Choosing a bariatric procedure carries important consequences and is not the first choice to lose weight. A potential patient should not try to obtain this procedure by circumventing accepted criteria or by choosing a less than scrupulous surgeon or facility.
Bariatric or weight loss surgery is not liposuction. The process, risk and benefits involved in these procedures are different. What do you need to consider if you are going to travel abroad for bariatric surgery? This is a rapidly growing sector within the larger industry of healthcare and medical travel. What are the most important considerations and issues for you to consider if you opt for weight reduction surgery in an international setting?
What is bariatric surgery? This surgical subspecialty encompasses several different procedures, targeted at an end point of weight loss. The procedures do this by reducing stomach capacity or they intentionally reduce absorption. The stomach loses the capacity and capability to fully digest and absorb the food eaten.
Specific procedures are also approved by the Center for Medicare Standards (CMS), The American College of Surgeons and The American Society for Bariatric Surgery. The three currently accepted procedures are the Roux-en-Y bypass, laparoscopic adjustable banding and the open and laparoscopic biliopancreatic diversion with duodenal switch.
Several other procedures available outside the US but the available literature is limited. It is challenging to have open discussions about procedures or treatments that are not approved or used in the US. Appropriate research and care is advised. There is the distinct possibility that some of these interventions achieve similar, or better, outcomes. The US healthcare system can be slow to approve newer treatments and medications. However, we should not immediately discount non-approved care as substandard. It simply has gone through US approval processes.
Who needs it? Choosing a bariatric procedure carries important consequences and is not the first choice to lose weight. A potential patient should not try to obtain this procedure by circumventing accepted criteria or by choosing a less than scrupulous surgeon or facility. Patients should have a body mass index 35 kg/m2. Most centers also require one or more of the following obesity related diseases to co-exist. Some examples include hypertension, diabetes, sleep apnea and others.
While the presence of these illnesses make you eligible for the surgery, they also increase operative risks. With all surgery, we are concerned that the consequences of the obesity and its associated disease(s) are more risky than the finite, but real risk of surgery and anesthesia complications.
What is the process? With any significant life choice we need to plan, do research and in cases where complexity is a factor, ask a specialist or consultant. In choosing bariatric surgery, you should have failed conventional medical therapies. Carefully choose a facility and surgeon who have skilled teams both in the destination hospital and a trusted relationship with US care providers to ensure that follow up and treatment care plan can be accomplished. Authorities recommend having nutritional therapists, psychological support staff, support groups, exercise therapists, special equipment and expert staff regularly manage and care for the morbidly obese patient.
Will the surgery impact your lifestyle? The first procedure listed reduces the stomach’s volume to ~30cc. That limits intake to a few sips of liquid or small bites of food. A food binge can become a life-threatening event. The band also reduces the stomach’s size, however it can be adjusted. Still your eating habits must change. The third choice above can reduce absorption of calories. There is also a loss of certain vital minerals and vitamins.
Supplements may be required and periodic blood work may be needed until you adjust.
What follow up and longer term care is required when choosing this option? The surgery and the wound is not the sole treatment for the patient’s obesity. A holistic approach is needed. Nutritional guidance, behavioral training, exercise habits are essential components to a strategy that returns you to health. Bariatric surgery can move patients from a position of the high risk from life-threatening disease states to a condition of a healthier life and potentially reduced complications from these disease(s). Some of the co-existent diseases, like diabetes, can become more easily managed as you lose weight.
Are there special patient concerns? A preoperative consultation may be very helpful to ensure that you can tolerate the anesthesia and surgery. The pre-trip evaluation can also ensure you are a good candidate before you make a deposit and have a company begin to book your trip. While procedures are less and less invasive, anesthesia risks are still important. If you have a strong history of heart disease or have had a recent heart attack, this surgery is likely a poor choice if performed too soon after your heart attack. People over the age of 65 carry an increased incidence of complications and death.
There is a growing pressure to potentially treat the obesity explosion in our younger population with this option. The stringent restrictions in place for this age group are appropriately difficult. The potential alteration in dietary and nutrition absorption would have significant effects on growth, development, hormonal balance and subsequent maturation.
Patients wishing to become pregnant should wait until after their BMI has stabilized for at least 12 to 18 months. Even then, special care to address potential mineral and vitamin deficiencies must be monitored and corrected. A healthy and growing pregnancy places significant demands on the mother. She needs to take in more calories and more essential nutrients than normal.
What happens if the treatment fails? This is a concern with any medical or surgical care plan. A quality bariatric team will investigate whether the patient is the source of the treatment failure. Is the dietary counseling being ignored? For example, a high fat ice cream or thick shake can bypass the above procedures. It is difficult to maintain your weight after going through these operative interventions.
Who should not have a bariatric procedure? Individuals with poor cardiac reserve, from several diseases are typically not candidates for surgery. The surgery requires a significant amount of lung capacity. Any substantial chronic obstructive pulmonary disease (COPD) or other lung disorder may disqualify a patient. The oversight bodies consider significant psychiatric and eating disorders to be a disqualification.
Okay we’ve moved through the personal hurdles, you’ve done your research and can now commit to the journey to change your life. What about the facilities and care providers? Using the society guidelines as a benchmark helps us look at facilities abroad. We can develop useful guidelines as a screening tool.
Surgeons must have completed a specific training program. This is commonly called residency or fellowship training. The surgeon(s) should posses a comprehensive understanding of managing these special patients. They must have developed or have in place a structure and processes to address support groups, counseling specialists, post-operative management teams and a full understanding of the operative choices and new approaches. This is critical to the patient’s outcome.
The surgeon you choose will be of a team managing your care before, during and after the operation. The surgeon needs assistants to be ready for your arrival and manage your needs to a safe discharge. The surgeon should perform at least 25 procedures per year. They should also be involved in Continuing Medical Education (CME). The recommendation is 25 credits specific to bariatric surgery every two years minimum.
Centers of Excellence have even more stringent criteria. The US criteria require the surgeon be performing more than 75% of their caseload with bariatric patients. The surgeon should be managing 50 patients per year minimum and the facility at least 125 cases per year. A dedicated bariatric surgeon should oversee the program and the facility actively ensures that the proper equipment is in place. Looking forward the team must have active processes in place to detect complications early, and have root cause systems analysis approaches to correct ‘built in’ problems. All the supportive and ancillary staff should be actively educated and work from written protocols that are in place.
Are the facility requirements different from conventional hospitals? I have worked at many hospitals. Except for my current one, they have all been challenged by obese patients. Their new facility that is better suited to serve these unique patients. Beds, wheelchairs and doorways need to be appropriately sized. Commonly radiology and imaging tables typically exclude obese patients. CT scan gantry beds commonly support patients in and out of the imaging ring.
Operative tables and anesthesiologist will be managing challenges not found on other patients. Recovery room personnel need to know how obese patients recover differently. Critical care units will need both adequate bed capacity and adequate training on complication management. Freestanding clinics should have clear collaborative relationships and policies to manage complications. It is not enough to call for an ambulance. The staff should be certified in Advanced Cardiac Life Support. This gives you the best chance at surviving heart attacks etc.
These procedures can and do change lives for the better. They are life altering in positive ways, but they are not a quick ticket or a risk free option to weight loss. All surgeries carry risks from the surgery itself, the anesthesia risk and then post operative risks. A well-trained team, with a quality facility and a highly skilled and experienced surgeon offer the best benefit for the least risk and the best value.
This is, after all, what we are looking for in medical travel and tourism. Not lowest price, but the best value. Your health is one of the most precious things you have. Treat it as the valuable commodity it is and protect your investment, by working with quality people who spend the time to ensure you understand what you need and where to obtain it.
Safe travel and best health!
Jim McCormick MD
Premiere Medical Travel
Dr. McCormick is originally from New York and now lives in Los Angeles. He is a practicing Emergency Medicine physician in Los Angeles. He has remained Board Certified for the last 10 years. Prior to that, he served for over 20 years in pre-hospital emergency services, both ground and air based operations. He graduated from medical school at the State University of New York Downstate in 1993. His residency in Emergency Medicine at the prestigious LAC+USC Medical Center was completed in 1997.
Dr McCormick is a founding member and co-inventor of the NuMask IntraOral Mask, a breakthrough medical device for ventilating patients. His next direction is a more strategic solution to the US healthcare challenges with the launch of a medical tourism business called Premier Medical Travel this fall. He is convinced that combining his MD and MBA will help to unleash the tremendous benefits this industry has to offer: our patients, our payers, our country and our future generations. He may be reached at jjmccormi@earthlink.net
References
- Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R) February 21st 2006
- Consensus Conference Statement. Bariatric Surgery for Morbid Obesity Health Implications for patients, health professionals and third party payers. Surgery for Obesity and Related Disease. J Am Coll Surg 2005 ; 200 : 593-604
- The Consensus Guidelines on Bariatric Surgery. California Association of Health Plans Obesity Initiative Workgroup. June 2006 www.calhealthplans.com
