A Global Survey by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) on Perceptions of Bariatric Medical Tourism (BMT) by Health Professionals: Guidelines from IFSO for BMT

Beriberi following sleeve gastrectomy

Bariatric surgery is being undertaken more frequently in response to rising levels of obesity but is increasingly also requested as a cosmetic choice. Nutritional deficiencies are a recognised consequence of gastrectomy, with potentially severe and permanent neurological sequelae. We present two cases of acute, severe polyneuropathy following sleeve gastrectomy. Severe thiamine deficiency was considered in both cases but with delayed proof and a significant initial differential diagnosis. Neurologists must have a high index of suspicion for the peripheral as well as central presentations of thiamine deficiency to avoid permanent disability. We also call for explicit information resources warning of the risk and signs of thiamine deficiency to be provided routinely to patients after gastrectomy.

A systematic review of patient and clinician experiences of bariatric tourism

BACKGROUND

Although bariatric surgery is highly cost effective, accessing this treatment in the UK and other western nations is often challenging. Patients are therefore increasingly engaging in bariatric health tourism despite its associated risks and warnings from health institutions. A systematic review was performed to assess the reasons why patients are travelling abroad for surgery and common practices among bariatric tourism service providers.

METHODS

Medline and PubMed were searched for articles analysing the experiences of patients and service providers. Articles published in English between 2010 and 2023 were considered and seven were included for review after title, abstract and full text analysis.

RESULTS

Four studies assessing patients' experiences and outcomes following bariatric tourism and three examining the perspectives of bariatric service providers were reviewed. Patients across the studies were mostly from western Europe, North America and the Middle East. The most common reasons for pursuing bariatric tourism were a lack of bariatric service provision in patients' home nations, high costs of surgery in the private sector and long waiting times. Examples of practice outside the scope of most internationally recognised guidelines were identified across multiple studies, especially regarding patients' pre-operative optimisation and follow-up. The studies therefore suggest that bariatric tourism may lead to significant health risks and issues that need managing once patients return home.

CONCLUSIONS

Bariatric tourism is a common practice with significant associated risks. The reasons underpinning its appeal however, reflect genuine problems with accessing bariatric services and a lack of pre-operative education and optimisation.

Relationship Between Preoperative Surgical Fear, Anxiety, and Satisfaction Levels in Individuals Choosing Bariatric Surgery Tourism: A Descriptive, Cross-Sectional Study

BACKGROUND

Bariatric surgical tourism is a rapidly growing sector. The aim of this study was to evaluate the preoperative surgical fear, anxiety, and satisfaction levels regarding bariatric surgery tourism processes and to examine the relationships between these variables.

METHODS

This descriptive, cross-sectional study was conducted between July and November 2024 with foreign patients who visited the general surgery clinic of a healthcare institution for bariatric surgery within the scope of health tourism. Data were collected through face-to-face interviews using the Patient Information Form, Surgical Fear Scale, and Surgical Anxiety Scale. All results were evaluated within a 95% confidence interval, with statistical significance set at p < 0.05.

RESULTS

The mean age of the patients was 39.39 ± 9.35 years, and 88.5% were from the UK. Additionally, 88.5% reported choosing bariatric surgery tourism due to high surgical costs in their home country. The mean score for surgical fear was 37.68 ± 20.58, while the mean score for surgical anxiety was 19.53 ± 12.90. Patients who lacked prior knowledge about bariatric surgery tourism had significantly higher surgical fear and anxiety scores (p < 0.05). Age, fear and anxiety associated with undergoing surgery in a foreign country, and total surgical anxiety scale score were identified as independent predictors of patients' satisfaction with their bariatric surgery tourism experience (R2 = 0.130; p < 0.01).

CONCLUSIONS

Preoperative knowledge levels and satisfaction with the information provided significantly impacted surgical fear and anxiety levels among bariatric surgery tourism patients.

European recommendations from healthcare professionals and people living with obesity on safe practice for bariatric and metabolic surgery medical tourism: a modified Delphi consensus statement from EASO, IFSO-EC, and ECPO

BACKGROUND

Bariatric and metabolic surgery tourism (BMT) is becoming an increasingly popular route to treatment for patients living with obesity. Recent reports have highlighted that some patients travelling abroad for bariatric surgery have received inadequate care, fraudulent care, and, tragically, some cases have resulted in death. This study aimed to define consensus in Europe regarding safe practices concerning BMT.

MATERIALS AND METHODS

IFSO-EC, EASO and ECPO initiated a task force to delineate safe practices in BMT. Two expert European panels were convened, one comprised of healthcare professionals (identified from EASO and IFSO-EC) and the other of patient representatives (identified from ECPO). The study utilized a modified Delphi consensus methodology, and 135 questions were administered. Surveys were conducted anonymously online, and consensus was defined as 70% agreement. Themes analyzed regarding BMT included regulation, pre-operative evaluation, operative care, post-operative care, advertising and online information.

RESULTS

One hundred and nineteen healthcare professionals and 88 patient representatives participated from 26 countries. The healthcare professional panel included 66 bariatric surgeons, 28 endocrinologists, 18 dietitians, three nurses, two psychologists, one general practitioner and one gastroenterologist. Three questionnaire rounds were conducted for the healthcare professional panel, and two were performed for the patient representative panel. Consensus recommendations were given across all themes relevant to BMT. These included evaluating and managing psychological health, sleep apnea, cardiovascular disease, liver health and dietetic assessment. The recommendations covered the requirements for regulatory standards, including surgeon accreditation and procedural volume. They also included recommendations regarding patient education, standardized operative care, online information provision, and follow-up.

CONCLUSIONS

Through collaboration with healthcare professionals and patients living with obesity, we provide European recommendations regarding safe practices concerning BMT. Further evaluation is required regarding outcomes following BMT. These data, alongside the Delphi consensus recommendations, will inform BMT clinical guideline development.

Characterizing barriers and facilitators of metabolic bariatric surgery tourism: a systematic review

BACKGROUND

Metabolic bariatric surgery tourism continues to rise and has become a growing concern for bariatric surgeons globally. With varying degrees of regulation, counselling and success, those that develop complications may have to deal with a multitude of challenges often distant from their country of operation. The aim of this study was to characterize the barriers and facilitators influencing individuals to undergo metabolic bariatric surgery tourism, in order to better understand the implications to the National Health Service and other healthcare systems.

METHODS

A systematic literature search, restricted to the English language, was performed to identify relevant studies. All studies were included until December 2022, the last search date. Study quality was assessed with the validated mixed-methods appraisal tool. A Braun and Clarke thematic analysis was undertaken to identify themes and subthemes.

RESULTS

A total of five studies met the inclusion criteria. Identified themes included: availability, accessibility, cost, eligibility, reputation, and stigma; the available evidence was of varying quality.

CONCLUSION

This work identifies a series of subthemes influencing the decision to undertake metabolic bariatric surgery tourism. The results highlight the limited literature available in understanding the complex motivational insights; the scale of the problem in the current healthcare system; cost and long-term outcomes. A National Emergency Bariatric Surgery audit would allow generation of more robust data to explore further the issues of clinical relationships and networks and to guide policy making.

Descriptive Analysis of International Bariatric Surgery Tourism Services

Inadequate access to public bariatric surgical services has favoured the growth of bariatric tourism. This study analysed data extracted from bariatric surgical centres that care for patients travelling from abroad. The research highlights apparent deficits in accreditation, communication, perioperative care, and travel health advice. An international registry of accredited bariatric tourism providers and patient education may be indicated.

The influence of geometric algebra in surgical practice of sleeve gastrectomy-single center experience

Laparoscopic surgery could be considered as an art of geometric algebra. However, very little is studied in the context of bariatric surgery. The current study aims to explore the possible influence concept of geometric algebra on the surgical process in the overweight and obese patients in the setting of laparoscopic sleeve gastrectomy (LSG). During the study period, clinical data of subjects who underwent LSG was retrospectively analyzed. Parameters examined include body mass index (BMI), umbilical-xiphoidal interval (U-X) and umbilical-fundus (U-F) interval. In this study, LSG was performed via central view approach (C) and left view approach (L). In both groups, the body surface projection points of viewing hole (V), main and accessory operating holes (O1 and O2) and surface display of fundus (F) were connected to form a geometric figure. The accessibility of the surgical instrument into the fundus, the need for elongated instruments and related intra- and post-operative parameters were noted. The overweight and obese subjects showed a significant increased U-X and U-F interval compared to the non-obese subjects. The length of both U-X and U-F interval were correlated with the BMI. The geometric figure is quite different between L and C approach with significant increase of area of quadrangle. Significant longer O1-F, O2-F and V-F interval was calculated in C approach of patients and thus the elongated instruments were frequently required. The integration of the concept geometric algebra with the proper selection of troca may provide a better surgical experience and smooth surgical process.

Effectiveness and Safety of Laparoscopic Sleeve Gastrectomy for Weight Loss in Mild Obesity: Prospective Cohort Study with 3-Year Follow-up

PURPOSE

Patients with mild obesity especially in absence of associated medical problems (OAMP) are commonly managed by non-surgical approaches. Laparoscopic sleeve gastrectomy (LSG) has proved itself to be effective and it is now the most performed weight loss procedure. We aimed to study the effectiveness and safety of LSG for weight loss in mild obesity.

METHODS

A prospective cohort study. Group A; BMI (30-34.9 kg/m²), and group B; BMI ≥ 40 or BMI ≥ 35 with OAMP. Demographic data, perioperative complications, % excess weight loss (EWL), % total weight loss (TWL), nutritional profile, and evolution of OAMP were recorded and statistically analyzed.

RESULTS

A total of 250 patients, with 80 patients (32%) in group A, and 170 (68%) in group B. The majority were female. The mean preoperative weight, BMI, and excess weight were 90.1 ± 9.52, 32.7 ± 1.4, and 21.5 ± 4.9 in group A, and 129.88 ± 26.12, 47.8 ± 8.2, and 62.3 ± 23.6 kg in group B respectively. The low BMI group had significantly lower OAMP, with higher pre-LSG non-surgical procedures rate. Overall post-operative morbidity rate was significantly higher in group B. %TWL was significantly lower in low BMI group. Nutritional profile was within the normal range in both groups at 3-year follow-up.

CONCLUSION

Laparoscopic sleeve gastrectomy is a safe and effective weight loss solution for mild obesity with better outcome than for higher BMI. Further studies are warranted to reconsider NIH's statement for medicolegal aspects, and for matching the current changes in bariatric surgery practice, safety evidence, and patients' demand.