Amanda Wilde (Host): There are countries that specialize in medical procedures for foreigners. We are talking about medical tourism specifically for bariatric surgery and possible postoperative complications with Dr. Francesca Dimou. Dr. Dimou is Associate Professor of Surgery at the USF Health Morsani College of Medicine, and the Director of the TGH and USF Bariatric Center.

 Welcome to MD Cast by Tampa General Hospital, a go-to listening location for specialized physician-to-physician content, and a valuable learning tool for world-class healthcare. I'm Amanda Wilde. Dr. Dimou, thank you for being here.

Francesca Dimou, MD: Thank you so much for having me today.

Host: So, what is surgical tourism? Is there more to it than what I mentioned in the introduction?

Francesca Dimou, MD: There is a little bit more nuances to it, specifically for bariatric surgery. And the unfortunate reality is with surgical tourism, what we sort of state is that it's people who reside in the United States going elsewhere for healthcare. And there are many reasons for that, but the challenges with bariatric surgery or what we know as weight loss surgery is we do have patients traveling to places like Mexico for their bariatric operation and then coming back to the United States to recover. This is from cost or insurance or whatever other barriers that they're able to seek for surgical tourism.

Host: So, it sounds like it's not always a first choice. Would that be fair to say, even though it's on the rise?

Francesca Dimou, MD: Absolutely. We unfortunately see a lot of patients who may not have insurance coverage for bariatric surgery here in the U.S. and they've tried other modalities. Maybe they even change their insurance carrier, and they still are unable to get the care that they need, so they look elsewhere. And it's also less costly outside of the United States.

Host: And then, what happens if a patient is outside of the U.S. and has a complication from the surgery?

Francesca Dimou, MD: Yeah, I think that's perhaps one of the most challenging parts of patients that I take care of, because sometimes what happens is patients fly back to the U.S. And then, what ultimately ends up happening, they develop a complication, they come to the hospital, and sometimes their insurance company will not pay for those complications. And so, it's certainly a financial burden to people.

Host: What are some of the common complications patients experience after bariatric surgery?

Francesca Dimou, MD: I think one of the most common complications, and I'm going to kind of go from less severe to most severe. So, less severe, most common nausea, throwing up, or they're unable to tolerate their liquids or their diet. So, that's kind of what we commonly see and they come into the hospital for dehydration.

One of the more severe complications, which is something that we certainly worry about, is something known as a leak. So, anytime we suture or staple the stomach, if someone were to drink, it can leak out of that suture line and patients can get very, very sick requiring hospitalization and sometimes another operation.

Host: So, is that a result of going to another country, these complications and the need perhaps for revisional surgery?

Francesca Dimou, MD: Yeah. I don't think it's unique to surgical tourism, but I do think that it can be challenging for patients because certainly we want patient safety. So if they have an operation done nearby and they stay within our healthcare system, we're able to keep a closer eye on them. We know their medical history and their medical conditions. And so, it does make things a little bit more continuity of care, so to speak. And also as mentioned, sometimes it's the unfortunate financial burden that patients may experience if they do go elsewhere for their initial care.

Host: Yeah. So, it's a little more risky to do that.

Francesca Dimou, MD: Yes, it is.

Host: If there are complications and another surgery is needed to remedy that, what are those risks? What are the risks of revision surgery?

Francesca Dimou, MD: So typically, for revisional surgery, which is something that we consider anytime a patient has had a prior bariatric operation and they need another operation for whatever reason that may be. Now, again, that can kind of be something, let's say, they need a conversion from a sleeve to a gastric bypass because of heartburn. And usually, when we do these things robotically, the risks are low. I would say 5% or less. In the more acute issues or severe issues such as malnutrition, repeated nausea, and vomiting, those sorts of things can be a little more risky because the patients have other medical conditions that may prevent healing, i.e. malnutrition.

Host: So, what would you say are the expectations patients should have when pursuing revisional surgery?

Francesca Dimou, MD: It's interesting because a lot of patients, I would say about 20% of my practice consists of patients needing revisional surgery. And a lot of times, unfortunately, it's patients who've dealt with problems for a long period of time. And so when they initially see me, I may need more of a workup to kind of get the full picture. And I know it can be frustrating for patients, because they've waited a long time to find an answer. But I usually tell them that we have to work together, get all of our ducks in a row, because we have to make sure that all of the information that we have is correct. So then, I give them the right operation that they need in order to get them feeling better.

Host: But certainly, revision's going to cost more time and more wear and tear on the body. Dr. Dimou, any parting thoughts or words of advice for patients as we wrap up this conversation about medical tourism and bariatric surgery?

Francesca Dimou, MD: I think the biggest thing is, for us as bariatric surgeons, I do want patients to know that we are constantly trying to advocate for them for better insurance coverage, better coverage as far as weight restrictions and those sorts of things. And to also continue looking into their insurance carriers to make sure that they have appropriate coverage for them because obesity is a disease. They deserve to have that treatment, and we will continue to fight with insurance companies to get them the care that they need.

Host: Well, hopefully, you will help us make changes for the better.

Francesca Dimou, MD: That's the goal.

Host: Dr. Dimou, thank you so much.

Francesca Dimou, MD: You're welcome. Not a problem. Thank you again for having me.

Host: Dr. Francesca Dimou is Associate Professor of surgery at the USF Health Morsani College of Medicine, and the Director of the TGH and USF Bariatric Center. Thank you for listening to MD CAST by Tampa General Hospital, which is available on all major streaming services for free. To collect your CME, please click on the link in the description. For other CME opportunities, including live webinars, on-demand videos, and local events offered to you by Tampa General Hospital, please visit cme.tgh.org. Thank you.