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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.1,2
Obesity and its related comorbidities are common among individuals with cognitive impairment, but the outcomes from bariatric surgery in this singular group remain uncertain.3,4,5,6,7 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.8 Moreover, 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 REPORT
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/m2, 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 38.5 kg/m2, i.e. a 55% loss of excess weight. His impaired glucose tolerance had been resolved; his ability to walk had developed; and he did not present any features of malnutrition. No cognitive evaluation test was performed after the surgery. Two years after the surgery, the family chose to leave the patient at a part-time non-profit institution for intellectually disabled people.
Case 2
JLC, a 28-year-old male with Down syndrome, with IQ of 68, presented with a BMI of 41.5 kg/m2, associated with hypertension. He underwent Roux-en-Y gastric bypass, with uneventful postoperative evolution. The main caregivers during the postoperative phase were his mother and sister, who both chose to perform caregiving functions full-time.
One year after the surgery, he presented BMI of 26.7 kg/m2, i.e. a 90% loss of excess weight, with resolution of his hypertension. No cognitive evaluation test was performed after the surgery. 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.9
A review 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 6,7,9,10,11,12,13,14,15,16,17,18,19 summarizes the main articles found and their respective characteristics and levels of evidence, according to the Oxford classification.
Table 2: Database search results for bariatric surgery among individuals with severe cognitive impairment, conducted on November 14, 2016
Table 3: Main studies on bariatric surgery among individuals with severe cognitive impairment
N = number of individuals.
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).20 In 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. Social support must be emphasized postoperatively, to avoid loss of adherence to the long-term follow-up. 6,7,8
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. Historically, predominantly restrictive procedures such as sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB) and gastric banding were avoided among individuals whose intellectual deficit was more severe, such as in cases of Prader-Willi syndrome.16,17,18 However, this trend diminished over the years, to the point that nowadays Roux-en-Y and mini-gastric bypasses, and even sleeve gastrectomy, in which weight loss relies exclusively on a restrictive mechanism, are considered valid options. 8,9,10,11,12,13,14,15,19 There is newer evidence showing that restrictive techniques may be safe and effective in this group of subjects.6,9,11 In individuals whose deficit is slight or even borderline, predominantly restrictive procedures do not present any formal contraindications.6,7,20,21,22 With the sole exception of the study by Miyata et al.,14 in which an individual with Prader-Willi syndrome presented an initial improvement of metabolic and weight conditions, followed by progressive worsening, the vast majority of the studies have consistently observed significant improvements following a variety of techniques, regarding both metabolic features and weight loss, albeit to a lesser extent than what is observed in the general population with obesity when bariatric surgery is implemented.6,7,8,9,10,11,12,13,15,16,17,18,19
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.23,24 Nonetheless, 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.
