Bariatric surgery in individuals with severe cognitive impairment: report of two cases

ABSTRACT CONTEXT: Bariatric surgery has become the gold-standard treatment for refractory morbid obesity. Obesity is frequently associated with certain syndromes that include coexisting cognitive deficits. However, the outcomes from bariatric surgery in this group of individuals remain incompletely determined. CASE REPORT: A 25-year-old male with Prader-Willi syndrome, whose intelligence quotient (IQ) was 54, was admitted with a body mass index (BMI) of 55 kg/m2, associated with glucose intolerance. He underwent the Scopinaro procedure for biliopancreatic diversion, with uneventful postoperative evolution, and presented a 55% loss of excess weight one year after the surgery, with resolution of glucose intolerance, and without any manifestation of protein-calorie malnutrition. A 28-year-old male with Down syndrome, whose IQ was 68, was admitted with BMI of 41.5 kg/m2, associated with hypertension. He underwent Roux-en-Y gastric bypass, with uneventful postoperative evolution. He presented a 90% loss of excess weight one year after the surgery, with resolution of the hypertension. CONCLUSION: Bariatric surgery among individuals with intellectual impairment is a controversial topic. There is a tendency among these individuals to present significant weight loss and comorbidity control, but less than what is observed in the general obese population. The severity of the intellectual impairment may be taken into consideration in the decision-making process regarding the most appropriate surgical technique. Bariatric surgery is feasible and safe among these individuals, but further research is necessary to deepen these observations.


INTRODUCTION
Bariatric surgery has become the standard treatment option for refractory morbid obesity.The observed overall impact of this surgery on obese patients has been found to be 40% regarding long-term reduction in mortality, 56% for coronary heart disease, 92% for diabetes complications and 60% for any type of cancer. 1,24][5][6][7] The majority of bariatric programs exclude patients with intellectual and/or developmental disabilities, from surgical indication.Only 6.2% of programs have not considered severe levels of impairment, i.e. intelligence quotient (IQ) of 50-70, to be a contraindication. 8reover, current guidelines emphasize the importance of a clear understanding among patients regarding the risks, benefits, outcomes and alternatives to surgery.This ability to give consent is possibly compromised in cognitively impaired individuals. 6

OBJECTIVE
To report the cases of two individuals with severe non-acquired cognitive impairment who underwent bariatric surgery.

Case 1
EGR, a 25-year-old male with Prader-Willi syndrome, whose IQ was 54, presented with a body mass index (BMI) of 55 kg/m 2 , associated with impaired glucose tolerance and walking disability.He underwent the Scopinaro procedure for biliopancreatic diversion, with uneventful postoperative evolution.The main caregiver during the postoperative phase was his mother, who chose to perform caregiving functions full-time.
One year after the surgery, he presented BMI of 38.One year after the surgery, the patient began to work part-time at a grocery store.
Table 1 summarizes the main clinical and laboratory outcomes relating to these two individuals.

DISCUSSION
Bariatric surgery among individuals with severe intellectual impairment remains a controversial topic.There is a tendency among these individuals to present significant weight loss and comorbidity control, but less than what is observed among individuals without cognitive impairment. 9review of the literature on this subject was conducted through an online search for the Medical Subject Headings (MeSH) terms Prader-Willi syndrome, Down syndrome, intellectual disability and bariatric surgery, in MEDLINE (via PubMed) and LILACS (via BVS) (Table 2).After extensive online research, we identified six case series, five case reports, one matched-cohort study and one scoping review that evaluated bariatric surgery among individuals with severe cognitive impairment.Table 3 6,7,9-19 summarizes the main articles found and their respective characteristics and levels of evidence, according to the Oxford classification.
Interestingly, despite the much higher frequency of Down syndrome in the general population (one per 700 to 1,000 newborns), we observed that the vast majority of the studies included individuals with Prader-Willi syndrome, which occurs less commonly (1 per 10,000 to 25,000 newborns). 20In fact, only the study by Daigle et al. 7 included two individuals with Down syndrome.
Whether this finding is due to non-treatment of these individuals or underreporting of the treated cases remains to be determined.There is a strong necessity for social support within this group of individuals, especially regarding family support and caregivers.
Since these individuals do not present the capacity to understand and formally consent to such procedures, the main caregivers need to be directly asked about this topic.[8] Since there is no consensus regarding which procedure is most appropriate, the severity of intellectual impairment may be taken   into consideration in the decision-making process regarding which technique to use.0][11][12][13][14][15]19 There is newer evidence showing that restrictive techniques may be safe and effective in this group of subjects. 6,9,1110][11][12][13][15][16][17][18][19] More studies are necessary, in order to provide evidence of higher quality that could lead to possible algorithms for this heterogeneous group of individuals.There is recent evidence that even mild cognitive impairment may play a role in the outcomes from bariatric surgery, such that it may lead to worse results and, especially, poor adherence to long-term follow-up. 23,24Nonetheless, a recent study by Rochette et al. 25 observed a significant decrease in the prevalence of mild cognitive impairment after bariatric surgery.Whether this may be applicable to individuals with severe cognitive disability remains to be further investigated.

CONCLUSION
Bariatric surgery is feasible and safe among cognitively impaired individuals, but further research is necessary.

Table 1 .
Outcomes from bariatric surgical procedures on two individuals with severe cognitive impairment BMI = body mass index; % EWL = percentage of excess weight loss; LDL-c = low-density lipoprotein cholesterol; HDL-c = high-density lipoprotein cholesterol.

Table 2 .
Database search results for bariatric surgery among individuals with severe cognitive impairment, conducted onNovember 14, 2016

Table 3 .
Main studies on bariatric surgery among individuals with severe cognitive impairment N = number of individuals.