Medical tourism in bariatric surgery

doi:10.1016/j.amjsurg.2010.01.002

The American Journal of Surgery

Volume 199, Issue 5, May 2010, Pages 604-608

https://doi.org/10.1016/j.amjsurg.2010.01.002 Get rights and content

Abstract

Background

The number of Canadians who self-refer for bariatric surgery outside of Canada or to private clinics within Canada remains undefined. The outcomes from this questionable practice have not been evaluated systematically to date.

Methods

We completed a chart review of known cases referred to our center for complications related to medical tourism and bariatric surgery.

Results

We present a series of patients who have experienced complications because of medical tourism for bariatric surgery and required urgent surgical management at a tertiary care center within Canada. Complications have resulted from 3 commonly used procedures: adjustable gastric banding, gastric sleeve resection, and Roux-en-Y gastric bypass.

Conclusions

Because of this review, we propose that a medical tourism approach to the surgical management of obesity—a chronic disease—is inappropriate and raises clear ethical and moral issues.

Section snippets

Methods

All cases of medical tourists with bariatric surgical complications were identified retrospectively from the experience of a team of bariatric surgeons and an appropriate chart review was completed. Demographic information was collected and final diagnoses were established. Surgical management was characterized according to case costs and human resource costs. Length of stay also was used in costing analyses. Advanced imaging studies were recorded and included in costing.

As an adjunct to this

Results

Chart reviews identified 10 patients who had self-referred for bariatric surgery within and outside of Canada and presented to our center as an urgent referral for complications related to surgical management of morbid obesity. These patients are presented in Table 1. Costs related to the care of these patients also are estimated in Table 1. Specific case presentations that highlight the challenges associated with these patients are detailed later.

Inquiries to the various health organizations

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Comment on: Impact of insurance plan design on bariatric surgery utilization. How can we help remove the insurance barriers to obtaining bariatric surgery?
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Citation Excerpt :
Laparoscopic adjustable gastric band (LAGB) has been reported to be the most sought bariatric procedure abroad, as well as that with the most frequent instances of complication management [14,24]. Complications reported after bariatric tourism, include LAGB slips, erosion, and pouch dilation, as well as leaks and abscesses reported after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric band (LRYGB) [8,14]. A comparison of complications between foreign care and local care in Alberta, Canada [25] reported a leak rate 43 times higher after SG, LRYGB, and LAGB, as well as a LAGB complication rate 3 to 4 times higher in medical tourists compared with the local cohort.
Medical tourism
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Medical tourism is defined as travel primarily for the purpose of receiving health care. Medical tourists may travel for a variety of procedures, including novel or experimental treatments. Medical tourists may also travel to developing or developed countries. Medical tourism represents a growing health care market, and this group of travelers presents unique challenges for public health and clinical medicine. In addition to traditional travel health recommendations, medical tourists have unique health needs and should be advised accordingly. Some of these needs include ensuring current medical conditions are stable enough for travel and the need for appropriate follow-up care after procedures.
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2017, Tourism Management
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In India, Maheshwari et al. (2012), who work as physicians in a cardiac care unit consulting foreign patients, call on governments to take action to meet local needs and interrupt patient outflows. Based on medical, economic, and moral grounds, scepticism is also expressed by medical doctors in ‘origin’ countries, such as the UK, US, Canada, Australia, and Germany (Barrowman, Grubor, & Chandu, 2010; Birch, Vu, Karmali, Stoklossa, & Sharma, 2010; Caulfield & Zarzeczny, 2012; Cheung & Wilson, 2007; Foss, 2012; Jeevan & Armstrong, 2008; Jones & McCullough, 2007; Mattoras, 2005; McKelvey, David, Shenfield, & Jauniaux, 2009; Miyagi, Auberson, Patel, & Malata, 2011; Pimlott, 2012; Terzi, Kern, & Kohnen, 2008; Wachter, 2006). The most commonly cited reason refers to increased health risks and is often supported by the authors' own experience with patient complications after treatment abroad.
This paper examines facets of the developing business relations between two important actors in the supply-chain of transnational healthcare: medical tourism facilitators and medical doctors (MDs) practicing privately and internationalising their services. The empirical focus is Greece, an emerging destination for medical care. Drawing on the sociology of the professions as an analytical framework, rich qualitative data reveals a conflictual aspect in the relation between the two actors, and informs the literature on transnational healthcare of barriers to market development. Particularly, MDs practicing privately often resist what is perceived to be medical tourism facilitators' pressures to control the 'rules of the game' in the submarket which inhibits their collaboration. The paper contributes, thus, to the sociology of the professions by bringing to light a new challenge for MDs engaged in the transnational business arena, represented here by the facilitators; and encourages tourism practitioners to consider MDs' self-understanding, attitudes, and expectations.
The fate of laparoscopic adjustable gastric band removal
2019, Canadian Journal of Surgery
Long-term complications and lack of weight loss have caused a surge in laparoscopic adjustable gastric band (LAGB) removal. This study reviews the trend of LAGB removal and examines outcomes of patients undergoing subsequent revision bariatric surgery at a single tertiary care centre in Canada.
All LAGB removals performed between January 2008 and December 2016 were reviewed. A subset of patients who underwent revision surgery was then analyzed for patient demographics, weight, body mass index and postoperative complications.
During the study period, 211 patients underwent LAGB removal (87.7% female). Most bands were inserted out of province. Reasons for band removal included dysphagia, band slip and weight recidivism. Fifty-nine patients (28%) underwent revision surgery at a mean of 12.8 ± 9.3 (range 0–55) months after LAGB removal. Mean age was 47 ± 9.7 (range 26–63) years, and mean pre-LAGB weight was 131.0 ± 30.0 kg. Following LAGB, the mean weight decreased to 120.5 ± 26.4 kg, but most regained weight after removal to a mean prerevision weight of 125.1 ± 27.0 kg. The lowest mean weight was achieved 12 months after revision surgery (98.7 ± 30.2 kg). The mean percent total weight loss was not significantly different after revision laparoscopic Roux-en-Y gastric bypass compared with revision laparoscopic sleeve gastrectomy (22.8 ± 9.6% v. 17.5 ± 6.5%, p = 0.179). The overall revision surgery 30-day complication rate was 18.6% and increased to 23.7% long-term. No deaths occurred.
The number of LAGB removals is increasing. Revision bariatric surgery leads to improved weight loss; however, revision surgery is associated with complications.
Les complications à long terme et l'absence de perte de poids sont à l'origine de l'augmentation du nombre de retraits d'anneaux gastriques ajustables (AGA) installés par voie laparoscopique. Cette étude se penche sur la tendance aux retraits des AGA et sur les résultats chez les patients qui subissent une chirurgie bariatrique de révision par la suite dans un centre de soins tertiaire au Canada.
Tous les retraits d'AGA effectués entre janvier 2008 et décembre 2016 ont été passés en revue. Un sous-groupe de patients ayant subi une chirurgie de révision a ensuite été analysé aux plans des caractéristiques démographiques, de la masse corporelle et des complications postopératoires.
Pendant la période de l’étude, 211 patients se sont fait retirer leur AGA (87,7 % de femmes). La plupart des anneaux avaient été insérés à l'extérieur de la province. Parmi les raisons invoquées pour les retraits, mentionnons dysphagie, glissement de l'anneau et reprise de poids. Cinquante-neuf patients (28 %) ont subi une chirurgie de révision en moyenne 12,8 ± 9,3 (éventail 0–55) mois après le retrait de l'AGA. L’âge moyen était de 47 ± 9,7 (éventail 26–63) ans et le poids moyen avant l'AGA était de 131,0 ± 30,0 kg. Après l'AGA, le poids moyen a diminué à 120,5 ± 26,4 kg, mais la plupart ont repris du poids après le retrait pour atteindre un poids moyen pré-révision de 125,1 ± 27,0 kg. Le plus bas poids moyen a été atteint 12 mois après la chirurgie de révision (98,7 ± 30,2 kg). La perte de poids totale moyenne en pourcentage n’était pas significativement différente après la dérivation de Roux-en-Y laparoscopique de révision, comparativement à la gastrectomie laparoscopique en manchon de révision (22,8 ± 9,6 % c. 17,5 ± 6,5 %, p = 0,179). Le taux global de complications des révisions chirurgicales à 30 jours a été de 18,6 % et est passé à 23,7 % à plus long terme. Aucun décès n'est survenu.
Le nombre de retraits d'AGA est en hausse. La révision de la chirurgie bariatrique a amélioré la perte de poids, mais elle s'accompagne de complications.
A comparison of revisional and primary bariatric surgery
2017, Canadian Journal of Surgery
Revisional surgery is an important component of addressing weight regain and complications following primary bariatric surgery. Owing to provincial need and the complexity of this patient population, a specialized multidisciplinary revision clinic was developed. We sought to characterize patients who undergo revision surgery and compare their outcomes with primary bariatric surgery clinic data.
We completed a retrospective chart review of bariatric revision clinic patients compared with primary bariatric surgery patients from December 2009 to June 2014.
We reviewed the charts of 2769 primary bariatric clinic patients, 886 of whom had bariatric surgery, and 534 revision bariatric clinic patients, 83 of whom had revision surgery. Fewer revision clinic patients underwent surgery than primary clinic patients (22% v. 32%). The mean preoperative body mass index (BMI) was 44.7 ± 9.5 in revision patients compared with 45.7 ± 7.6 in primary bariatric surgery patients. Most revision patients had a prior vertical banded gastroplasty (VBG; 48%) or a laparoscopic adjustable gastric band (LAGB; 24%). Bands were removed in 36% of all LAGB patients presenting to clinic. Of the 134 procedures performed in the revision clinic, 83 were bariatric weight loss surgeries, and 51 were band removals. Revision clinic patients experienced a significant decrease in BMI (from 44.7 ± 9.5 to 33.8 ± 7.5, p < 0.001); their BMI at 12-month follow-up was similar to that of primary clinic patients (34.5 ± 7.0, p = 0.7). Complications were significantly more frequent in revision patients than primary patients (41% v. 15%, p < 0.001).
A bariatric revision clinic manages a wide variety of complex patients distinct from those seen in a primary clinic. Operative candidates at the revision clinic are chosen based on favourable medical, anatomic and psychosocial factors, keeping in mind the resource constraints of a public health care system.
La chirurgie de révision est une intervention importante lors d’une reprise de poids ou lors de complications à la suite d’une chirurgie bariatrique primaire. Compte tenu des besoins provinciaux et de la complexité de cette population de patients, une clinique de révision multidisciplinaire spécialisée a été créée. Nous avons voulu caractériser les patients qui subissent une chirurgie de révision et comparer leurs résultats aux données de la clinique de chirurgie bariatrique primaire.
Nous avons procédé à un examen rétrospectif des dossiers des patients de la clinique de révision bariatrique par rapport aux patients ayant subi une chirurgie bariatrique primaire entre décembre 2009 et juin 2014.
Nous avons examiné les dossiers de 2769 patients de la clinique bariatrique primaire, dont 886 avaient subi une chirurgie bariatrique, et 534 patients de la clinique de révision, dont 83 avaient subi une chirurgie de révision. Un moins grand nombre de patients de la clinique de révision ont subi une chirurgie comparativement aux patients de la clinique primaire (22 % c. 32 %). L’indice de masse corporelle (IMC) préopératoire moyen était de 44,7 ± 9,5 chez les patients de la clinique de révision, contre 45,7 ± 7,6 chez les patients ayant subi la chirurgie bariatrique primaire. La plupart des patients de la clinique de révision avaient déjà subi une gastroplastie verticale (48 %) ou une pose d’anneau gastrique ajustable par voie laparoscopique (24 %). Les anneaux gastriques ont été retirés chez 36 % de tous les patients de ce dernier groupe s’étant présentés à la clinique. Parmi les 134 interventions effectuées à la clinique de révision, 83 étaient des chirurgies bariatriques (pour perte de poids) et 51 concernaient des retraits d’anneaux. Les patients de la clinique de révision ont obtenu une diminution significative de leur IMC (de 44,7 ± 9,5 à 33,8 ± 7,5, p < 0,001), qui, au moment du suivi après 12 mois, était semblable à celui des patients de la clinique primaire (34,5 ± 7,0, p = 0,7). Les complications ont été considérablement plus fréquentes chez les patients soumis à une chirurgie de révision que chez les patients soumis à une chirurgie primaire (41 % c. 15 %, p < 0,001).
Une clinique de révision bariatrique gère une grande diversité de patients complexes, qui sont différents de la population suivie dans une clinique d’intervention primaire. À la clinique de révision, les candidats à l’opération sont choisis en fonction de facteurs médicaux, anatomiques et psychosociaux favorables, en gardant à l’esprit les ressources limitées du système de santé public.

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The North Pacific Surgical AssociationMedical tourism in bariatric surgery

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Health Reports (Statistics Canada, Catalogue 82-003)

Trends in bariatric surgery in Canada, 1993–2003

CMAJ

Canadian Task Force on the Periodic Health EPeriodic health examination, 1999 update. 1. Detection, prevention and treatment of obesity

CMAJ

Bariatric surgery waiting times in Canada

Can J Surg

The third wave—medical tourism in the 21st century

South Med J

The North Pacific Surgical Association
Medical tourism in bariatric surgery