vs 7.0%.
Furthermore, complication rates did not significantly differ between older and younger patients. Among seniors, there was postoperative bleeding in 0.6% of patients, pulmonary complications in 1.9%, cardiac complications in 1.9%, wound complications in 1.9%, and stricture complications in 1.2%; there were no deaths.
The percentage of excess body weight loss (% EBWL) in patients who had gastric bypass surgery was not significantly different between the older and younger patients at 12 months (60.4% EBWL vs 71.9% EBWL).
Among patients who had undergone gastric banding, there was comparable weight loss in older and younger patients at the 12-month mark (29.9% EBWL vs 35.8% EBWL) and at the 24-month mark (45.3% EBWL vs 33.4% EBWL).
"In contrast to the countless operations that are performed on patients over the age of 65 [years —] like hip replacements, various kinds of cancer surgeries, liver and lung resections — typically as surgeons we don't hesitate for a second in performing those operations," said Dr. Kuhn.
"One of the obstacles is the anxiety of [perceived] risk," said Dr. Kuhn. "The patients are definitely in need of about 100 pounds of weight loss. They are sicker, with more comorbid problems."
Bruce Wolfe, MD, FACS, a member of the executive council of the American Society for Metabolic and Bariatric Surgery and a professor of surgery at Oregon Health and Science University in Portland, concurred that advancing age had been identified as a risk factor for adverse outcomes following gastric bypass surgery and other bariatric procedures in older analyses.
"The notion that the surgery should be performed infrequently, if at all, in progressively older, severely obese patients has had some basis," said Dr. Wolfe. "What is important is that we look at the current status of surgery. There have been a number of improvements reported overall in the outcomes of bariatric surgery in various databases that have not found advancing age [to be a risk factor for adverse outcome after the mid-60s]."
The study's findings show that discouraging the surgery in patients who are not much older than 65 years needs to be reexamined, said Dr. Wolfe, noting that a limitation of the study was that the oldest patient in the study was aged 77 years.
"[Surgery in patients] who are just older than 65 was shown to be safe, but the safety of patients in their late 70s was not addressed," he said.
Dr. Kuhn has disclosed no relevant financial relationships. Dr. Wolfe is a consultant for Ethicon Endo-Surger Inc and Allergan Inc and is an investigator for EnteroMedics Inc.
American Society for Metabolic and Bariatric Surgery (ASMBS) 26th Annual Meeting: Abstract PL-207. Presented June 25, 2009. |
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