Europe Agrees on Safe Practices for Weight Loss Tourism

An expert panel of healthcare professionals and people with obesity in Europe recently endorsed recommendations for the safe practice of bariatric and metabolic surgery medical tourism (BMT).

The consensus recommendations, published online in the International Journal of Surgery, lay the groundwork for the development of BMT clinical guidelines, according to the authors.

Medical tourism is when people travel to another country to have a procedure done, usually at a lower price than in their home country. Such procedures can sometimes be botched and lead to poor outcomes and even death.

“Medical tourism involves specific complexities, such as the duration before a patient can safely travel home after a procedure, the recommended length of venous thromboembolism prophylaxis (given the increased risk associated with flying), the necessity of independent translators, and ensuring clear communication between the medical center and the patient’s doctor in their home country,” lead author Laurence Dobbie, MD, King’s College London, London, told Medscape Medical News.

“Different countries have varying standards and regulations,” said Dobbie. “This is what necessitated the requirement for these guidelines.”

The most important point of the recommendations, he added, is to identify centers that adhere to established standards, such as the European Association for the Study of Obesity (EASO) Centres for Obesity Management. “However, enforcing these standards would require oversight by each country’s healthcare regulatory body.”

Clinic Doing the Procedure Responsible

Given “growing concern” about BMT resulting in inadequate care, fraudulent care, and death, the EASO, the International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter, and the European Collation for People Living with Obesity initiated a task force to delineate safe practices in BMT.

Two expert panels from 26 European countries were convened. One consisted of 119 healthcare professionals and the other had 88 patient representatives. 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 discussed, and consensus was defined as 70% agreement. The themes analyzed regarding BMT included regulation, preoperative evaluation, operative care, postoperative care, and advertising and online information.

Consensus was reached regarding the necessity for preoperative evaluation of psychological health, sleep apnea, cardiovascular disease, liver health, and dietetic assessment. The panelists also recommended regulatory standards, including surgeon accreditation and procedural volume, as well as patient education, standardized surgical care, online information, and comprehensive follow-up.

The full set of recommendations is in the paper. Examples include the following:

Regarding the regulation of BMT, the panel agreed that the procedure should only be performed at accredited centers, be undertaken only by surgeons who have national or international accreditation and have completed at least 50 procedures yearly, and that bariatric and metabolic surgery procedures in the stages of research development should not be performed in the context of medical tourism.

Regarding BMT provision of care, the experts agreed that 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 traveling abroad; have written and verbal consent taken prior to bariatric and metabolic surgery; be cleared to travel home by their treating bariatric surgical team once any complications have been addressed; and receive 2 years of follow-up by the organization performing the surgery.

Specific recommendations also were made for eligibility for bariatric surgery abroad, operative care, and advertising and online information.

The authors noted that there are limited data on outcomes from BMT and that the

consensus recommendations provide guidelines for healthcare professionals while more quantitative data is gathered to inform clinical practice.

“The entire process — including preoperative assessment, surgery, and postoperative care — should be managed by the clinic performing the procedure,” Dobbie emphasized. “The only exception would be if there is a bilateral agreement between the patient’s home country doctor/healthcare team and the international healthcare team.”

“Patients may choose to consult a doctor in their home country before undergoing surgery, and it is important that their general practitioner or family medicine specialist receives a copy of their discharge summary,” he added. “However, the primary responsibility for patient care should rest with the clinic carrying out the procedure.”

Patients ‘On Their Own’

Bariatric surgeon Mir Ali, MD, medical director of MemorialCare Surgical Weight Loss Center at Orange Coast Medical Center in Fountain Valley, California, agrees with the European recommendations. “Those of us who work at US-certified bariatric surgery centers of excellence are already following these strict guidelines,” he told Medscape Medical News. “After certification for centers of excellence began some years ago in the US, there was a significant decline in complication rates.”

“The problem with the consensus is that each country regulates and monitors things very differently,” he said. “I have seen people with good results, but I have also seen people with serious complications that necessitated additional corrective surgery.”

“Ideally, implementing a global consensus on bariatric surgery would help patients worldwide,” he added. “Unfortunately, because of the great differences in medical practice throughout the world, it would be difficult to implement a global ideal practice for bariatric surgery.”

The bottom line is that “clinicians and patients need to be aware that when they go out of the country for medical care, they are on their own for the most part,” he warned. “It is important to research the clinic/doctor to find the most qualified person. I have had many patients regret their decision to go abroad for surgery.”

The consensus statement had no funding. Many panel members reported grants from nonprofit organizations and/or from industry. See the paper for specific conflicts of interest disclosures. Ali declared no conflicts.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.