Obesity surgery (also known as bariatric and metabolic surgery) is one of the most common reasons for people to do so called 'medical tourism' – where they travel to another country to have the procedure carried out at usually a much lower price than in their home country. However, such procedures can sometimes be botched and lead to infections, temporary or permanent injuries and/or scarring, and in the worst cases, be fatal. Regarding Europe, there is currently no published data evaluating how to improve the safety of obesity surgery medical tourism.
Seeking this type of obesity surgery medical tourism is particularly common for people living in the UK and Ireland due to long waiting lists for obesity surgery which sometimes reach several years in the state health systems of these countries. Within the UK there are likely 1000s of cases every year, but it is very difficult to get accurate estimates as this type of medical tourism is unregulated, and healthcare professionals in the UK will commonly not receive the discharge letters / operative notes from abroad, wherever the obesity surgery tourism has taken place.
A collaboration between key organisations in the field - The European Association for the Study of Obesity (EASO), the International Federation for Surgery of Obesity and Metabolic Disorders European Chapter (IFSO-EC) and the European Collation for People Living with Obesity (ECPO) - has gathered opinions from members of all three organisations to agree a set of standards to apply to medical tourism in the context of obesity surgery. Their consensus paper is published in the International Journal of Surgery, and its authors include Dr Laurence Dobbie, National Institute for Health and Care Research (NIHR) Academic Clinical Fellow in General Practice, School of Life Course & Population Sciences, Kings College London, UK; Professor Volkan Yumuk, President of the EASO and based at Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Istanbul, Turkey; and bariatric surgeons Professor Ralph Peterli, St. Clara Hospital and University Hospital, Basel, Switzerland and Professor Barbara McGowan, co-chair of EASO's Obesity Management Task Force; and Susie Birney, Operations Director at ECPO, Dublin, Ireland.
IFSO-EC, EASO and ECPO initiated a task force to delineate safe practices in obesity surgery. 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). 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. A total of 135 questions on obesity surgery practices and recommendations were put to the experts, and consensus was defined as 70% agreement.
The recommendations were divided into six areas, and included (only selected examples included, see full paper for more):
Regulation
- Bariatric and metabolic surgery in Europe should only be performed at centres of obesity management which are accredited by either EASO (The European Association for the Study of Obesity) or the country's representative national Bariatric and Metabolic surgery (BMS) society or Surgical society.
- Only surgical procedures/methods which are accredited by either IFSO (International Federation for the Surgery of Obesity and Metabolic Disorders) or a National Bariatric and Metabolic Surgery society, which regularly evaluates surgical procedures, should be performed in the context of surgical tourism.
- Bariatric and metabolic surgical procedures in the stages of research development should not be performed in the context of medical tourism.
Provision of care
- In the context of surgical tourism, bariatric follow up should be provided for 2 years by the unit performing the surgery.
- Prior to bariatric surgery, patients should be provided with clear information about the risks and benefits of the surgery including the increased risk of having this surgery away from home, before travelling abroad.
- Patients should have written and verbal consent taken prior to bariatric and metabolic surgery
Eligibility
- In the context of medical tourism, patients with BMI <30 kg/m 2 should not undergo bariatric and metabolic surgery.
- A copy of the patient's medical records, from the patient's home country, should be assessed for the medical history, prior to proceeding with bariatric surgery abroad.
Operative care questions
- In the context of medical tourism, patients should stay at least 5 days post-operatively in the geographical location of the bariatric and metabolic surgery before travelling home.
- In the context of medical tourism, the operating bariatric surgeon should liaise with the patient's treating doctor/general practitioner in their home country to facilitate follow-up.
- Patients should be advised on the changes in the absorption of some medications (i.e., anti-epileptics, anticoagulants, psychotropic medications) following bariatric and metabolic surgery.
- In the context of medical tourism, when patients have significant complications following bariatric and metabolic surgery, they should only be cleared to travel home by their treating bariatric surgical team once these have been addressed.
Advertising and online information
- When discounted rates or special offers for bariatric and metabolic surgery are offered by bariatric centres, this raises concern about the quality of the care provided.
- Bariatric centres should provide publicly available information regarding the financial cost and required payment methods for bariatric surgery at their site.
- Bariatric centres should provide publicly available information regarding the type of accreditation their surgeons have (i.e., international or national accreditation and what institution has awarded it).
Patient representative panel results
- Patients must be informed whether the bariatric surgery being offered is internationally recognised.
- Patients must be provided with all relevant clinical documentation from their bariatric surgery to allow them to have safe follow up in their home country.
- Patients must be provided with a translator if they cannot speak the same language as their bariatric surgeon.
Among their conclusions, the authors say: "We recommend multiple aspects in providing bariatric surgical care abroad, aligning with international standards. Surgical units should provide at least 2 years of follow-up, in line with published literature. The multi-disciplinary team (MDT) is central to bariatric care; we recommend MDT assessment for all patients undergoing obesity surgery abroad. We recommend an upper gastrointestinal endoscopic evaluation before obesity surgery, as a recent study shows patients undergoing obesity surgery have various endoscopic pathologies, potentially impacting procedure choice. For lifestyle, we recommend pre-operative alcohol screening and counselling on limiting alcohol intake pre- and post-operatively due to the increased risk of alcohol use problems following obesity surgery."
Dr Dobbie says: "Across Europe, people living with obesity often wait several years, or lack access entirely, to obesity surgery in their home countries, prompting many to seek treatment abroad. Unfortunately, some of these providers fail to meet basic standards of care, resulting in serious injuries and, tragically, even death. These new guidelines—developed in collaboration with healthcare professionals and patients from across Europe—set out clear standards for obesity surgery in the medical tourism sector, with the aim of improving patient safety and preventing further harm."
EASO President Professor Yumuk says: ""There have been too many cases of poorly performed, and in some cases, unsafe obesity surgery carried out abroad under what we would call medical tourism. In producing these guidelines, the obesity community has come together to make sure obesity surgery in Europe is safe and meets appropriate standards, wherever it takes place."
Dr Peterli says: "In my view, the interdisciplinary and interprofessional work involved in the development of this consensus paper was very important in order to protect patients if they do not receive prompt and competent help in their own country for the treatment of severe obesity. At the same time, it was also very instructive for me to learn about the most important aspects of the problem together with patient organizations and those affected. However, we will have to continue to work together to eliminate or at least minimise the negative effects of surgical tourism, while acknowledging there is also serious surgical tourism that is positive for those affected."
Professor McGowan adds: "This is an important consensus which highlights the standards people should expect when considering bariatric surgery abroad. It aims to increase awareness for safety considerations and the importance of post-operative after care. I am pleased to be part of this important work which we hope will reduce complications and improve outcomes for patients."
Susie Birney, Operations Director at ECPO, Dublin, Ireland, says: "Patient safety is our priority and unfortunately many of our council members will have numerous accounts of their members from across Europe who have had unfortunate incidents while seeking surgery abroad. What is even more disturbing is the knowledge that there are many more stories untold because people feel stigmatised and judged for their actions. This is a time when patients need support and guidance and it is important to see this consensus highlight the minimum standards patients should demand, and deserve, when it comes to treatment."
