Quality of life after Roux-en-Y gastric bypass surgery

AORN Journal,  April, 2007  by Carol Hager

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Worldwide, the incidence of obesity is rising, (1) leading to a related increase in obesity-associated comorbidities and directly affecting longevity and quality of life. Obesity is noted not only to result in social and economic problems, but also to decrease longevity and increase morbidity risks. (2) In 2001, the Surgeon General reported that 300,000 deaths annually are the result of obesity. (3)

According to Raum and Martin, (4) the only effective treatment for morbid obesity and its comorbid conditions is bariatric surgery, such as the Roux-en-Y gastric bypass procedure. No medications; lifestyle changes; or psychotherapeutic, acupuncture, hypnosis, or nutrition programs remotely approach the capacity of bariatric surgery to reduce or eliminate the diseases caused or exacerbated by morbid obesity?

The primary purpose of this quality improvement (QI) project was to determine how patients evaluated their quality of life before and after gastric bypass surgery. This project also measured changes in four conditions or comorbidities frequently associated with the diagnosis of morbid obesity (ie, hypertension, psychiatric disorders, diabetes, hyperlipidemia) by comparing preoperative medication use to postoperative medication use.

Another goal was to gain information concerning bariatric surgery to share with and improve the understanding of perioperative staff members involved in the care and safe passage of these patients through the surgical experience. For perioperative nurses, part of the understanding includes acknowledging potential personal bias and discrimination toward patients who are obese. In essence, this was an exploration for deeper understanding of people facing not only life-and-death health issues, but also the psychosocial stigma of obesity.

DIAGNOSING AND TREATING OBESITY

There are many definitions of obesity, including excess accumulation of body fat, imbalance between energy taken in and energy used, (5) and disordered satiety. (6) Development of obesity is related to a complex mix of genetic and environmental factors (3,7) as well as lifestyle factors such as diet and exercise. (8,9) Obesity can be seen in children and adults, men and women, the rich and the poor, and the well-educated and those with minimal formal education. Geographic, economic, and cultural pockets of higher incidence of obesity are increasing worldwide.

Clinical guidelines for diagnosing obesity concur that body mass index (BMI) (Table 1) is significantly correlated with total body fat content. (8) Research suggests that an ideal BMI of between 18.5 kg/[m.sup.2] and 25 kg/[m.sup.2] reflects the lowest levels of chronic disease and leads to improved health. (10) Recently, the trend is to use a combination of the BMI, waist circumference, and the presence of comorbidities to more accurately reflect a healthy weight. (8)

Medically supervised treatment of obesity generally includes a combination of diet, exercise, and behavior modification. Weight loss and rebound weight gain with dieting, however, is seen frequently in people who are obese, with only rare exceptions. One study showed a nearly 100% failure rate during a five-year period among people who dieted for weight control. (11) Pharmacologic agents may be included to enhance efforts toward weight loss and the resultant improved health status. Historically, medications such as orlistat and sibutramine have been shown to facilitate effective weight loss, and using them to manage obesity is among the recommendations made in primary care settings. (8,9,12) These medications are prescribed to initiate and maintain weight loss, especially when used in combination with behavior modification; however, research shows that there is the potential for regaining lost weight after the medication is discontinued. (1)

Surgical interventions, such as Roux-en-Y gastric bypass, are recognized as an alternative for weight reduction for individuals in the severely obese population who have not lost weight with traditional, conservative medical management. Most patients who present for bariatric surgery have already made multiple attempts to achieve sustained weight loss via nonsurgical options. (2) Surgical interventions are available for those with increased risk of morbidity and mortality as a result of repeatedly failed medical management of obesity. In fact, surgical intervention has been documented to be the definitive treatment at this time for morbid obesity. (13)

COMORBIDITIES OR COMPLICATIONS OF OBESITY

Being overweight is not the only presenting factor for this patient population. Waist and upper abdominal fat distribution has demonstrated a strong relationship to increased risk of obesity-related comorbidities. (1) Comorbid conditions in obesity can be related to physical, metabolic, and overlapping consequences of increased adipose tissue and mass. This overlap may have both additive and potentiating effects. (6) Related to this pathophysiology is the concept of the effect of increased intra-abdominal pressure generated by the presence of excess adipose tissue. (14) Physiologic challenges such as hypoventilation, venous stasis, increased cardiac filling pressures, and high lumbar cerebrospinal fluid pressures can result from increased intra-abdominal pressure. These physiologic changes predispose people who are obese to develop a long list of comorbid disease states. (14)