Getting more than what you pay for? Managing complications of bariatric tourism at an academic center near the US-Mexico border

A retrospective review of a prospectively maintained database identified patients who underwent bariatric surgery in Mexico and then presented to our institution for management of postoperative complications from January 2014 to December 2024. Patient demographics included age, gender, Charlson Comorbidity Index (CCI), body mass index (BMI) at initial presentation, and type of insurance coverage. Data were also collected on the type of bariatric procedure performed abroad, type of presenting complication, and time from index operation to presentation at our institution.

Clinical outcomes included the type and number of procedural interventions required for complication management, hospital length of stay (LOS), total number of days spent in the intensive care unit (ICU), emergency department (ED) visits, hospital readmissions, total parenteral nutrition (TPN) requirement, and TPN duration.

To estimate the financial impact of these complications on our health system, all encounters including the initial presentation/admission and any subsequent hospital readmissions, ED visits, and outpatient procedures related to the bariatric complication were identified for each patient. Hospital charge and payment data were extracted for each of these encounters and totaled for each patient. These data account for the total cost of hospitalization, staffing, medical and procedural interventions, and material/supply costs. Continuous variables were reported as mean ± standard deviation (SD) or range. Categorical variables were reported as a frequency and percentage.

With expansion of the bariatric tourism industry, surgeons in the US will increasingly be met with the challenge of managing patients who experience early and late complications following bariatric surgery abroad. Information regarding postoperative complications and associated hospital costs for these patients in the US are lacking. In this study, we report a series of 91 patients who underwent bariatric surgery in Mexico and then presented to our institution for complication management over a 10-year period. As an academic center located approximately 30 miles from the US-Mexico border, our health system is uniquely positioned to address the medical and surgical challenges of bariatric tourism. To our knowledge, this study represents the largest series of bariatric tourism complications and related financial implications in the literature.

We encountered a variety of postoperative complications with a wide range of clinical acuity. The most common complication was anastomotic/staple line leak, representing 33.0% of the tourism patients identified in this study, which is substantially higher than the estimated leak rate of less than 1% in the US based on national data [19]. While this rate is almost certainly an overestimation of the actual leak rate in Mexican centers due to the absence of a true denominator, it’s likely that US health systems can reasonably expect to encounter a high rate of serious complications such as anastomotic/staple line leak among tourism patients that present for care. Sheppard et al. studied the consequences of 62 tourism patients in Alberta, Canada and found the complication rate ranged from 42.2% to 56.1%, considerably higher than the local complication rate of 12.3% for bariatric surgery [17]. The authors also conservatively estimated the leak rate in the tourism group to be 43 times higher than patients who had surgery locally. While the actual denominator of patients engaging in bariatric tourism and therefore the true complication rate in this patient cohort is unknown, the high reported complication rates are likely exacerbated by the relatively short hospital stays these patients have at surgery centers abroad. A study of four high-volume bariatric centers in Tijuana, Mexico found that patients remained in the hospital for an average of 2.2 days postoperatively [20]. This likely results in patients returning to their home countries prior to the recognition of serious complications. US health systems are likely to encounter a large proportion of these potential postoperative complications given short hospital stays abroad and subsequent travel, which can introduce additional risk. However, we also encountered several less severe complications that did not require procedural intervention, including dehydration, minor incisional bleeding, and postoperative nausea/vomiting. The wide range of potential complications among bariatric tourists highlights the importance of postoperative management by experienced bariatric centers capable of performing the multitude of interventions that may be required for ongoing sequelae of these complications. This also underscores the importance for patients to establish postoperative follow-up with a local accredited bariatric surgery center upon returning home.

While postoperative complications can have potentially life altering consequences from a health standpoint, they can also result in a significant financial burden for patients. In our cohort, serious complications such as anastomotic/staple line leak, stricture, enterocutaneous fistula, and perforated GJ ulcer generated hundreds of thousands of dollars in hospital charges per patient. These costs can result in significant medical debt, even among insured patients [21]. According to a 2022 Kaiser Family Foundation report, an estimated 41% of adults in the US have some form of health care debt according to a broad definition including health care debt on credit cards or owed to family members [22]. The report also found that people with medical debt report cutting spending on food, clothing, and spending down savings to pay for medical bills. Tourism patients are particularly vulnerable to the impact of medical debt, as a common motivation for seeking care abroad is an inability to afford the same procedure at home. These complications can also have negative financial consequences for local health systems and public health insurance programs [23]. A survey of 25 Canadian surgeons reported an estimated 560,000 Canadian dollars spent on postoperative complication management for 59 bariatric tourism patients over a 1-year period [24]. Another Canadian study reported even higher costs for complication management after SG and RYGB [25]. Our analysis shows that the cost of complication management varies significantly depending on complication severity, with many patients requiring several costly procedural interventions over several months to years. The ratio of payments to hospital charges also varied considerably, which is dependent on several factors including insurance coverage [26]. Medicaid generally provides lower levels of reimbursement for services compared to fees paid by Medicare or private insurers [27]. Over 40% of patients in this study were insured by Medicaid, which potentially placed added financial strain on our health system in these cases due to lower reimbursement rates. Although the true impact of bariatric tourism complication costs on California’s Medicaid program is not clear, studies from the plastic surgery literature of complications from aesthetic procedures provide some insight. Khan et al. estimated that Medicaid pays about $730 million per year for complications from aesthetic procedures performed abroad [28]. Complications from bariatric tourism likely have similar consequences for our national health programs.

Given the potential risks associated with bariatric tourism, surgical societies have issued statements and recommendations with a primary concern for patient safety. The American Society for Metabolic and Bariatric Surgery (ASMBS) has issued several guidelines for global bariatric care [29]. If patients decide to seek care abroad, ASMBS recommends pursuing surgery at Joint Commission International (JCI) accredited centers, verifying surgeon credentials, obtaining complete medical records, and establishing a plan for postoperative follow-up at a local bariatric surgery program for longitudinal care. The American College of Surgeons (ACS) has issued similar recommendations for patients [30]. Surgical societies in Mexico have also attempted to establish consensus guidelines for the safe practice of bariatric tourism [12]. Despite this, a 2021 global survey of 383 bariatric surgeons worldwide by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) found that among surgeons who managed bariatric tourism patients, 24% of respondents stated they had no access to adequate documentation regarding a patient’s operation [15]. In addition, 12% of surgeons felt bariatric tourism was associated with higher mortality and only 49% felt that IFSO guidelines were followed by the foreign operating surgeon. Continued efforts are needed to encourage adherence to ASMBS and IFSO guidelines by international centers offering bariatric surgery, as a lack of information regarding a patient’s surgical care can be potentially detrimental to efforts by US surgeons tasked with managing complications. Some authors have advocated for the development and dissemination of discharge safety checklists to facilitate information transfer [31]. The development of national and international registries has also been proposed with the goal of tracking incoming and outgoing bariatric tourism patients in order to create a unified data source to track complications and inform patient decision-making [32].

Strategies aimed at educating patients regarding the inherent risks of bariatric tourism and which specific features to screen for at foreign centers may help to improve recognition of complications and reduce perioperative morbidity. Patients should be familiarized with the signs and symptoms of common postoperative complications to facilitate expeditious care. For example, patients should be aware that traveling after bariatric surgery can increase the risk of venous thromboembolism [33]. Depending on the country, there may also be a risk contracting infectious diseases endemic to different regions. Perhaps most importantly, patients should arrange for comprehensive bariatric care postoperatively in their home country that is covered by insurance and ensure the complete transfer of medical documentation. An analysis of websites from 34 international centers offering bariatric surgery found that only 67.7% of centers advertised some form of planned postoperative follow-up and just 14.7% provided a discharge summary to patients [14]. In light of this, patients should request complete medical records from foreign bariatric centers, including any preoperative workup, imaging, detailed operative notes, and any recommended postoperative care. Developing collaborations between domestic and nearby foreign accredited surgery centers may also help to facilitate the transfer of clinical expertise and information to optimize patient safety.

There are several limitations to this study, namely it’s retrospective, single-center design. Based on chart review, we were unable to accurately evaluate what proportion of patients had received appropriate postoperative instructions, documentation of their surgical procedure, or had a plan for postoperative follow-up in the US. We also were unable to identify the reasons patients decided to pursue surgery abroad, which would have provided important insight into this patient cohort. Our analysis of bariatric tourism complications was limited to patients who had surgery in Mexico, which may limit generalizability. In addition, the true cost of complications to patients and our health system was uncertain, as we were only able to obtain internal hospital charge/payment data as opposed to cost data, which is more complex to determine. An analysis of out-of-pocket expenses for patients experiencing these complications would be helpful to better define the potential impact of bariatric tourism on individuals and should be a focus of further studies. It should be emphasized that a major limitation of this study, and the study of bariatric tourism more broadly, is a lack of knowledge regarding the true number of patients who engage in this practice and their clinical outcomes. Thus, measurements and discussions of complication rates in this patient cohort should be interpreted with scrutiny. Further studies are warranted to more completely evaluate the clinical and financial impact of bariatric tourism complications on local and national health systems. Establishment of local and national patient registries may aid in these efforts.

Bariatric tourism can present patients and local healthcare systems with significant clinical and financial challenges. Further studies are warranted to more comprehensively evaluate the implications of this practice.