The Lived Experience of Individuals following Roux-en-Y Gastric Bypass Surgery: A Phenomenological Study

Sample

A purposive criterion-based sample was employed for this study. After approval of the Barry University Institutional Review Board (IRB), Bariatric healthcare practices in a metropolitan area of the southeastern United States were contacted to locate potential participants for the study. Participants had undergone the Roux-en-Y gastric bypass procedure that combines both restrictive and malabsorptive mechanisms. The dates of surgery were between 2 and 9 years prior to the study to allow for the individual to share a more substantive meaning of the experience.

Ethical considerations

Ethical considerations were an essential component of this qualitative study. Informed consent and HIPAA forms were completed prior to study participation. Individuals were invited to select a pseudonym. Confidentiality was maintained by keeping the forms in a locked file separate from the transcripts. This was a minimal-risk study, and there were no direct benefits to the individual participants. Participants were provided a list of available community referral sources free of charge in the event they experienced any emotional difficulty.

Data collection procedures

An in-depth interview was conducted with each participant in a setting of his or her choosing. The length of interview was individually driven but was usually 50–65 minutes in length. Participants were asked to attend a follow-up interview 1 to 2 weeks following the initial meeting. The participants reviewed the transcript of the interview for accuracy. This second interview lasted 20–60 minutes. The total time commitment was approximately 2 hours. Data collection was achieved by an audiotape recording of the interviews. Supplemental data included personal observations and field notes. The researcher transcribed the interview verbatim and sought to elucidate meanings. Audiotapes were transcribed exclusively by the researcher.

Data analysis

Utilizing phenomenological methods consistent with van Manen's hermeneutic approach, data analysis occurred upon completion of the interview. The researcher followed a methodical process incorporating van Manen's (1997) ² suggested method and the process was ongoing until saturation was achieved.

Research rigor and trustworthiness

In order to enhance trustworthiness, the researcher engaged in a variety of strategies including prolonged engagement, triangulation, peer debriefing, member checking, audit trail, and reflexivity.^3–6 To further enhance the credibility of the findings, the qualitative technique referred to as “member check” was completed. ⁷ The researcher conducted repetitive cycling between the parts and the whole to make sense of the phenomenon in relation to the written descriptions, and the researcher repeated exploration of the units of meaning and depth of dialogue between the research and participants through immersion in the transcribed narratives. Authenticity was achieved through the use of semistructured interviews with open-ended questions to obtain rich detailed descriptions of the bariatric experience.

Audit trails were made available to peer reviewers and/or the dissertation committee to establish dependability. Data trails included field notes, documents, photographs, personal notes, transcribed interviews (raw data), coding, and the text of the final product. Confirmability was established in this study by recording the phenomenological activities so another researcher may follow the course of the researcher.

Demographics

The study included 12 participants: 8 women and 4 men. Two initial participants were obtained through recruitment flyer, and snowball sampling resulted in the 10 other volunteers. All of the participants reported that they were enrolled in private insurance plans that covered their procedure. Each of these individuals had Roux-en-Y gastric bypass surgery between March 1998 and August 2006. Interviews were conducted between January and March 2008. Table 1 offers a summary of the demographic data in aggregate form.

Themes

The complex phenomenon of life following Roux-en-Y gastric bypass surgery was illuminated through the powerful descriptions of moods, feelings, and emotions offered by the 12 participants in this study. An overarching theme of paradox became evident and permeated the participants' sense of time, person, relationships, and space. Additional themes related to these four existentials include surgery as renewed hope for life, finding balance, filling the void, and transformation of self-image.

Theme 1: Surgery as renewed hope

Each participant described their experience of hope in unique and varied terms. Many offered discussions of their preoperative life and the desire for surgery as a means of achieving an improved future. The participants provided stories about their exhaustive attempts to overcome obesity in the past. Diets, nutritional interventions, medications, psychotherapy, and behavioral interventions had resulted in short-term weight loss but did not offer the promise of a changed future. All participants shared a sense of hope in their decision to choose surgical intervention for their obesity. Most cited that surgery was viewed as the ultimate chance to conquer obesity.

Participant 1 shared her sorrow and despair resulting from obesity and subsequent infertility. To counter the infertility, her husband offered her comfort and suggested they plan to adopt a child. “That was such a dark time. I was a mess and wanted to die. … I was a failure as a wife. I wanted to kill myself.”

Adopting a child, she said, might fix the infertility, but it did not help her with her obesity. Then she was introduced to gastric bypass surgery by her physician. She said, “And suddenly there was a chance. … Surgery was my only hope.” In the years after surgery, Participant 1 was able to conceive. She relates that her daughter serves as proof of her overcoming infertility. However, gastric bypass surgery is the marker of her triumph over obesity. She states, “This is proof of my success. I can never, not ever forget how much gastric bypass surgery changed my life.”

Another patient, Participant 7, spoke of how surgery offered her hope for a better future. Her reality was laden with a family history of obesity, diabetes, and peripheral artery disease. “We had more family with amputations, and limbs lost. … I just did not want to be one of those people.” She recalls her father advising she had made a bad decision.

Weight was seen as the cause of helplessness and depression for another participant, Participant 9. She explained, “I tried to kill myself because of my weight. I was miserable.”

She stated that the idea of surgery served as a source of hope. “I thought I would die from obesity. … But my doctor offered me a chance.” She further articulated the realization that she now had the beginning of hope.

Clearly, surgery was expressed as a hopeful action. Participants voiced a belief in a positive outcome following gastric bypass surgery. The belief that surgery would make a difference for their life was unanimous. Some participants expressed that fear and surgical risk was not enough to prevent them from being hopeful. Hope countered the paradox of any fears they may have felt.

Theme 2: Finding balance

Finding balance was the theme expressed by the participants as they described their realization that there were risks and benefits, gains and losses, and ups and downs associated with gastric bypass surgery. The participants expressed that finding balance was a continuous and evolving process as they engaged in the phenomenon. Many of the participants described finding balance in several ways. Participant 10 articulated the following:

If you ask me to draw my picture of it [the gastric bypass experience], I would draw an elephant on a tiny red ball at the circus … it took so much energy to get here. It had a lot to do with strength and support, but mostly I had to figure out how to spread me out … just as I was. And even when I learned how to keep myself on the ball, I still did not give myself credit for everything I had gotten in return. I was still thinking about losing weight.

Participant 4, a vibrant participant, described his struggle to find the positive aspects of gastric bypass surgery against the losses he experienced in the 2-year period after his surgery. He admits that the surgery gave him increased mobility, flexibility, recognition of his sexual orientation, and an overall sense of freedom. However, he described postoperative losses that included the loss of his marriage, custody of his children, sobriety, and his job.

He further explained that in order to attain health, he needs to reconcile his feelings of insecurity and failure with the benefits of his weight loss.

Participant 4 continued to describe his first anniversary following surgery as a milestone. His friends celebrated his success with champagne. However, he felt distraught that his wife did not attend the party and never told their sons that they were invited. He recalled feeling overwhelmed and anxious for weeks. “I was having panic attacks. … I couldn't figure what was making them come on.” Suddenly, he said, he came to the recognition that the benefits he gained from his gastric bypass surgery were countered by the loss of his family.

Theme 3: Filling the void

The participants discussed a strong sense of emptiness after gastric bypass surgery. Many shared just how much they had come to rely on food as a means to calm their nerves, ease their pain, and placate loneliness. After surgery the newly created pouch enabled only minute portions of food to be consumed, but their hunger was not satiated despite their full stomachs. Food that had served as a source of comfort to most was suddenly ineffectual in meeting the overwhelming physical and emotional emptiness they experienced. Participants identified varied ways to fill this void created by their gastric bypass surgery.

Some participants voiced a similar sense of hollowness following bypass surgery that correlated to missing food or food-related sources of comfort. They further explained how this void affected their lives, their relationships, and their sense of self. Participant 4 shared that approximately 15 months after surgery he had stopped losing weight and felt alone and overwhelmed. He sought ways to satisfy the holes left by gastric bypass surgery.

Participant 4 reflects on how he currently deals with his emotions:

I try to release myself from the emptiness and when I am angry, upset, and … my kids or if my ex-wife calls and gives me another punch in the chest. I tend to go to my new addiction. … Tattoos! Because I like to hurt, the more I hurt the better I feel. … It eases the empty feelings. … I know that sounds crazy.

Participant 7 felt abandoned following the death of her father approximately 6 months after surgery. She articulated a need to satisfy her emptiness and discovered that food was no longer an option.

Participant 7 identified that food had been a means to “ease her problems” all her life. After surgery she filled her closet and the void created by the loss of her father with shoes as a substitute for food. Today she finds that talking to her husband, engaging in regular physical activity, planning to adopt a baby, and working in a job she loves offer her alternatives to food and shoes.

Participant 8, a woman who proudly shared her story, describes how she attempted to satisfy the sensation of emptiness.

Participant 8 presented an illustration of how shopping served to fill the void created by gastric bypass surgery. She added in the follow-up interview: “I was so out of control then. I just did not understand that I had any addiction let alone that shopping could be a problem.”

Theme 4: Transformation of self-image

The participants credit Roux-en-Y gastric bypass surgery as a transforming event. But the external view may oppose the internal view. Body image is multifaceted and consists of several components including the issue of accurate body perception. In discussing the lived experience following gastric bypass surgery, participants shared a sense of other's seeing their transformation distinctly different from their personal view of self. Most articulated a distortion in their image. Participant 2, who had had surgery more than 5 years before the study recounted:

My sister insisted we take some pictures at her son's graduation. I hate cameras and I knew how fat I would look. The pictures were so bad, at least I thought so then. About a month ago I opened a drawer and there they were. I was actually small. It was so strange to see. I really felt fat during that time and now I know the camera does not lie.

Participant 8 shared her mixed feelings regarding her transformation. While feeling pride and happiness as a consequence of weight loss she struggled with a sense of disappointment. She was conflicted that the transformation was not entirely due to her actions.

Participant 4 explains that his external metamorphosis was quicker than the internal. It was described as incongruous at times.

Participant 1 described her thoughts about her change from obesity to normal weight. She is quite proud of her accomplishments and sees her body as beautiful. But she indicated that there is still some melancholy, because she believes that those who meet her now will never fully appreciate the efforts that went into her transformation.

Overarching Theme: The paradox

The overarching themes that surfaced across the narratives illuminated the paradoxical nature of the lived experience following Roux-en-Y gastric bypass surgery. A paradox is a statement or concept that seems self-contradictory or absurd but in reality expresses a truth. The participants described the life-changing experience of surgery as painful, yet it also served as a source of pain relief. The losses on the scale were balanced with gains in health, mobility, and socialization. The dramatic weight loss was seen as positive and energizing, yet it was also physically and emotionally draining. The desire to lose a part of themselves was linked to the desire to gain self-esteem and self-confidence. There was a unanimous expectation of the study participants that weight-loss surgery offered the potential for a wonderful future. Most participants alluded to the fact that they expected to be utterly joyous with the favorable attention they anticipated after surgery. Yet most revealed that they were unprepared for the emotional incongruity this would create. Participant 8 stated,

I knew I would be treated better if I lost weight. But the first time the waiter I had known for 12 years actually acknowledged me in the same restaurant I had gone to for 12 years, I was irritated beyond belief.

Participants described a process of coming to terms with negating the person that they had been in order to become a new and improved version and to improve the quality of their lives. The feeling of being a different person on the exterior while remaining the same person was described as contradictory. Multiple participants expressed anxiety and grief as they mourned the loss of the old person, who had both good and bad qualities, in an effort to nourish and sustain the new being. One participant shared that “Roux-en-Y gastric bypass surgery is not the end all to be all. Those who believe that it will fix everything are truly deluded.”

The participants expressed a sense of irony as they celebrated the loss of each pound but mourned the parts of their lives that were consequences of obesity. There was sadness and anger conveyed as participants shared their belief that some people who now acknowledge them as worthwhile people are the same people who had ignored them because of their large size. The interpretation of their body image was often oppositional to the comments they heard from others.

Participants voiced that there were many emotions that they expected to change dramatically after surgery. It was seen as ironic that they remained despite their weight loss. Participant 10, one of the youngest participants, shared:

It's funny you know and sad about bypass patients: we are ashamed when we are fat, and we are ashamed when we finally do something about it.

The paradox was also evident as Participant 11, the oldest participant offered:

I felt like a fake until my nurse said it is not wrong to be medically treated for a disease that is killing you.

During a time when they expected happiness and joy many participants experienced anger, fear, and frustration. Participant 9 spoke of getting upset at a support group meeting on the topic of shame.

Participant 3 spoke of redefining his perspective after weight-loss surgery. “I had to learn to think in a different way. Every problem isn't because I am fat.” Self-discovery required identification of targets of stress and emotional pain. Participant 3 related that some ongoing targets of his anger included a “world that deems it politically inappropriate to defame people for their color or sexual preference, but not only opens the door but then expects the doorman to humiliate and exclude the obese man.” He shared that his experience after Roux-en-Y gastric bypass required “trying very hard to integrate gratitude and positive affirmation” into his thoughts and attitudes following surgery even when it would have been easier to revert to engrained negative images. “You know I will always hear my dad calling me a ‘fat slob.’ That can't go away even with positive thinking.”

Summary

This phenomenological inquiry sought to describe the lived experience of individuals after Roux-en-Y gastric bypass surgery. The aim was to allow each individual to describe their experiences using their own words and chronicle their story in an attempt to uncover the essence of their experiences. The themes identified in the inquiry are complex and intensely human. The ability for participants to share their thoughts and ideas enabled the researcher to dwell with the data and grasp some meaning. Within each meaning there are incongruities that can only be understood within the context of the participants' lifeworlds.

The themes that evolved from the phenomenological process included: surgery as renewed hope for life, finding balancing, filling the void, and the transformation of self-image. The overarching essence of the narrative descriptions was that of paradox. The participants gave voice to the physical, emotional, and psychosocial aspects of the phenomenon of bariatric surgery. Their “nod” gave affirmation to the researcher that the phenomenological process was effective in uncovering meaning of their experience following Roux-en-Y gastric bypass surgery. It is the hope of this researcher that illumination of the Roux-en-Y gastric bypass experience may lead to advances in the care and treatment of these individuals.