The demand for bariatric surgery by medical travelers will continue to grow in coming years despite greater coverage of the cost of weight loss surgery at home by many government and private insurance health programs around the world.

Weight loss surgery has become a staple procedure in medical travel as medical tourists take advantage of competitive international pricing.

Bariatric surgery can be had for about the same price in Mexico, Korea or Turkey.

Why more medical tourists will seek weight loss surgery

As this surgery now starts to be paid for at home, more people will tend to stay home for the operation. Even so, there are several reasons why medical travelers will continue to opt for weight loss surgery abroad, and why bariatric medical tourism will continue to grow.

Evidence is mounting that existing weight loss surgery practices are creating a need for a second or even third weight loss surgery in about half of patients.

Poor long term results from weight loss surgery

Weight loss surgery may not be as successful in managing weight loss as it was expected to be. Patients are asking for a “re-do.”

• In the UK, data shows that a significant percentage of patients fail to keep the weight off long term.
• 63 per cent of patients in Brazil put weight back on within two years of their operation, according to one study of 782 patients.
• A German review of studies on weight loss surgery found 30 per cent of patients regained their lost weight between 18 and 36 months.
• In a Dutch study of patients who had gastric banding, 30 per cent needed the operation redone after 5 years and fully half of them after 10 years.

Patients are refused repeats of weight loss surgery

Because so many patients are regaining weight, growing numbers of them are requesting a second weight loss operation. Many will be refused repeat operations by their doctors.

Individual responsibility for weight gain

Patients are still generally seen as individually responsible for any weight gain after a first surgery and would be expected to pay for a repeat of the surgery.

Greater risk of complications and death

Weight loss surgery may not produce desired outcomes in many cases, but this does not seem to deter people from seeking out the surgery.

Results for a second operation are poor, with a higher risk of complications and death during surgery. Surgeons and insurers are more reluctant to readily cover higher risk procedures, and more quickly reject please for repeat surgery.

Body Mass Index too low

In government or insured programs, surgery is fully covered only if patients have a Body Mass Index (BMI) of 40 or above, or over 35 in certain cases. Yet significant numbers of people with a BMI of 30 or less are seeking weight loss surgery.

Medical travel is the alternative to longer wait list for weight loss surgery

As bariatric surgery becomes more popular at home, wait lists will grow and some people will opt to be medical travelers and seek this surgery abroad.

Because they do not qualify for surgery at home, they travel as medical tourists to any of dozens of hospitals or clinics in other countries. International competition is keen for these patients, and cost of these surgeries has dropped. In India, gastric banding surgery is advertised as low as US$6,800.

Complications and risks

According to the Medical Defence Union, the doctors’ insurers, common problems with this surgery, whether at home or abroad, include

• post-operative complications such as infections
• bands slipping or leaking and delays in diagnosing these problems
• difficulties and complications in adjusting bands
• alleged failure to obtain consent from patients, for example about the risks involved or the post-operative diet required

In at least one case the patient died following an infection, which it is alleged was caused by perforation of the gut. In another case a patient had to be placed on a ventilator after a leak following a gastric bypass led to an infection.

Does the bariatric surgeon abroad or care manager have responsibility?

Overall, gastric bypass surgery (Roux-en-Y and gastric sleeve) is now clearly preferred over gastric banding surgery as these procedures seem to be more effective long term. The destination bariatric surgeon who usually schedules a surgery upon request may not see any reason to counsel the patient on other choices and against gastric banding. If the surgeon is not skilled in one of the more complex alternatives, the patient may not get the appropriate counsel.

If a destination surgeon is performing a banding surgery, has the patient been properly briefed on the risks, the after-care needed, and the need for finding a surgeon at home who will tighten loose bands, reposition slipped ones, and routinely check for signs of infection at the port site?

Weight loss surgery after care

“The surgery is the first step,” says bariatric surgeon Jaime Ricardo Ramos-Kelly whose American patients come to Tijuana, Mexico for surgery. “The after care is even more important than the surgery.”

Dr. Kelly says he conducts annual follow-ups on all his patients who come from the US, and coordinates with American healthcare providers called fill centers to help his gastric band patients.

“You have to interact with the patient for a long time,” Kelly said. “If I just place a band and I don’t know what happens to that patient, that patient is going to fail.”

Risk management for bariatric surgery

In the U.K., it has been reported the number of negligence claims against independent bariatric surgeons doubled in the 2 years between 2008 and 2010.

The U.K.-based MDU has issued this advice to its members performing bariatric surgery. Destination surgeons and international patient care managers may be wise to incorporate this advice into the care programs they provide medical travelers. The organization suggests

• Patients should be given clear and understandable information about the recognized risks of the procedure, the post-operative diet required and weight loss to be expected
• If there has been a time lag between the initial discussion and the date of surgery, it is important to check the patient still consents to procedure and that it remains appropriate.
• There must be a clear consent discussion between the patient and the surgeon shortly before surgery and the discussion must be documented.
• Surgeons need to be aware of recognized clinical protocols and be prepared to justify their actions if they do not follow them.
• Surgeons need to ensure they are adequately trained and experienced to undertake bariatric surgery.
• The surgical team should include staff with relevant experience and expertise and it is advisable to have protocols which define appropriate standards of care and roles and responsibilities.
• Patients need to have information about what to expect in terms of the recovery time and process, what problems may occur and what to do if they have any difficulties. Patients’ home physicians should be kept informed.

Why do patients regain weight?

It is hard to predict which patients will do well with surgery, whether at home or abroad, as there are a number of physiological and psychological variables that affect long term weight loss with these patients.

Willpower

Crucial to the success of bariatric surgery is that patients are mentally prepared for the vigorous diet plan they must follow for the rest of their lives. Their newly reduced stomachs will only cope with small side-dish size portions and patients need to acquire the willpower to resist old temptations and habits that draw them into overeating.

Stomach stretch

It is possible to stretch the newly reduced stomach by eating a little more each time. Some patients adjust by grazing or drinking lots of water so their stomachs can manage more food.

Food addiction

For some, their stomachs may have physically shrunk, but their addiction to food remains. Anorexia and bulimia have shown us hunger is not only a biological process but also emotional and psychological. It can be about feelings of comfort or control.

Depression

Some patients become clinically depressed as a result of the dramatic transformation to their bodies and the effects this has on their relationships, lifestyle and sense of identity.

Bariatric surgery is often seen as the easy solution to a growing problem — but it is not a perfect solution unless patients change their minds as well as their bodies.