Ensuring patient safety and surgical standards in medical tourism for bariatric and metabolic surgery: European Delphi consensus

Bariatric and metabolic surgery (BMS) is a very effective intervention for obesity and obesity-related metabolic disease. Widespread availability of surgery worldwide has resulted in many patients traveling abroad for medical care outside of their home healthcare systems, most frequently choosing bariatric and metabolic surgery medical tourism (BMS-MT). BMS-MT is not only timesaving and cost-saving, but there are also safety, quality, and long-term follow-up concerns[1]. The European Association for the Study of Obesity (EASO), the International Federation for the Surgery of Obesity and Metabolic Disorders—European Chapter (IFSO-EC), and the European Coalition for People Living with Obesity (ECPO) joined forces to develop European guidelines for safe practice in BMS-MT using an adapted Delphi consensus process. The guidelines are crucial to provide high-quality BMS-MT care by accepted international standards for surgical safety[2]. The Delphi procedure to come to these recommendations involved a multi-round iterative survey among the health experts and the persons with a lived experience of obesity. A discussion and survey were performed in a guided round among the expert panel members, such as bariatric surgeons, anesthetists, obesity specialists, patient representatives, and policymakers, to achieve consensus on the issues. The procedure was to come to the key areas, i.e. preoperative assessment, indications for the surgery, postoperative care, and follow-up procedures within the context of BMS-MT. Final consensus statements were critically appraised based on predetermined threshold values for agreement to come to a firm and evidence-based list of recommendations[3]. Preoperative assessment was made a pillar in the optimization of BMS results, especially in cross-border surgical tourism practice. The consensus emphasized preoperative testing conducted in the country of origin of the patient before travel. The tests should comprise extensive metabolic profiling, psychological evaluation, nutritional screening, and risk stratification using validated scoring systems. Preoperative report standardization, imaging, laboratory, and drug history with easy transferability between border-crossing providers was highly recommended by the panel. Surgical safety and evidence-based procedural recommendations were deemed to be the most critical determinants of successful BMS-MT. To avoid perioperative care risks and surgical variation, the consensus set the requirement for the BMS process to be conducted in high-volume, internationally accredited bariatric surgery centers such as IFSO-EC only[4]. The centers should possess open reporting systems, international accreditation requirements, and unrestricted onsite access to specialist multidisciplinary teams. The intraoperative standardization was also emphasized in the consensus, for example, by the implementation of enhanced recovery after surgery (ERAS) guidelines, protocolized anesthesia protocols, and standardized operative techniques for minimizing perioperative morbidity[5]. Postoperative care and follow-up were termed as issues due to the transnational aspect of BMS-MT. Systematic postoperative follow-up for the management of complications, micronutrient deficiency, and metabolic outcomes was recommended by the expert panel. More specifically, postoperative advice and dietary advice should be provided to patients. Micronutrient supplementation programs and follow-ups should also be offered at regular intervals. The consensus suggested that patients should be enrolled on remote follow-up programs on telemedicine platforms by surgical centers as well as the local healthcare units to ensure the continuum of care. In addition, the national healthcare units should offer opportunities for the integration of BMS-MT patients into ongoing programs for the treatment of obesity to ensure long-term outcomes. BMS-MT regulation and transparency were identified by the agreement as an ethical challenge[6]. The subgroup suggested an international registry for BMS-MT to gather information, monitor surgery outcomes, and enhance patient safety. Healthcare centers that provide BMS to patients from overseas should report success rates and complications as well as standardized outcomes, to enable informed patient decisions. In addition, marketing restrictions should be made more stringent so that patients would not be exposed to misleading claims that could negatively impact patient safety[7]. The accord also addressed the issue of shared decision-making by BMS-MT. The group of experts underlined that patients should be fully advised about surgical risks, expected results, and other therapeutic alternatives due to the nature of obesity treatment and the irreversibility of some bariatric surgeries. Culturally adapted communication should allow patients to make informed decisions based on accurate and complete information[8]. The revised Delphi consensus statement of EASO, IFSO-EC, and ECPO supports BMS-MT safety standards. The standards optimize patient safety, surgical excellence, and long-term results of cross-border bariatric and metabolic surgery by including the views of healthcare providers and patients. Government policymakers, healthcare providers, and accreditors need to include these principles to optimize patient safety and ensure safe medical tourism in bariatric and metabolic surgery.