The ambivalence of losing weight after bariatric surgery

Living the dream - but not without hardship: stories about self-directed weight transformation from severe obesity

DESIGN

In-depth interviews were conducted with eight women and two men, aged 27 to 59 years, who had carried out self-directed WL from SO for 5 years or more.

TWO THEMES RAN ACROSS THE STORIES

fear of weight-regain, and food and emotion. We performed a case-based narrative analysis of especially rich interviews that illustrate these. Results pointed to persistently cultivating new competencies, establishing new eating habits, re-establishing old physical-training habits, and forming new relational bonds. Participants reinvented themselves and their lives. However, the stories are not all about transformation, but also about new and old health problems.

CONCLUSION

The study directs attention to 'different obesities', not only to initial weight from which WL takes place, but also linked to the experiential horizons that the persons embody from childhood on. Furthermore, there was no way back in the present stories, always haunted in the wake of the lost weight. A double burden imposed on the person with obesity related to meta-stories in society deepens the understanding of this imperative: being vulnerable health-wise and exposed to stigmatization.

Stigma Toward Bariatric Surgery in the Netherlands, France, and the United Kingdom: Protocol for a Cross-cultural Mixed Methods Study

Background

Bariatric surgery is an effective procedure for the treatment of obesity. Despite this, only 0.1% to 2% of eligible individuals undergo surgery worldwide. The stigma surrounding surgery might be a reason for this. Thus far, no research has systematically studied the nature and implications of bariatric surgery stigma. The limited studies on bariatric surgery stigma are often conducted from the perspective of the public or health care professions and either use small and nonrepresentative samples or fail to capture the full essence and implications of the stigma altogether, including attitudes toward patients and perpetrators of the stigma. In addition, studies from patients’ perspectives are limited and tend to address bariatric surgery stigma superficially or implicitly. Finally, the extent to which cultural factors shape and facilitate this stigma and the experiences of patients have not yet been researched.

Objective

This study aimed to explore the perceptions, experiences, and consequences of bariatric surgery stigma from the perspective of the public, health care professionals, and patients before and after bariatric surgery. Furthermore, although the concept of stigma is universal, every society has specific cultural norms and values that define acceptable attributes and behaviors for its members. Therefore, this study also aimed to explore the extent to which cultural factors influence bariatric surgery stigma by comparing the Netherlands, France, and the United Kingdom.

Methods

This paper describes the protocol for a multiphase mixed methods research design. In the first part, we will conduct a scoping review to determine the current knowledge on bariatric surgery stigma and identify knowledge gaps. In the second part, semistructured interviews among patients before and after bariatric surgery will be conducted to explore their experiences and consequences of bariatric surgery stigma. In the third part, surveys will be conducted among both the public and health care professionals to determine the prevalence, nature, and impact of bariatric surgery stigma. Surveys and interviews will be conducted in the Netherlands, France, and the United Kingdom. Finally, data integration will be conducted at the interpretation and reporting levels.

Results

The study began in September 2020 and will continue through September 2025. With the results of the review, we will create an overview of the current knowledge regarding bariatric surgery stigma from patients’ perspectives. Qualitative data will provide insights into patients’ experiences with bariatric surgery stigma. Quantitative data will provide information related to the prevalence and nature of bariatric surgery stigma from the perspective of the public and health care professionals. Both qualitative and quantitative data will be compared for each country.

Conclusions

The findings from this study will lead to new insights that can be used to develop strategies to reduce bariatric surgery stigma and improve access, use, and outcomes of bariatric surgery.

International Registered Report Identifier (IRRID)

PRR1-10.2196/36753

Investigation of Body Awareness and Affecting Factors in Patients with Bariatric Surgery

BACKGROUND

Major weight loss after bariatric surgery (BS) makes the body sensitive to the environment. The factors associated with body awareness are unknown in patients with BS. In this study, we aimed to investigate the body awareness and the affecting factors in patients with BS.

METHODS

Our study included 81 patients who had BS at least 6 months ago and 40 people of the same age and gender who had not. Participants' body awareness was evaluated with the Body Awareness Questionnaire, body compositions with bioelectric impedance device, joint position sensation (JPS) with photography method, physical activity level with International Physical Activity Questionnaire, quality of life with the Short Form-36, depression status with the Beck Depression Inventory, and cognition with the Montreal Cognitive Assessment Scale. Mann-Whitney U and Chi-square tests were used for the comparison of the groups, and Spearman correlation analysis was used for in-group correlation analysis.

RESULTS

Body awareness was found to be higher in patients with BS compared to the control group (p = 0.002). Body awareness had a positive correlation with cognition (r = 0.277, p = 0.012), quality of life sub-scales (r = 0.245-0.374, p < 0.05), the amount of change in total body weight (r = 0.241, p = 0.027), and body mass index (BMI) (r = 0.269, p = 0.032); negative correlation with depression (r =  - 0.409, p = 0.016) and deviation in the JPS (r =  - 0.223, p = 0.046).

CONCLUSION

Body awareness of patients with BS was found to be high after surgery. Body awareness in patients with BS is associated with the amount of weight loss and BMI, depression, cognition, JPS, and health-related quality of life.

Development and Validation of New BODY-Q Scales Measuring Expectations, Eating Behavior, Distress, Symptoms, and Work Life in 4004 Adults From 4 Countries

PURPOSE

The BODY-Q is a rigorously developed patient-reported outcome measure (PROM) for patients seeking treatment for obesity and body contouring surgery. A limitation of the uptake of the BODY-Q in weight management treatments is the absence of scales designed to measure eating-specific concerns. We aimed to develop and validate 5 new BODY-Q scales measuring weight loss expectations, eating behaviors, distress, symptoms, and work life.

MATERIAL AND METHODS

In phase 1 (qualitative), patient and expert input was used to develop and refine the new BODY-Q scales. In phase 2 (quantitative), the scales were field-tested in bariatric and weight management clinics in the United States (US), The Netherlands, and Denmark between June 2019 and January 2020. Data were also collected in the US and Canada in September 2019 through a crowdworking platform. Rasch measurement theory (RMT) analysis was used for item reduction and to examine reliability and validity.

RESULTS

The new BODY-Q scales were refined through qualitative input from 17 patients and 20 experts (phase 1) and field-tested in 4004 participants (phase 2). All items showed ordered thresholds and good fit to the Rasch model. The RMT analysis provided evidence of reliability, with PSI values ≥0.72, Cronbach alpha values ≥0.83, and test-retest values ≥0.79. Better scores on 4 scales (exception expectations scale) correlated with lower BMI, with the strongest correlation between the eating-related distress scale scores and BMI (r= -0.249, P < 0.001).

CONCLUSION

The new BODY-Q scales can be used in research and clinical practice to assess weight loss treatments from the patient perspective.

Psychosocial Changes of Bariatric Surgery in Patients' Everyday Life: a Scoping Review

PURPOSE

Although the post-bariatric clinical and physical changes are well-known, the psychosocial changes in patients' everyday life are less clear. Therefore, we tried to summarize comprehensively the currently available literature on the psychosocial changes of bariatric surgery (BS) by means of a scoping review.

MATERIALS AND METHODS

The scoping review was conducted following the Arksey and O'Malley framework, the Joanna Briggs Institute Reviewer's Manual 2015, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. PubMed, EMBASE, and PsycINFO were searched for data dating from January 2008 through October 2019. Only gastric bypass and sleeve gastrectomy procedures were considered for this review. To explore and describe the essence of the experienced changes deeply, only qualitative studies were included. The synthesis was performed using the qualitative content analysis technique.

RESULTS

The literature search yielded 1420 unique records, and 1371 articles were eliminated on the basis of irrelevant title and/or abstract. Forty-nine full-text articles were reviewed. Ultimately, eight articles were included in this scoping review. The qualitative content analysis emerged in 12 categories, which were further condensed into three major thematic areas, namely, "subjective self-image," "interpersonal relationships," and "it's not all gold that glitters," which reflect the post-operative psychosocial changes.

CONCLUSION

A wide range of psychosocial changes occurs following bariatric surgery. To maintain the improvements and to prevent negative changes, long-term support by specially trained health professionals is crucial.

Majority of female bariatric patients retain an obese identity 18-30 months after surgery

PURPOSE

When bariatric surgery is performed, a successful outcome is usually described as % total weight lost (EWL) or a change in BMI. These definitions fail to address the importance of post-operative psychosocial adjustment. Previous research has alluded to a 'mind-body lag' where the patient's experienced body feels larger than their physically smaller post-operative body, perhaps as a result of amygdalae conditioning. The purpose of this study is to further investigate this psychological issue and assess its relationship to health locus of control, alexithymia, health quality of life and weight regain in bariatric surgery patients.

METHODS

Forty female bariatric surgery patients between 18 and 30 months post-op completed demographic data, survey instruments and anthropometric testing. Their evolving self-view, health locus of control, tendency toward alexithymic thought, and health quality of life were measured to identify significant relationships. Hermans' Dialogical Self Theory was used to understand the conflicted self-view of the participants.

RESULTS

The majority of participants retained an obese view of self despite weight loss. Those who retained an 'I-obese' viewpoint were significantly more likely to see external situations and powerful others as controlling their weight, have difficulty identifying their feelings and score significantly lower in vitality, social functioning and mental health.

CONCLUSION

Despite losing weight, the majority of participants retained an obese view of self that was significantly associated with a lessened health quality of life. Use of the Evolving Self-View (ESV) exploratory tool may allow early identification of post-operative patients with a prolonged 'I-obese' self-view and provide an opportunity for intervention.

LEVEL OF EVIDENCE

Level III, cross-sectional case-control study.

Patients' experiences of life after bariatric surgery and follow-up care: a qualitative study

OBJECTIVES

Bariatric surgery is the most clinically effective treatment for people with severe and complex obesity, however, the psychosocial outcomes are less clear. Follow-up care after bariatric surgery is known to be important, but limited guidance exists on what this should entail, particularly related to psychological and social well-being. Patients' perspectives are valuable to inform the design of follow-up care. This study investigated patients' experiences of life after bariatric surgery including important aspects of follow-up care, in the long term.

DESIGN

A qualitative study using semistructured individual interviews. A constant comparative approach was used to code data and identify themes and overarching concepts.

SETTING

Bariatric surgery units of two publicly funded hospitals in the South of England.

PARTICIPANTS

Seventeen adults (10 women) who underwent a primary operation for obesity (mean time since surgery 3.11 years, range 4 months to 9 years), including Roux-en-Y gastric bypass, adjustable gastric band and sleeve gastrectomy, agreed to participate in the interviews.

RESULTS

Experiences of adapting to life following surgery were characterised by the concepts of 'normality' and 'ambivalence', while experiences of 'abandonment' and 'isolation' dominated participants' experiences of follow-up care. Patients highlighted the need for more flexible, longer-term follow-up care that addresses social and psychological difficulties postsurgery and integrates peer support.

CONCLUSIONS

This research highlights unmet patient need for more accessible and holistic follow-up care that addresses the long-term multidimensional impact of bariatric surgery. Future research should investigate effective and acceptable follow-up care packages for patients undergoing bariatric surgery.

Testing a model of body image in the bariatric surgery patient

PURPOSE

The purpose was to test a published model of body image in the bariatric surgery patient in the clinical office setting.

BACKGROUND

A model was created based on clinical observations during field work and the literature. It focuses on five concepts of body image: body attitude, body checking, appearance orientation, perceived body size, and perceived body space. Testing this model 3 months after surgery is important because morphology changes rapidly influencing early changes in body image, yet there is a paucity of research at this time point.

METHODS

For this study of 67 bariatric surgery patients, sequential sampling was used. Body image and anthropometric measures (body mass index and other weight loss indicators) were obtained at baseline and 3-months postoperatively. Established model testing criteria were used.

RESULTS

Over 3 months, mean body mass index was significantly reduced. Mean body image was significantly improved regarding all concepts in the model, except body checking. Body image improvement varied widely when individual responses were examined.

CONCLUSIONS

The model was successfully tested. Data on the five concepts in the model provided a body image profile at 3 months indicating individuals' degree of improvement. Areas of non-improvement in the early postoperative phase may signal the need for interventions, like support or psychological counseling, for patients who might be struggling with views of themselves after surgery. Preliminary recommendations are made regarding several of the instruments and their use clinically. Researchers should take into consideration the study's short 3-month time frame when designing future studies.

Impact of Depression on Weight Variation after Bariatric Surgery: A Three-Year Observational Study

INTRODUCTION

The association between obesity and depression has been repeatedly established. However, little is known about the impact that the diagnosis of depression before bariatric surgery (DDBS) may have on weight loss.

OBJECTIVE

To evaluate the impact of DDBS on weight outcomes.

METHODS

Retrospective study of patients submitted to BS. Patients with no weight, no current medication data, or those submitted to revision surgery were excluded. Patients were considered to have DDBS based on taking antidepressants prior to BS or if there was a medical history of past or current depression. Patients with and without a depression history were compared using independent t test. A multivariate logistic regression model was created to evaluate predictors of weight variation (variables included: age, sex, and type of surgery).

RESULTS

A total of 616 patients did not have a history of depression and 230 had DDBS. There was a statistically significant difference in the BMI variation between groups. On average, individuals with DDBS lost 1.4 kg/m2 less than those without DDBS. In the multivariate analysis, the group with DDBS, compared with the group without DDBS, presented on average less -0.9 kg/m2 (95% CI -1.7 to -0.2, p = 0.018) BMI variation.

CONCLUSION

DDBS is a predictor of lower weight loss after the surgical procedure. Even after adjusting for confounding variables such as age, sex, and BS type, this effect remains.

Aspects of well-being when struggling with obesity

Purpose: We aimed to gain deeper insight into how people struggling with obesity handle their life situation by addressing how well-being might unfold. For many people, obesity becomes a lifelong condition characterized by repeated weight fluctuations while their weight increases gradually. From an existential perspective, constantly waiting for weight loss can cause an experience of not reaching one's full potential. How people with obesity experience well-being, within their perceived limitations, is less reflected in previous research.Methods: We established a qualitative study using in-depth interviews with seven men and 14 women with obesity (body mass index 335 kg/m2) aged 18-59 years. The study had an exploratory design including a phenomenological-hermeneutic perspective, with a lifeworld approach.Results: Three themes describing aspects of well-being were developed: coming to terms with the body, restoring the broken relational balance and reorienting the pivot in life. The thematic findings were abstracted into a main theme: striving to make living bearable. The movement towards well-being can be seen as a struggle towards an experience of balance to make bearable living.Conclusions: We suggest that well-being as a dialectic between vulnerability and freedom might become a health-facilitating experience for people struggling with obesity.

Analysis of Portuguese language blogs about bariatric surgery: key doubts of internauts regarding the postoperative period

BACKGROUND

The Internet, particularly blogs have become an important tool for patients to disseminate and exchange information on a variety of health topics, including bariatric surgery. By virtue of its interactivity being free of judgement from health care providers, blogs expose gaps in patients' knowledge and understanding.

PURPOSE

This study analyzes the main doubts expressed in blogs by patients in the postoperative period of bariatric surgery.

METHOD

This is a qualitative exploratory study of 11 blogs of patients, who underwent bariatric surgery, that were available on the Internet between October 2013 and May 2017. The data were collected through a structured instrument and analyzed according to Bardin's suggestions. The sampling method used was intentional.

RESULTS

Evolution of diet, weight loss, plateau effect, weight regain, physical exercises, physiological changes, complications, use of contraceptive and pregnancy were the main areas of concern.

CONCLUSION

More needs to be done to educate and prepare bariatric patients for the postoperative period. The content found in blogs serves towards building better links with patients, helps them make better decisions, and provides them an opportunity to be active participants in their own treatment.

Evolving self view and body image concerns in female postoperative bariatric surgery patients

AIMS AND OBJECTIVES

To explore the experience of postoperative bariatric surgery patients as they adjust to diminished weight and differentiate that adjustment from the more general concept of body image.

BACKGROUND

Bariatric surgery is an effective way to reduce weight and comorbidities associated with obesity. Complete success requires that patients must adjust psychologically as they lose weight. If this does not occur, bariatric patients may experience a "mind-body lag," in which the patient's internal body image lags behind the external changes. Hermans' Dialogical Self Theory of "I-positions" is a foundation with which to understand this problem.

DESIGN

Descriptive correlational study of postoperative bariatric patients explored the concept of "I-obese" and "I-ex-obese" in an effort to quantify previous qualitative findings and develop a survey questionnaire.

METHODS

Bariatric patients (N = 55) between 18-30 months postoperative completed one-hour interviews. Cluster analysis and chi-squared analysis compared mean scores and explored the prevalence of "I-positions" and body image concerns in the participants.

RESULTS

Cluster analysis of the survey data identified participants as falling into either "I-obese," "I-ex-obese" or "mixed I-obese" categories. There were significantly higher body image concerns in the "I-obese" participants than those identified as "I-ex-obese." The majority of female participants reported high body image concerns. There was no significant association with weight loss percentage.

CONCLUSION

This research establishes a connection in this study sample of women who experience body image concerns and prolonged "I-obese" identification 18-30 months after their bariatric surgery.

RELEVANCE TO CLINICAL PRACTICE

To date, the primary measure of bariatric surgery success has focused almost exclusively on the amount of weight loss. Implementing psychological as well as physiological care, however, may be the key to full recovery and long-term success. Practitioners can use this new information to plan effective pre- and postoperative psychological preparation and support.

Evaluation of an exercise programme for post-bariatric surgery patients: views of participants

OBJECTIVE

Exercise programmes typically are evaluated with fitness assessments and psychological survey measures but seldom include participants' insights. The purpose of this study was to evaluate the benefits, facilitators and barriers of a 12-week exercise programme for post-bariatric surgery patients from the participants' perspective.

METHOD

Over a 2-year period, 20 patients recently having undergone bariatric surgery completed a 12-week programme that included participation in structured exercise and in focus groups designed to supplement standard evaluation data and provide insight into participants' views.

RESULTS

Participants were highly adherent to the programme, and focus group results reflected a clear positive evaluations. Benefits included helpful information, developing commitment, physical fitness and social support; notably, weight was seldom mentioned. Participants cited structure, accountability and group support as facilitators of exercise. Participants cited few barriers, although very few had set plans for continuing exercise after programme completion.

CONCLUSION

Participants saw many benefits to the exercise programme, and those benefits reflected lifestyle changes rather than a focus on weight. Programme structure, accountability and the support of the group were facilitators to exercise. Participants cited few barriers. However, the lack of plans for continued exercise suggested the need for a transition phase to help participants continue an active lifestyle after the 12-week structured programme.

Space perception, movement, and insight: attuning to the space of everyday life after major weight loss

Physiotherapists are well placed to help people adjust and engage meaningfully with the world following major weight loss. Recent research indicates that the body size a patient has lived with for years can continue to affect movement and perception even after largescale weight loss. This article explores this discrepancy in depth from the perspective of phenomenology and space perception and through the concepts of body image, body schema, and affordances. It draws on an empirical example in which a nautical engineer described his lived experience of returning to work following bariatric surgery and the discrepancies he experienced while adjusting to his new situation, particularly when moving his smaller body around the ship's engine room, previously inaccessible to him. Analysis of this empirical example suggests that transitions in weight and size following bariatric surgery are both highly explicit in awareness (i.e., body image) and outside awareness (i.e., body schema). Major weight loss can open up new affordances and possibilities of being in the world, but only after adjustments in body image and body schema. The article suggests ways in which such insights can contribute to physiotherapists' clinical development and practice when working with patients undergoing major weight loss.

Do factors related to participation in physical activity change following restrictive bariatric surgery? A qualitative study

AIMS

To explore participants' ability to participate in physical activity (PA), and barriers and facilitators to PA, at 12 months following restrictive bariatric surgery, and how these differed from participants' pre-surgery perceptions. Motivators for PA post-surgery were also explored.

METHODS

Qualitative one-on-one in-depth interviews were conducted pre- and 12 months post-surgery. Data were analysed using inductive thematic analysis.

RESULTS

Fourteen adults (12 females), with a mean (range) age of 41.4 years (25.0-56.0), body mass index (BMI) of 31.7kg/m² (22.3-48.2), and excess weight loss of 66% (2-127) completed both interviews. Lack of participation in PA during the first 3-6 months post-surgery was a common theme. Although participants reported increased ability to participate in PA, attributing this to a reduction in obesity-related physical barriers to PA, many participants reported that some pre-surgery obesity-related barriers to PA remained at 12 months post-surgery. For most participants, pre-surgery non-obesity related barriers to PA also remained at 12 months post-surgery. Facilitators to PA were consistent pre- and post-surgery. Weight loss and improvement in physical appearance were the most common motivators for PA post-surgery.

CONCLUSIONS

At 12 months following surgery, many participants reported residual obesity and non-obesity related barriers to PA. These barriers may explain the small, if any, pre- to post-surgery change in PA levels reported by earlier research. Facilitators to PA did not change and post-surgery motivators for PA were mostly esteem-related. These data are relevant to shape interventions aimed at optimising PA in this population.

Patient experiences of outcomes of bariatric surgery: a systematic review and qualitative synthesis

Although bariatric surgery is the most effective treatment for severe and complex obesity, less is known about its psychosocial impact. This systematic review synthesizes qualitative studies investigating the patient perspective of living with the outcomes of surgery. A total of 2,604 records were screened, and 33 studies were included. Data extraction and thematic synthesis yielded three overarching themes: control, normality and ambivalence. These were evident across eight organizing sub-themes describing areas of life impacted by surgery: weight, activities of daily living, physical health, psychological health, social relations, sexual life, body image and eating behaviour and relationship with food. Throughout all these areas, patients were striving for control and normality. Many of the changes experienced were positive and led to feeling more in control and 'normal'. Negative changes were also experienced, as well as changes that were neither positive nor negative but were nonetheless challenging and required adaptation. Thus, participants continued to strive for control and normality in some aspects of their lives for a considerable time, contributing to a sense of ambivalence in accounts of life after surgery. These findings demonstrate the importance of long-term support, particularly psychological and dietary, to help people negotiate these challenges and maintain positive changes achieved after bariatric surgery.

The experience of regaining weight following weight loss surgery: A narrative-phenomenological exploration

Weight loss surgery (WLS) is gaining ground as the most effective treatment against obesity. In the literature, however, we see a divide among individuals who have undergone WLS based on the amount of weight lost and maintained: successful and unsuccessful patients. In this article, we focus on the notion of unsuccessful patients-exploring the accounts of three women who have regained weight following WLS. In doing so, we endeavor to better understand how weight regain has meaning, and its impact and implications for the lives of individuals who undergo WLS. The findings reveal how weight-regain stories are easily silenced, buried beneath social, cultural, and institutional/medical narratives of successful weight loss and transformation. People who have such experiences may feel reticent to reveal them and in doing so increase their own suffering, therefore leaving the popular narratives unchallenged.

Translating weight loss into agency: Men's experiences 5 years after bariatric surgery

Fewer men than women with severe obesity undergo bariatric surgery for weight loss, and knowledge about men's situation after surgery, beyond medical status, is lacking. Our aim was to explore men's experiences with life after bariatric surgery from a long-term perspective. We conducted in-depth interviews with 13 men, aged 28–60 years, between 5 and 7 years after surgery. The analysis was inspired by Giorgi's phenomenological method. We found that agency was pivotal for how the men understood themselves and their lives after surgery. Weight loss meant regaining opportunities for living and acting in unrestricted and independent daily lives, yet surgery remained a radical treatment with complex consequences. Turning to surgery had involved conceptualizing their own body size as illness, which the men had resisted doing for years. After surgery, the rapid and major weight loss and the feelings of being exhausted, weak, and helpless were intertwined. The profound intensity of the weight loss process took the men by surprise. Embodying weight loss and change involved an inevitable renegotiating of experiences connected to the large body. Having bariatric surgery was a long-term process that seemed unfinished 5 years after surgery. Restrictions and insecurity connected to health and illness persist, despite successful weight loss and embodied change. Bariatric surgery initiated a complex and long-lasting life-changing process, involving both increased capacity for agency and illness-like experiences.

"They think surgery is just a quick fix"

Background

To prevent weight regain, patients undergoing weight loss surgery are encouraged to change their exercise and dietary habits. Building on previous research, the aim of this study was to explore women's experiences of changing exercise habits – focusing on women participating in a group based rehabilitation program including surgical as well as non-surgical participants.

Findings

Based on interviews with the 11 women included in this study, as well as participant observation, two themes were identified; 1) Pushing ones tolerance limits, and 2) Rebutting the “quick fix” fallacy. Taken together, the findings showcase how being a part of this mixed group involved having to relate to social stigmas, as well as notions regarding successful and non-successful surgical outcomes. Although such notions may be useful in identifying potential challenges related to changing exercise habits, they do not illuminate the complexity of undergoing such changes following weight loss surgery.

Conclusion

The findings point to the need of acknowledging patients' own exceriences to determine how successful they are after surgery. Given the findings, I argue for the need to reconsider the notion of success in relation to group based interventions.