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Is Bariatric Surgery Riskier and Less Beneficial in Men?



Regular readers of these pages will recall the recent article series on the pros and cons of bariatric surgery.

As I pointed out, this is a rapidly evolving field of medicine and new data is now accumulating at an unprecedented pace.

Yesterday, JAMA released a new study in which Matthew Maciejewski and colleagues report the results of a large retrospective propensity-matched case-control analysis of patients who underwent Roux-en-Y bariatric surgery at Veteran Administration (VA) centres across the US.

This study is remarkably different from previously reported bariatric surgical studies in that it involves a predominantly male (74%), older (mean age 49 years – if you consider that old?!?), heavier (>30 had a BMI > 50), and sicker patients.

Overall, the study shows that over an almost seven-year follow-up, bariatric surgery compared to usual care, did not significantly reduce the mortality risk of these older, severely obese high-risk men.

These results contrast strongly with the consistently positive outcomes that have now been reported in younger, healthier, and predominantly female populations.

Thus, contrary to expectations, where greater benefits are generally expected with greater disease burden, this study does not support the use of roux-en-y bariatric surgery in older severely obese men.

The authors attribute this lack of positive effect of surgery in part to the rather high surgical risk of these patients. In fact, 11 of the 847 (1.3%) cases died within 30 days of surgery, a rate that is four times that reported in lower risk populations.

As this surprisingly high perioperative mortality essentially cancels out any potential survival benefit, the authors suggest that lower-risk procedures like adjustable gastric banding or sleeve gastrectomies, which have considerably lower perioperative risk than Roux-en-Y gastric bypass, may need to be considered in these patients.

However, the authors also note that reduction in comorbidities, medication use, and over all costs, were not significantly reduced in these patients – a finding for which they offer no ready explanation.

These findings, that follow closely on previous week’s post on the paucity of obesity studies in men, highlight that it may be wrong to simply expect men to have the same benefits of bariatric surgery commonly reported in women.

While the authors caution that roux-en-y bariatric surgery may confer no survival benefit in older and sicker severely obese men, performing such surgery may still be an option as the associated weight loss at least results in an improved quality of life for these individuals.

Clearly, as outlined in my recent series, bariatric surgery is not for everyone and should always involve a careful discussion of risk/benefit ratio – apparently not just in women.

AMS
Edmonton, Alberta

7 Comments

  1. This data is not helpful, the perioperative mortality rate is 1.29%. This mortality rate is more than a factor of 10 greater than it should be, so you can draw your own conclusions

    Bill

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  2. Interesting Study.

    I wonder what the long term effect would have been if they had first done the VSG and then after the subjects had lost some weight and were at less operative risk, the patients had they VSG’s converted to Duodenal Switches, Duodenal Switch has a much better long term outcome then the R-N-Y (ruin why?), especially for those with higher BMI’s like these patients, and doing it in two stages is common practice in those with high BMI’s.

    I think it is time for the medical community to stop assuming that the RNY is the better surgery when long term outcomes and patient quality of life factors indicate that the RNY is a distanct 2nd to Duodenal Switch.

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  3. You say the weight loss conferred by roux-en-y bariatric surgery gave them an improved quality of life – but nowhere in that study was there any mention of complications or the rate of complications for the men in that study. I know what the list of complications are for roux-en-y bariatric surgery (or almost any other bariatric surgery, for that matter), and I can tell you right now that those complications do not add to one’s quality of life, even with a drastic weight loss. And with this study only covering 6 years, how many of those patients were able to maintain that weight loss? The study doesn’t say, and like all studies of bariatric surgery, there is no long-term follow-up that show how long the weight loss lasts, whether it’s permanent, or a temporary thing lasting only a few years before the weight starts creeping back.
    I’m sorry, but any procedure that isn’t going to be able to guarantee safe, permanent weight loss, well, that procedure is less than effective and does more harm than good, in my book. And helping the few people it has, over harming the many it has, doesn’t mean it’s something that should continue to happen just because doctors don’t have any better ideas on how to make fat people thin.

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  4. The best “Bariatric Surgery” in my book is no Bariatric Surgery.

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  5. Hi, I’m Jerry I’d like to introduce myself. I am an anecdote. More to the point, I am an n of 1.

    I am a 54 year old male who is currently a little less than 2 years post op from Roux-en-Y gastric bypass. A few months ago, I very nearly lost my life to an incarcerated internal hernia and resultant small bowel obstruction (SBO) – one of the more serious complications that can occur in a gasteric bypass patient. I was lucky – the hernia went undiagnosed for several months and I had to change bariatric surgery programs (to one twice as far away) before my condition was properly diagnosed. A midline laparotomy (aka “open” procedure) was required to extract the bowel from where it had become incarcerated. This type of complication is so incredibly dangerous specifically because many emergency rooms and radiologists will miss it. By the time they can see something definitively wrong, infarction (bowel death) has occurred; at which point survival can be a crap shoot.

    So how do I feel about gastric bypass now? I’d do it again in a heartbeat. I looked at this surgery for 6 years before committing. Very slowly and very carefully. It was not a spur of the moment decision. I went into this with my eyes wide open.

    I certainly hope my life is longer than it otherwise would have been; with progressively worsening diabetes, that certainly would not have been all that long. Clearly, I can’t prove it will be. But that’s not really the point, is it? Let me count the benefits to date – I have not used insulin since surgery. I was off all oral diabetics meds within 3 months of surgery. My A1c is in the normal range for the first time – as is my BMI. I can shop for clothing in regular stores. I cannot begin to tell you how much differently I am treated – by clerks and waitresses and cab drivers and perhaps surprisingly, by doctors and nurses.

    So to those those who might wish to deny me the one thing in 50 years that has actually helped – simply because it might hasten my death or because my weight might come back after “x” years — or simply because I am merely an anecdote; an n of 1; I say go ahead and have a go at it. I understand you’re well-intentioned. But just how much of my risk do you want to manage?

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  6. I cannot begin to tell you how much differently I am treated – by clerks and waitresses and cab drivers and perhaps surprisingly, by doctors and nurses.

    I makes me so sad to hear that. Nobody should be forced to take other people’s prejudices into consideration when deciding whether or not to have a dangerous form of surgery. Ideally, health would be the only consideration.

    And, it occurs to me that the US Veteran Administration has nothing to gain from promoting weight loss surgery if its risks outweigh its benefits, unlike the sponsors of many of the studies that have primarily been done on women. I’d like to believe that medical studies are all well designed and unbiased but sadly, I know that’s far from true.

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  7. It’s very interesting to me to see this study because usually medical studies are done on men and it’s just assumed women will respond the same way.

    And to those going on about the risks of bariatric surgery, statistically speaking, you are wrong. The surgery helps many more than it hurts as complications are rare. This has been shown over and over in many studies many of which do include men in them even if the majority of the subjects are women.

    As for this study, given how anomalous it is, I suspect it won’t be repeatable with future studies on bariatric surgery in men. Personally, I think the problem is that medical care at the VA generally sucks and not that bariatric surgery is not effective in men.

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