Patient demographics and clinical characteristics. Twenty-six (26) patients met the inclusion and exclusion criteria of this study and underwent non-emregency colorectal cancer surgery after preoperative weight reduction assistance. The study consisted of 15 (57.7%) male and 11 (42.3%) female participants, and their mean age was 60.6 (SD ± 12.4) years (Table 1). HbA1c was 6.2% (SD ± 0.6). Demographic and clinical characteristics of patients who received preoperative weight loss support are presented in Table 2.
Program completion and weight loss. The completion rate of preoperative weight loss support was 100%. The mean weight of the 26 patients was 79.8 kg (SD ± 15.6) at the time of the initial outpatient consultation in preparation for surgery (before preoperative weight loss support) and 75.7 kg (SD ± 14.3) at the time of hospital admission (after preoperative weight loss support) (P < .05) (Table 3). BMI was 30.4 kg/m² (SD ± 4.7) before preoperative weight loss support and 29.4 kg/m² (SD ± 5.0) after preoperative weight loss support (P < .05) (Table 3). Overall, the average percent weight loss was 4.9% (SD ± 3.4) (Table 2).
The weight loss percentage was 5% or more in 14 patients (53.8%) and less than 5% in 12 patients (46.2%). The average weight loss duration was 45.5 days (SD ± 25.5); during this period, no adverse effects of weight loss were reported. The average amount of weight loss was 4.1 kg (SD ± 3.2). Two (2) patients had a weight gain of 0.5 kg and 1.5 kg, respectively.
Weight loss and SSIs. SSIs were observed in 5 of 26 patients (19.2%) who received preoperative weight loss support. They included superficial incisional SSI in 1 patient (20%), deep incisional SSI in 1 patient (20%), and organ/space SSI in 3 patients (60%). Four (4) patients (15.4%) achieved a weight loss percentage of 8.8%–10.8% and did not exhibit SSI (Table 4). The weight loss percentage was 3.4% (SD ± 3.7) for the SSI group and 5.0% (SD ± 3.2) for the non-SSI group. The maximum value of HbA1c in patients with SSIs was 8.1%, and the minimum value was 5.8%.
Attributes of nurses who provided preoperative weight loss support. Five (5) subjects were women with 17.6 years (SD ± 2.4) of nursing experience and 2.8 years (SD ± 1.8) of experience in preparing outpatients for surgery.
Inhibitory factors of weight loss. For factors that inhibited patient weight loss, the authors extracted 7 subcategories in the following 3 categories: 1) weight loss that occurred prior to outpatient examination in preparation for surgery, 2) lack of motivation for weight loss, and 3) time and duration required for weight loss (Table 5). Inhibitory and promotional factors of weight loss were cited by the nurses and reflected conversations they had with patients. The notations for interview results are as follows: subcategories are in quotation marks (“ ”), and citations are in italics.
Under the first category of inhibitory factors (ie, weight loss that occurred prior to outpatient examination in preparation for surgery), two subcategories were extracted: 1) “already received dietary guidance for diabetes treatment” and 2) “striving to lose weight on one’s own prior to examination at outpatient services.” Nurses used the following patient quotes to illustrate these two subcategories, respectively:
• “I don’t need this guidance because I have already heard it as guidance for diabetes.”
• “I’d like to lose weight in my own way. I will take care of myself.”
Lack of motivation for weight loss was another category of inhibitory factors. In this category, we extracted the following two subcategories: “difficulty accepting cancer” and “difficulty losing weight.” The patients were in a mental state wherein they could not accept the fact that they had colorectal cancer and experienced difficulty losing weight preoperatively. Consequently, nurses experienced difficulty in motivating patients to lose weight and reported the following observations:
• Although I’d try to somehow explain with a sense of “I’m sorry but…,” some patients did not completely accept the disease, which makes it difficult for them to accept the idea that they need to go on a diet.
• While I am sure they are aware that they need to accept the fact that they have cancer, I feel that a little more time is required. I felt that it was extremely difficult to be directly involved with the patient and to motivate them.
Time and duration required for weight loss. In this category, patients had “concern that the outpatient examination time will be prolonged.” In terms of achieving weight loss in a short period, “weight loss plateau” was observed, whereas “limitation to the frequency of outpatient follow-up preparation for surgery” was perceived as a problem by the nurses and patients, as shown in the following quote:
• It takes quite a bit of time. After testing, patients come to the outpatient services to prepare for surgery and after being examined by the doctor; they come back, which alone is quite a time commitment. In addition, consultations with the departments of rehabilitation and nutrition take at least 30 min each, which together take about 1 hour. Therefore, as expected, the patients cannot be convinced that this guidance is worthwhile.
Weight loss promotional factors. For the categories of factors that promote patient weight loss, we extracted 9 subcategories in the following 4 categories: 1) successful weight loss experience, 2) acquisition of knowledge about obesity and postoperative complications, 3) family support, and 4) alleviation of knee pain and low back pain (Table 5).
Successful weight loss experience. In this category, we extracted the following two subcategories: “history of regaining weight following weight loss,” and “previous experience dieting.” Furthermore, the motivation provided by nurses on an outpatient basis in preparation for surgery helped patients understand dietary management and exercise implementation, as shown by the following report of a nurse:
• There was a young obese woman who, amazingly, lost 10 kg on her own by dieting, but still, she rebounded, and the doctor asked her to attend guidance to lose weight. She said, “I have to try because I’ve already lost weight once,” and she was really motivated; she undertook the nutrition and rehabilitation support without a hitch.
Acquisition of knowledge about obesity and postoperative complications. In this category, physicians and nurses provided explanations to the patients about the relationship between postoperative complications and obesity and incorporating diet management and exercise habits into one’s lifestyle. The following feedback from nurses reflects the words of patients and also suggests that the diet and exercise diary, changes in muscle mass, and HbA1c results improved motivation by demonstrating the effects of weight loss:
• From the day of receiving guidance, patients changed, so when they came for their follow-up 2 weeks later, I looked at the completed diary, and as expected, find that many patients had stopped snacking and were engaged in appropriate exercise.
• Being involved in helping patients prepare for surgery independently through diet, rather than leaving everything up to the doctor’s treatment, means that they can receive surgery safely, which makes the patients try hard to prepare for surgery, and the fact that they look forward to surgery with motivation.
Family support. Family support for preoperative weight loss was another supporting factor, and the subcategories were “participation in preoperative weight loss support at the request of the spouse” and “dietary management by the spouse.” The latter was performed by recording a diet and exercise diary and cooking at home. Nurses reported:
• Patients who lost weight were often those who had someone to provide support.
Alleviation of knee and low back pain. Patients had “awareness of knee pain and low back pain” caused by obesity and experienced an increase in muscle mass from exercising with “pain relief from weight loss.” Therefore, they understood the importance of weight loss. The following reflects nurses’ recall of patient interactions:
• The patient understood, saying “My knees hurt” and “My lower back hurts,” and so “I have to lose more weight.”
• I said, “Just as they say, losing weight lowers the burden on my body.”