Bariatric Surgery: Patient Incision Care and Discharge Concerns

   Because bariatric surgery provides greater and more durable weight reduction than behavioral and pharmacological interventions for persons who are morbidly obese, the number of operations is increasing in hospitals of all sizes.¹ According to Trus, Pope, and Finlayson,² the national annual rate of bariatric surgery increased from 2.4 to 14.1 per 100,000 persons from 1990 to 2000, while the average length of hospital stay for bariatric surgeries decreased from 6 to 4.1 days.² One of the more common surgical techniques is the Roux-en-Y gastric bypass (RYGBP), which can be performed as an open or laparoscopic procedure³; for the laparoscopic procedure, discharge home may occur 23 to 72 hours following surgery.^4,5

   Postsurgically, in addition to following diet and activity guidelines, persons face incision care and other challenges when discharged home. The short hospitalization, the physical and psychological aspects of the procedure, and potential comorbidities can impact the patient’s knowledge of incision care and concerns about going home. Little is known about how incision care information is imparted or about patients’ concerns about the postsurgical period specifically related to bariatric surgery. The purpose of this study, which used a cross-sectional design, was to examine incision care and discharge concerns of patients who had undergone RYGBP bariatric surgery.

Literature Review

   Bariatric surgery. Obesity and its associated comorbid conditions (eg, diabetes mellitus, hypertension, hyperlipidemia, and obstructive sleep apnea) have markedly increased in the US.^6,7 These diagnoses are associated with premature death and disability.⁶ Yet, study results have shown that the hospital mortality rate for bariatric surgeries is low (overall 0.4%).² Rates for re-operation (1.3%) and pulmonary embolism (0.3%) remain stable and the rate of respiratory failure has declined.² Because of information in the media regarding obesity, the public is more aware of bariatric procedures and more surgeries are being performed. Using information from a large national US database, Livingston and Ko⁷ identified that 2.8% of the American population was eligible for obesity surgery. A utilization and in-hospital outcomes study of bariatric surgery in the US was conducted over a 10-year period (1995 to 2004). According to the admission/discharge data/hospital records in California that form the annual hospital patient discharge database maintained by the California Office of Statewide Health Planning and Development, 60,077 persons underwent a RYGBP; most patients were women <65 years of age with private insurance.⁸

   Current bariatric surgical procedures include gastric restriction (vertical banded gastroplasties and circumgastric adjustable banding) and gastrointestinal bypass (GBP) that also has a restrictive component.⁹ The GBP procedure of choice in the US is the RYGBP, which was first described in 1967.⁶ The RYGBP procedure can be performed using an open surgical incision or laparoscopic procedure. The technique reduces stomach capacity and causes a change in digestion by bypassing parts of the small intestine.³ With this procedure, the stomach is divided into two compartments. The small stomach pouch is connected to the jejunum, creating a gastrojejunostomy. Further down, the Roux limb extending from the duodenum and proximal jejunum is anastomosed to the distal jejunum.³ Food can now mix with bile and pancreatic fluids for digestion but bypasses portions of the small bowel, limiting the body’s ability to digest food. The amount of food taken in is restricted by the size of the stomach pouch and the intestine connection. Bowel obstruction related to internal hernias and dumping syndrome can develop.

   The first successful laparoscopic gastric bypass procedure was described in 1994.⁶ Because they are minimally invasive, laparoscopic procedures decrease length of stay, postoperative pain, postoperative ileus, wound infections and seromas, incisional hernias, blood loss, adhesion-related morbidity, and need for postoperative intensive care.^3,6 The laparoscopic RYGBP has technical challenges related to patient size and procedure complexity but it can be performed on very large persons.^6,10

Postsurgical Considerations

   Persons undergoing bariatric surgery have little physiologic reserve and because of their large size they do not manifest complications in the same manner as normal-sized persons.^11,12 In addition, preoperative conditions that commonly affect persons who are morbidly obese such as hypertension (34%), arthritis (27%), sleep apnea (22%), gastroesophageal reflux disease (GERD) (22%), and diabetes (18%), will continue into the postoperative phase and may affect recovery.^7,12 Complications may occur during hospitalization or at home.

   Clinicians must be vigilant for complications during recovery.^11,12 Using information from the National Hospital Discharge Survey (NHDS) database, Livingston¹² found that the in-hospital complication rate following bariatric procedures was 9.6%. The two most feared complications are pulmonary embolism (0.3%)² and leaks from anastomoses or staple line.¹¹ From a study of the Nationwide Inpatient Sample of bariatric surgery admissions from 1998 to 2002, Santry and colleagues¹ reported pulmonary complications were the most frequent systemic complication and occurred in 4% to 7% of admissions.¹

   Long-term, calcium, iron, and vitamin B₁₂ deficiencies may develop and result in anemia and osteoporosis/osteomalacia. In a follow-up study of 423 patients who had undergone a laparoscopic mini-gastric bypass, 9.7% developed anemia.¹³ Low hemoglobin may occur because of the inability to convert ferrous iron to ferric iron in the small stomach pouch.³ In a retrospective study of 435 patients who had bariatric surgery, Thaisetthawatkul and colleagues14 reported that 71 out of 435 patients (16%) developed peripheral neuropathy — a rate significantly higher than after cholecystectomy (four out of 126 patients or 3%). Malnutrition may be the most important risk factor.¹⁴ Poor calcium absorption may result in bone fractures. In addition, patients will have altered absorption of oral medications. Bowel obstruction related to internal hernias and dumping syndrome also can develop. Zingmond et al8 found the the main reason for hospital admission up to 3 years after the RYGBP was a procedure-related complication, followed by hospital admission for delayed elective procedures such as knee arthroplasty and plastic surgery procedures.

Surgery and Educational Needs

   Information access. Information about patient teaching and discharge needs for bariatric surgery patients is limited in the literature. In a study of 297 consecutive patients, Giusti and colleagues (Switzerland)¹⁵ evaluated the impact of preoperative teaching on surgical choices. Teaching consisted of three weekly, 2-hour interactive sessions. Patients were asked which operative procedure (gastric banding, gastric bypass, or undecided) they had in mind at the first and last session. After the teaching sessions, the number of patients who were undecided decreased (23% to 1%); gastric banding preference decreased (34% to 20%); and gastric bypass increased (43% to 70%). The authors concluded that an informed patient is better able to select a surgical procedure.¹⁵

   Madan and colleagues¹⁶ assessed Internet access of 127 bariatric clinic clients to bariatric information using a questionnaire format. Of these patients, 89% owned a computer, had Internet access, and had an email address. In addition, 85% had searched the Internet for bariatric information. Based on these data, the authors recommended that bariatric clinics post information about the clinic and maintain email availability.

   Information quality. The quality of websites used by patients is a concern. To assess the quality and accuracy of information about bariatric surgery provided on websites, Nichols and Oermann¹⁷ evaluated 40 websites using criteria of the Health Information Technology Institute — credibility, content, disclosure, links, design, interactivity, and caveats. The seven top bariatric sites for patient education and guidance were the American Obesity Association; the National Institute of Diabetes and Digestive and Kidney Diseases; the Mayo Clinic; Vanderbilt Medical Center; WebMD Health Resources: Dr. Elliot Goodman (“Weight-loss surgery: is it for you?”); Ethicon Endo-Surgery, Inc.; and the American Society of Bariatric Surgery.¹⁷ The authors concluded that because surgery is life-changing, it should not be taken lightly and patients should be told about quality websites for information in order to discuss procedures with clinicians and make informed decisions.¹⁷

   Information retention. Madan and Tichansky¹⁸ used a true/false quiz to assess recall of bariatric education of 63 patients pre- and postoperatively. Before surgery, patients were expected to score 100% on this test. Patients took the test, on average, 8 months after surgery; the mean score was 96%. Only 36% of patients > 1 year postsurgery achieved 100% on the test. The authors concluded that patients often forget critical information.

   Discharge preparation. Stellato and colleagues¹⁹ examined patients in their practice (N = 316) who underwent an open RYGBP from 1998 to 2002. Patients were screened for the discharge criteria and received preoperative education. Discharge criteria after RYGBP included adequate oral intake, pain control with oral analgesia, and an adequate understanding of the operation and its effects, demonstrated by correctly answering a written test before discharge. The authors noted that the number of patients discharged home on the second day increased over the years and concluded that, with screening and preoperative education, patients could safely be discharged home in 2 days.¹⁹

   The discharge educational needs and concerns of patients who had undergone a variety of surgical procedures have been summarized in the literature.²⁰ While hospitalized, surgical patients identified the following as critical discharge knowledge: recognizing complications, activity guidelines, diet, symptom management, and wound care.^21-25 Jacobs,²³ using a mailed-to-home questionnaire among 45 patients, reported areas where information preparation for discharge was inadequate: complication recognition, exercise, difficulty with urination, and bowel trouble. Other patient discharge concerns identified include suture removal, how to improve their physical condition, medications, fatigue, and bowel habits.^22-28 Some patients express concern regarding well being and quality of life after operative procedures.^{21,22,24,27,29} The amount of information given before discharge has been reported to be insufficient for 30% to 50% of patients.^26,30 Results of a 40-patient study indicated that information needs were not affected by the person’s age or educational level.²¹ In another correlational, predictive study of 60 persons with open thoracotomy surgery for primary lung cancer, pain, depression and fatigue significantly affected both what a person learned in the hospital and the postoperative recovery.²⁷ Symptoms such as pain, fatigue, and dyspnea increased in relation to other aspects of care.^21,28 Because needs/concerns expressed before discharge have been found to be significantly related to needs expressed at home, patients were able to predict their information needs before discharge.²²

   Teaching in preparation for discharge may be done by different members of the healthcare team. Breemhaar and colleagues,²⁶ in their study of 54 patients with cholecystectomy or herniorrhaphy, using open-ended interviews, reported that 50% of patients identified the nurse and 30%, the physician as the person providing the instruction. Sometimes nurses ranked an area of educational concern higher than patients; for example, Anthony and Hudson-Barr²⁴ found that the need to understand wound care was considered more important by nurses than by patients.

   Clinical pathways. Some settings use clinical pathways to facilitate teaching and care. Rouse and colleagues³¹ developed and implemented a clinical pathway for bariatric surgery patients. The pathway included preprinted orders, discharge home instruction sheet, and daily guidelines for patients. Using the pathway in all patients from July 1995 to September 1997, length of stay and wound infections decreased and communication and collaboration across the multidisciplinary team increased.

   In summary, patients undergoing bariatric surgery require preparation and follow-up when discharged from the hospital but research findings about the discharge concerns of these patients is lacking. Studies examining discharge concerns for other types of procedures have identified the following common concerns: recognizing complications, activity guidelines, diet, symptom management including pain, and wound care. The purpose of this study was to examine knowledge about incision care and discharge concerns of patients who had undergone RYGBP bariatric surgery. The following research questions were explored: 1) What does the patient know and fear about incision care before going home; and 2) What are general discharge concerns about going home after bariatric surgery?

Methods

   Design and procedures. Incision care knowledge and fears and discharge concerns of bariatric surgery patients were part of a larger, cross-sectional study undertaken to examine discharge and wound care concerns of patients with a wound discharged home from an acute care hospital. Participants (N = 31) were recruited from a bariatric surgery center in a large, urban teaching hospital. Participants had undergone either an open (n = 29) or laparoscopic (n = 2) RYGBP and were scheduled to be discharged home. Patients <21 years of age, unable to understand and respond in English, who had surgery for complications of a previous bariatric procedure, or were too ill to respond to a questionnaire were excluded.

   The study was approved by a Human Investigation Committee for the Protection of Human Rights. Advanced Practice Nurses identified potential participants, briefly explained the study, and obtained the patient’s consent to allow the research nurse to arrange an appointment to implement the study’s protocol. The mean time from hospital admission to study participation was 1.1 days (SD = 3 days). To avoid any difficulties with reading, questionnaires were read to all participants. Questionnaire completion time was 1 hour.

   Instruments. The Demographic and Health Questionnaire, developed for use in many studies, was used to obtain information about age, sex, race, education, chronic health problems, and self-rating of current health and reading ability. Self-assessed health was rated on a 10-point scale ranging from 1 (sick) to 10 (healthy). Self-assessment of reading was used as a consideration of literacy level. Ten-point scales were used to assess ability to read (1 = do not read to 10 = excellent reader) and how much they liked to read (1 = not at all to 10 = a great deal).

   Several questions examined incision care. Participants were asked what they had been told to use to cleanse their incision and what dressing to use at home. They reported if they could see their incision, reach their incision, and whether they wanted to do their own incision care at home. Participants rated their fear of doing incision care at home on an 11-point scale ranging from 0 (no fear) to 10 (a lot of fear); amount of information they received about doing incision care, 0 (no information/do not know what to do) to 10 (too much information/know what to do); their knowledge about incision care, 0 (do not know how to care for wound) to 10 (ready to care for wound). They were asked where or to whom they would go for wound care information — ie, physician, nurse, Internet, family/friends, library, and coworkers.

   The Pain Questionnaire was adapted from an American Pain Society pain questionnaire.³² Participants assessed wound pain in terms of worst pain in 24 hours, average pain in 24 hours, and current pain. Pain ratings were on 11-point scales ranging from 0 (none) to 10 (worst). The pain ratings were correlated (median r = .58). A composite pain score, developed from tabulating the three pain items, had a reliability coefficient alpha of .83 in this study. This instrument has been used in research that examined pain in injection drug users with various levels of chronic venous insufficiency; reliability coefficient alpha value was .92.³³

   The Beliefs about Wounds and Their Care Test had 14 true/false questions related to wound care. It was newly developed for this study based on patient comments about wound care heard by the research team. It included statements such as: Wounds need to dry out, hands should be washed before a dressing change, and peroxide is good for wounds. Possible correct total score ranged from 0 to 14. The Beliefs about Wounds and Their Care Test had a reliability coefficient alpha of .53.

   Because a discharge concerns questionnaire that examined multiple issues could not be found in the literature, a questionnaire also was developed for this study. The Discharge Concerns Questionnaire comprised 32 items related to concerns about going home culled during a literature search.²⁰ The research team (the authors) determined whether items were appropriate and how they should be scaled. Because the questionnaire would be read to participants, it was not tested for reading level. The first five patients responding to the study did not have difficulty with the items so the questionnaire remained the same throughout the study. Because the sample size was small, a factor analysis could not be performed. Items were classified by content and included activity (12 items), wound (eight), activities outside the home (six), pain (three), nutrition (two), and bowel concerns (one). Each question was rated on a 7-point scale ranging from 1 (not concerned) to 7 (very concerned). Items were tabulated for a total concerns score. The Discharge Concerns Questionnaire had a coefficient alpha of .91.

   Statistical analysis. Means and standard deviations were used to examine the level of a participant’s response on a scale. Correlations were used to examine relationships among variables such as knowledge, fears, and concerns.

Results

   Participant characteristics. Of the 31 participants, 28 (90%) were women and three were men, mean age = 45 years (SD = 12 years); 17 were African-American (54.8%) and 14 were Caucasian. Twenty (20, 64.5%) reported post-high school or college education and 16 (51.6%) were married. Common chronic health problems included hypertension (n = 18), arthritis (n = 3), heart problems (n = 2), and diabetes mellitus (n = 2). Participants had a mean self-health rating of 6.2 (SD = 1.7); thus, tending toward the healthy end of the scale.

   Incision care. Almost all persons (30, 97%) could see their incision and all 31 (100%) could reach their incision. Of the 31 participants, 20 (65%) had taken care of a wound in the past; only one person had practiced incision care in the hospital. Regarding wound cleansing, 18 patients (58%) did not know what solution to use to cleanse the incision at home; four were told soap and water; two, normal saline; two, hydrogen peroxide, and two, no solution. Regarding at-home dressing application, 17 (55%) patients were told to not apply a dressing to the incision, 10 were not told anything about a dressing, and four used gauze (per response to the question, “What dressing have you been told will cover the incision?”). Twenty-five (25, 81%) participants wanted to do their own incision care at home; six did not. Fear of wound care was rated low (M = 2.9, SD = 3.5); knowledge of incision care, midrange (M = 4.9, SD = 3.6); and amount of information received about incision care in the hospital, low (M = 3, SD = 3.4). The physician was the most frequently cited source sought for wound care information; nurses were fifth behind the Internet, family/friends, and books (see Figure 1). Correct scores on the Beliefs about Wounds and Their Care (true/false) Test ranged from 3 to 12 (M = 9.0, SD = 1.7).

   The lower the knowledge level about incision care, the higher the fear of incision care (r = .46, P = .008). Reading ability ratings correlated with fear of wound care (r = -.54, P < .002). Knowledge and fear were not significantly related to age, sex, race, or education. Self-rated knowledge about incision care was positively, but not significantly, associated with the total score on the Beliefs about Wounds and Their Care (true/false) Test (r = .32, P = .08). This suggests that a person’s subjective rating of knowledge was somewhat close to an objective test score.

   Discharge concerns. Table 1 presents the mean scores for subscales within the Discharge Concerns Questionnaire. The greatest concerns regarding discharge are presented in Table 2. Three of the items involved pain; three, complications; and five, activity. Participants reporting greater pain (see Figure 2) had more concerns about discharge (r = .49, P < .005). Concern about postdischarge pain was inversely related to self-reported reading level (r = -.35, P = .05).

Discussion

   Obesity surgery has increased since the 1991 the National Institute of Health’s obesity surgery consensus statement.⁷ Knowledge about incision care and discharge concerns of patients who had undergone RYGBP bariatric surgery was examined. It was found that study participants had received little information about incision care and only one person had practiced it. Lack of information about incision care was associated with greater fear of performing it. The areas of greatest concern related to pain, complications, and activity.

   Livingston¹² noted that the rate of bariatric procedures performed is rapidly increasing, resulting in the need to establish practice standards. These practice standards should include discharge preparation and teaching. Elkins and colleagues³⁴ examined noncompliance with behavioral recommendations following bariatric surgery for 100 consecutive patients. Patients had undergone the RYGBP and charts were reviewed at 6 and 12 months postoperatively. Lack of compliance with care was highest for lack of exercise (41%) and snacking (37%); 9% reported experiencing some medical complication following the surgery. The authors concluded that research is warranted to clarify factors that impact long-term outcome.³⁴ Patients who have had bariatric operations require close medical follow-up.⁷ Close follow-up also necessitates preparation for discharge from the hospital.

   Obese persons carry a psychological burden generated from prejudice and discrimination.³⁵ Emotional disturbances have been shown to complicate the postoperative course.³⁵ Psychosocial stress in morbidly obese persons should not be a contraindication for bariatric surgery but these patients should receive pre- and postsurgical counseling to reduce anxiety before, and increase compliance after, surgery.³⁶ As a personal testimony to the surgery, Ryan³⁷ emphasized the importance of asking questions, attending classes and support groups, and following the surgeon’s guidelines for successful outcomes. Discharge preparation is critical.
Approximately 2.8% of the American population is eligible for obesity surgery.⁷ Of these, a disproportionate number are African-American, poorly educated, and impoverished; 38% rely on Medicaid or Medicare insurance.⁷ Participants in the current study tended to have a high educational background, were women, and were racially diverse. Participants readily shared information about their background and discharge concerns. Surgery centers need to accommodate the educational and financial constraints of all educational levels of patients when planning long-term postoperative care.

Limitations

   The small sample size of the study limited generalizability and because of lack of research resources, participants were not followed after discharge. Sarwer⁹ acknowledged the difficulty of retaining and following bariatric patients after surgery. The timing of the interview in relation to the day of discharge could not controlled; hence, some patients may have lacked knowledge of incision care because instruction had not yet been offered.

   Because this study was part of a larger project, data were not collected about body weight, psychosocial variables, or knowledge of the surgical procedure. Psychosocial issues and quality of life would be important variables to include in studies as to how they impact discharge concerns.

Conclusion

   The number of bariatric surgical procedures is increasing and length of hospitalization for the procedures is decreasing. Discharge information must enable the patient to manage postoperative care, assess for complications, and follow prior directions for meals and eating. This study found that patients received little home care education, which impacted fear. Concerns were similar to patients undergoing other types of surgery — ie, pain, activity, and complication awareness. If discharge teaching is performed pre-operatively, clinicians need to remember that information may be forgotten, possibly due to the stress of the upcoming surgery, and repetition of content is probably needed. More research regarding discharge preparation after bariatric surgery is warranted.

This project was funded by the Detroit Medical Center (DMC) Nurse Scholar Grant, 2003–2005.

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