Patients travelling abroad for bariatric surgery “underestimate the risks associated with” the procedure, a study has found.

A national patient register for those who undergo bariatric surgery abroad would help appropriate follow-up medical treatment when complications occur, the study co-authors suggested as currently there is none pertaining to Irish medical tourists.

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The co-authors of the study, Challenges associated with Global Bariatric Medical Tourism, published in this month’s Irish Medical Journal, pointed out that it would be helpful if formal registration for those patients including the time and location where the surgery took place.

“The limited access to timely bariatric service in Ireland has led to significant waiting times. Cheaper weight loss procedures in certain parts of the world have incentivised patients to seek bariatric surgery abroad. There are multiple challenges associated with global bariatric tourism,” the co-authors noted.

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“Patients do not have access to adequate information regarding the bariatric procedure and they resort to informal blogs to access this information resulting in patients to underestimate the risks associated with bariatric surgery and believe that their surgeries will be complication-free.”

The study carried out by University Hospital Galway, Wexford General Hospital, Royal College of Surgeons in Ireland and Ninawa School of Medicine, Iraq examined four bariatric cases and found that all patients underwent “surgical intervention including reversal of the index bariatric procedure” when they returned to Ireland after surgery abroad.

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To date eight people are officially known to have died abroad while undergoing cosmetic surgery abroad - of those figures, several were during or soon after bariatric surgery.

The four cases included those of a 58-year-old male with BMI of 32.1kg/m2 presenting with a two-month history of persistent vomiting after undergoing insertion of an intra-gastric balloon (IGB) in Thailand having lost 22 kg since the insertion of the balloon.

The second case was of a 49-year-old female with BMI of 35.1kg/m2 presenting with an acute abdomen secondary to gastric perforation eight-years post laparoscopic gastric band insertion in the Middle East.

In the third case is of a 53-year-old male with a BMI of 36.2kg/m2 presented with refractory indigestion due to IGB insertion one year ago in Prague, in the Czech Republic.

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The patient had the IGB for over 12 months that failed to lose weight. The fourth case was a 47-year-old female with a BMI of 58.3kg/m2 who presented with an anastomotic leak at day-5 post gastric bypass performed in Turkey.

The total cost to the HSE and in essence to the taxpayer for dealing with the complications from these four bariatric cases carried out abroad was €48,220

“Global bariatric procedures can carry a significant risk of complications if appropriate post- operative care is not accessible. Managing these complications have been a huge burden on an already under-resourced healthcare system. This requires stricter regulations with appropriate patient education and follow-up.

“Having a registry of patients who have bariatric procedures elsewhere will ensure appropriate care post-operatively and facilitate dealing with post- operative complications if they arise,” the authors noted.

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They also said that limited access to timely bariatric service in Ireland has led to significant waiting times. “Cheaper weight loss procedures in certain parts of the world have incentivised patients to seek bariatric surgery abroad. There are multiple challenges associated with global bariatric tourism.

“Patients do not have access to adequate information regarding the bariatric procedure and they resort to informal blogs to access this information resulting in patients to underestimate the risks associated with bariatric surgery and believe that their surgeries will be complication-free.”

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The co-authors as a result of their findings have also called for the “name of the performing surgeon and their contact number, dates of expected follow-up, emergency plans, and most importantly data regarding the details of the weight-loss equipment used as this would potentially improve patient outcomes when dealing with complications” to form part of a national register.

“Importantly, it will also aid in estimating the annual cost of bariatric medical tourism to the HSE., the co-authors said.

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“Global bariatric surgery is associated with significant risk of complications without appropriate post-operative care. The management of such complications carries a significant burden to the Irish healthcare system thereby requiring regulations in order to control such post-operative complications,” the authors highlighted.

Due to the overall lack of bariatric resources in Ireland only 1 in 100,000 people per annum undergo bariatric surgery. Bariatric procedures are currently only offered to patients who have failed non-surgical measures and have a consistent Body Mass Index (BMI) of greater than 40 kg/m2 or BMI of 35 to 40 kg/m2.

Currently, bariatric procedures are only offered in two public hospitals in Dublin and Galway. The high demand for such procedures has led to long waiting times as evidenced by figures published by the Health Service Executive (HSE) where only 154 bariatric procedures were performed in 2020, a drop from 169 from the previous year, amounting to €1.3 million to the HSE.

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It is estimated that a total of €5.7 million was spent on bariatric procedures over the last five years with one of the biggest barriers to offering greater numbers of bariatric surgery being the availability of adequate funding.

Obesity is a growing pandemic in Ireland, with an estimated 6 out of 10 adults deemed overweight or obese. Obesity is a significant contributor to morbidity and mortality as it is a major risk factor for the development of conditions such as type 2 diabetes mellitus, cardiovascular events, cancer, and chronic conditions such as osteoarthritis, renal disease, and obstructive sleep apnoea.

The annual cost to the healthcare system of Irish adult obesity is estimated to be €1.3bn of which €400m is attributed directly to healthcare cost. Non-operative management options such as lifestyle modification and weight-lowering drugs.

In order to avoid this, the HSE has a Treatment Abroad Scheme (TAS) where consultants can refer patients for procedures in the European Union, European Economic area or Switzerland if the procedure is not available in Ireland or cannot be accessed within a timely fashion.

The referrals will have more credibility as the consultants will have to research the accreditation, qualifications, morbidity and mortality data before referring patients. The question is whether surgeons will have the time to accommodate this ancillary work in their current busy practice.

The co-authors also found that during the Covid-19 pandemic, new challenges have emerged in dealing with medical tourism. “Primarily, given that some of the bariatric procedures are temporary weight loss measures, leaving them for longer than intended duration would increase the risks of complications including erosion, migration, small bowel obstructions, leakage and intra-abdominal collections.

“With the travel bans imposed due to the pandemic, it is more likely that these patients would not have an opportunity to reverse these procedures in a timely manner”.