Should Medical Travel Bariatric Surgery Doctors Be Sanctioned?

Medical Tourism In Bariatric Surgery TableShould surgeons who do bariatric surgery on patients traveling considerable distances for care be sanctioned? asks Dr. Arlen Meyers.

Or should facilitators and surgeons do better screening of medical tourists and provide comprehensive care management?

Three doctors in Edmonton, Alberta, writing in the American Journal of Surgery, describe their experience with 10 bariatric surgery patients who had had weight loss operations away from home.

Their conclusions:

  • Medical tourism for bariatric surgery will continue to grow.
  • New management algorithms may be needed to treat this patient population because they “undoubtedly will require the expertise and care of a bariatric surgical team at some point in their lives and, as such, will continue to burden the limited resources currently available.”
  • A medical tourism approach to the surgical management of obesity is inappropriate and raises clear ethical and moral issues.

Their paper, Medical Tourism In Bariatric Surgery, prompted Dr. Meyers to ask his question in a LinkedIn group.

We agree with their first conclusion. Weight loss surgery medical tourism has a very good future.

Bariatric surgery medical tourists need long term care management

As to their second conclusion, we believe that all involved – patients, agents, surgeons and care managers – need to understand the long term needs of these patients and integrate long term care management into bariatric surgery medical travel programs. Follow up of these patients should be seen not as a burden on scarce resources but as an extension of a good health care program that embraces choice, even if the choice is to go abroad for surgery.

Their third conclusion, that a medical tourism approach to the surgical management of obesity is inappropriate and raises clear ethical and moral issues, is not supported by the data they present.

Complications of weight loss surgery

The Canadian surgeons reviewed 10 cases that had come to them with problems caused either directly or indirectly, from their weight loss surgery. All had had surgery outside of Alberta (Canadian government health care is structured through each province), but they do not say where these patients actually had their surgery. They do not say who of those 10 went elsewhere in Canada, traveled to the US for surgery, or traveled to a further away medical destination.

While the authors imply these patients received a lower quality of surgery, this may not be the case. The problem may not at all be one of “medical tourism” but patient education and/or patient compliance.

Gastric banding surgery for medical tourists

8 of the 10 patients had gastric banding surgery. What the authors highlight as the problems for medical tourists after this surgery are important evidence that reveal the sort of treatment planning and care management required for such medical travelers.

The one patient who had Roux-en-Y surgery had what might be considered a routine complication. Its resolution was simple and inexpensive and required no surgery. She was rehydrated, medicated, given vitamins, and sent to a bariatric dietitian.

The one patient who had gastric sleeve surgery had major complications. The authors suggest her troubles were due to the initial bariatric surgery yet they may just as easily have been caused by the follow up surgery in the US.

Her case: she experienced abdominal pain while flying to the US on vacation (we are not informed how long after the surgery the patient went on the vacation). While abroad, she eventually sought medical attention for the pain, had corrective surgery, developed severe sepsis, had further surgery followed by intensive care. She returned to her home in Canada when she was deemed stable.

More screening for gastric banding surgery medical tourists

The evidence the authors present of complications that the remaining 8 of the 10 patients had after their gastric banding surgery is instructive.

They describe gastric banding patients who came to them seeking relief from typical complications of this surgery including slippage of the band, erosion, and obstruction. Gastric banding clearly requires more ongoing care management over time. It is more vulnerable to patient non-compliance.

The evidence they present about gastric banding outcomes supports a policy my medical travel company, Cosmetic Surgery Travel, put in place many years ago. We do not accept medical travelers who want gastric banding unless we can verify independently that they have a qualified surgeon or primary care physician at home who knows they are having the surgery abroad and will help monitor their progress over time once they return.

We have learned, too, that surgery for some very obese patients (BMI>45) requires a few extra steps and/or surgical tools and care, and we have specially selected a few hospitals and surgeons to work with for these patients.

Bariatric surgery medical tourism is here to stay.

One Response to Should Medical Travel Bariatric Surgery Doctors Be Sanctioned?

  1. Christina deMoraes says:

    I agree with Julie. I too have protocols in place to help diminish the risk to the patient, and – directly or indirectly – our own reputations as their “facilitator” and that of the surgeon!

    I have had bariatric surgery myself, the BPS/DS, or “DS” as it is called. Today’s “vertical sleeve” shares the same procedure on the stomach that the DS has so I am very familiar with the procedure AND what my patients will most likely experience in the post op. Due to my own experience and the tons of education I gained while researching before deciding on my own DS, I put very strict protocols into play for handling WLS (bariatric) patients.

    Personally, after my own research, I have never endorsed the band procedure or anything similar due to the myriad of problems and complications post op! I had one patient come to Brazil that had had the band done and although she had lost the weight and was content, the band had begun to eat into her stomach and was causing problems. She came to Brazil once it was removed and she was stable (she had IMMEDIATELY begun regaining the weight the band had helped her lose!), to have the Vertical Sleeve done. It may be a more invasive procedure (VS/VG) compared to the band but unlike the band, it is a permanent one and an obvious solution to those whose weight problems benefit from reduced capacity/intake.

    Did I inform MY patients of these important pros and cons as I was initially speaking to them? YES! Did I provide them information that helped THEM to make their OWN decisions? YES. I have ALWAYS felt my first responsibility is to be an ADVOCATE for my patient rather than a marketing agent for the surgeon!

    It is what we should all be doing but most facilitators cannot while they are commissioned agents of one doctor or another… and when it comes to doctors and surgeons doing their own “facilitating,” sadly, they are often times the worst “advocates” for their patients!

    Personally, bariatric surgery is near and dear to my heart because I know FIRST HAND the life-changing effects it has on a person. I will ALWAYS want to help provide this life-transforming procedure to one of my peers because I understand its power… but I also respect it and know that it comes with risks. My job, along with the surgeon and the patient, is to help mitigate the risk. (There is also a huge risk that comes with being obese, as we all know.) While we do not always have the luxury of accompanying our patient through many months of post-op recovery, we can and should make sure we FACILITATE the support they should have once they return home. (Again, patient advocates KNOW how to accomplish this!)

    And of course, it goes without saying that while they are in our direct care in the post op period, STRICT protocols must be implemented that help to lessen the inherent risks wherever possible! We need to take more precautions! The medical tourism patient stays a day or two longer in the hospital (probably longer than they would back at home!), a leak test is done before they are discharged, a nurse accompanies them in their hotel for a few days making sure they are being orientated on nutrition, post-op foods and behavior changes, the hotel kitchen is prepared to make them liquid meals or they are otherwise provided, have them bring a blender with them!!

    There ARE things we can do. The problem is, “we” are afraid to put our foot down and actually TELL the patient what he needs to do! They want to go home a few days early (because they are not feeling well) and they are allowed… or worse, they don’t even ASK for clearance, they just leave! Perhaps we think that because they are often “paying out of pocket” that that means the patient runs the show?! NO! That is not really what they want, trust me. =)

    It is when we slack on protocol that problems occur… and even if it is absolutely purely and simply patient negligence, (and we have ALL had those difficult patients!) we all know that it is OUR reputations as facilitators, concierges, surgeons that suffer in the end because we did not make the best effort, even going above and beyond, to help avoid something we knew was possible. Patients DO look to us for advice and they WANT to feel cared for and ADVOCATED for! You will find that when you are “strict” with your protocols that you will attract a higher quality patient that respects and understands what you are trying to do for them.


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