Patients' perspective on obesity surgery - expectations, experiences and self-reported outcomes

Abstract

Overweight and obesity constitute a major challenge to human health worldwide, involving over 1.4 billion people. In Sweden, more than a third (36%) of the population is overweight, and 13% are obese. For the vast majority of morbidly obese patients, conventional treatment (e.g. dieting, pharmacotherapy and behavioural therapy) often fails in the long-term. Bariatric surgery is currently the only successful treatment. In 2011, 8,600 patients underwent such surgery in Sweden. In bariatric surgery research, the patient's perspective is rarely highlighted, which means that there is a lack of knowledge about problems that patients might experience, how they address them and whether these problems affect the outcome. Aim: To explore patients’ expectations, experiences and self-reported outcomes in connection with bariatric surgery in order to determine whether or not and how these aspects affect HRQoL, everyday life, weight loss, eating behaviour and gastrointestinal side-effects. Methods: The effort to acquire scientific knowledge included seeking the unique in each individual case as well as group correlations and differences. For this reason, the data collection methods were both inductive and deductive, comprising interviews and questionnaires. Results: Eating behaviour, HRQoL and everyday life were reported to be very poor before surgery. The patients viewed bariatric surgery as the last resort to regain control over eating and weight and thereby their overall health. The surgery per se was considered the control mechanism and few patients felt that they were involved in the treatment. In the first year after the procedure, overall health, eating behaviour and social life were improved dramatically due to the physiological restriction brought about by surgery and subsequent weight loss. In the second year, the patients reported good but slightly decreased HRQoL, eating behaviour and everyday life compared to the previous year. During this year most patients experienced a weaker physiological restriction and were aware that willpower was essential in order to maintain what they had achieved. A small group of patients experienced loss of control over eating, leading to a negative self-image and fear of future weight gain. Several patients viewed dumping as something positive and wished for it to return when it ceased. Surplus skin was a major concern for the majority of patients two years after surgery, something they wished to correct by means of plastic surgery. Comparison of laparoscopic Gastric Bypass (GBP) and Duodenal Switch (DS) surgery for super-obesity two years after the operation revealed that DS patients had significantly more gastrointestinal problems (diarrhoea; p=0.002, anal leakage of stool; p=0.015, and daytime defecation; p=0.007) than GPB patients. Both groups reported a significant improvement in psychosocial function, eating behaviour and HRQoL after surgery and no significant difference between the groups was evident. Patients who experienced poor control over eating two years after surgery had significantly lower HRQoL in seven out of eight domains in the SF-36 Health Survey questionnaire (p <0.05) compared to those who had control over eating. They also reported more Emotional (p <0.001) and Cognitive Restraint eating (p<0.05) and did not exhibit a significant weight loss between the first and second year after surgery (p=0.15) in contrast to patients who experienced being able to control their eating (p<0.001). Conclusion: From the patients’ perspective, the issue of controlling food intake seems to play an important role for surgery outcome as well in their everyday lives. This knowledge can be used to make the patients more involved in their treatment and strengthen their belief in their own ability to influence the outcome as opposed to solely relying on the physiological constraint created by the operation, which seems to decrease over time. Healthcare resources would probably be better employed by identifying the small group of patients with poor post-operative control at an early stage and providing extra interventions for them.

Keywords: Bariatric surgery, patients’ perspective, loss of control, eating behaviour, health related quality of life, well-being, surgery outcome, patient reported outcomes, gastrointestinal functions