This study aimed to explore patients’ main expected dreads, difficulties, or challenges in the long term after MBS, in conjunction with patients’ preoperative expectations regarding physical, social, and psychological aspects. Despite prioritizing being informed about potential complications, it did not discourage patients from choosing MBS.
Mobility, health, and remission of comorbidities emerged as the most important reasons for undergoing surgery. This is in line with previous literature showing that the primary motivation for individuals pursuing MBS is connected to physical health (8–12). While weight loss has also been recognized as an important motivation in previous literature (12, 13), it did not emerge as one of the three primary reasons in our study. Interestingly, Hult et al. identified weight loss as the leading motivation, not only in their overall study population but also in a subgroup of patients from the Netherlands (12). An explanation for this difference might be the higher observed BMI in their population, compared to a lower BMI in ours, suggesting that individuals with a higher BMI may prioritize weight loss as a more important reason for opting for MBS. In our study, we also found a higher expected %TWL in patients with a higher BMI (35% versus 31%). Furthermore, the proportion of patients with BMI > 50 kg/m2 in our study was small.
Although weight loss was not frequently mentioned as the most important reason to undergo MBS, our study population has high expectations in terms of weight loss post-surgery, with a median %TWL of 32% and a %EWL of 81%. This aligns with previous studies, reporting expected %EWL ranging from 71–94% (8, 12, 13). However, gastric bypass surgery has been associated with reported %EWL ranging from 27–69% after ten years (15). This shows a considerable disparity between anticipated and realized weight loss outcomes, which can result in postoperative disappointment. Nowadays, it is preferable to quantify weight loss in terms of %TWL rather than %EWL (19). Unfortunately, previous studies relied solely on %EWL for their measurements, making a reliable comparison between their results and our outcomes infeasible. In the questionnaire, we did not define a specific timeframe for expected weight loss after surgery. Consequently, participants might have referred to expected weight loss in the short term after surgery rather than in the long term.
Our study reveals a notable difference in weight loss expectations between age groups, with patients over 50 years anticipating more excess weight loss compared to those under 30 years (83% versus 76%). However, the %TWL did not differ between the age groups. These findings contradict previous studies indicating that younger patients tend to have higher expectations regarding weight loss (20, 21). A potential explanation could be that younger patients typically have fewer comorbidities, allowing them to focus more on weight loss.
Although participants had unrealistic weight loss expectations, their estimations for comorbidity resolutions were accurate. The anticipated total remission rates for comorbidities were as follows: 61% for hypertension, 87% for OSAS, and 67% for diabetes mellitus. These rates align closely with those reported in a meta-analysis by Buchwald et al., where hypertension resolution occurred in 62% of the patients and OSAS resolution in 86% (22). However, the expected total remission rate of diabetes mellitus in our population was lower than the actual remission rate reported by Buchwald et al. (67% vs. 77%) (22). Similarly to our expected remission rate, Svanenik et al. reported an actual diabetes remission rate of 67% in their patients (23). Overall, these findings suggests that our preoperative information session on MBS is effective regarding obesity-related comorbidities. Patients older than 50 years anticipated higher resolution rates for OSAS compared to their younger counterparts. Notably, these higher expected remission rates align with those reported in the literature, suggesting that older patients' expectations are realistic (22). Unfortunately, we were unable to compare the expected remission rates for other comorbidities, as patients younger than 30 years did not have any additional comorbidities. In the literature, the reported remission rate of obesity-related comorbidities is higher in younger adults compared to older individuals (24).
Our findings suggest a prioritization of physical factors over social and psychological factors when seeking MBS. Although the expected changes in physical, social, and psychological domains after MBS were addressed separately through open-ended questions, there was overlap in the responses across these domains. Differentiating between the domains appears challenging for patients, which is understandable given the interconnected nature of these domains. For instance, feeling better when in the company of others can be categorized as both psychological and social. Mobility, pain reduction, and physical fitness emerged as primary motivations for individuals considering MBS in our study, alongside considerations such as improved health and remission of comorbidities. Consistent with prior research, low percentages of self-image and emotional well-being were seen as the top three motivations for undergoing MBS (25). Conversely, findings from a study conducted by Hult et al. revealed that self-esteem, mental health, and social life were ranked as very important by 72%, 76%, and 56% of the participants, respectively (6, 12). However, their study considered a broad spectrum of motivations to undergo MBS as very important.
Our results show that patients consider it important to be informed about both short-term and long-term complications. However, the complications do not induce anxiety or heavily influence the consideration of undergoing MBS. This aligns with the conclusions drawn by van Rijswijk et al., who found that patients are willing to accept considerable risks, including short-term complications (≤ 30 days after surgery), acute internal herniation (≥ 30 days), and mortality (≤ 30 days), to achieve their weight loss goals (17). However, only the short-term complications were incorporated in the study of van Rijswijk et al. (17), while we also included long-term complications. Furthermore, we conducted subgroup analyses to assess patients' perceptions of complications. The primary findings from these analyses indicate that female patients exhibit greater anxiety of developing complications and have a stronger desire for comprehensive information. These subgroup differences should be considered when discussing treatment options with patients, such as taking more time for explanations or referring them to reliable sources.
Strengths and Limitations.
The strengths of this study are the large sample size and the administration of the questionnaire in two independent hospitals. Additionally, it expands upon previous literature by adding patients’ main expected dreads, difficulties, or challenges in the long term after MBS. Our study has some limitations that need to be mentioned: first, the questionnaire is not validated. However, it was developed based on literature and clinical expertise. Second, we did not inquire about the preferred bariatric procedure, while this could influence results regarding weight loss expectations or specific complications. Third, the generalizability of the study may be limited as this study was solely conducted in the Netherlands. Administering the questionnaire globally could enhance generalizability. Finally, due to our study design, we were not able to compare preoperative expectations with postoperative outcomes. Nevertheless, to answer our research question, the cross-sectional study design was deemed appropriate. Future studies could explore the concordance between patients’ preoperative expectations and postoperative outcomes.