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Chapter 1: Why are more people choosing to travel abroad for surgery?
With the marked increase in the number of people choosing to travel abroad for surgery, Irish surgeons are seeing increasing numbers of patients admitted through emergency departments with complications arising from those procedures.
The Royal College of Surgeons in Ireland is offering clear guidance to help people understand and manage the greater risk involved in having an operation in another country. To discuss this, I'm joined by Professor Deborah McNamara, President of the Royal College of Surgeons in Ireland and Consultant General and Colorectal Surgeon in Beaumont Hospital.
By Professor Helen Henehan, Consultant Bariatric Surgeon in St Vincent's University Hospital. And by Alan Keogh, a patient who had bariatric surgery abroad. You're all very welcome. And I might start with you, Deirdre, if I may. How many people are travelling abroad? Do we know how many people are travelling abroad for surgery?
So it's really hard to get accurate figures on that, David. One of the things that we've noticed is that there's a lot of direct advertising to patients and that is framing surgery as something that is almost a trivial procedure and really underestimating the risks. So many people travel for surgery.
Chapter 2: What risks are associated with undergoing surgery in another country?
Sometimes they're a bit embarrassed about travelling for surgery. Maybe it's for some personal type of operation, some cosmetic procedures, weight reducing surgery. And so it's really hard to get accurate figures. We do know that the HSE does support some travel abroad and we do have accurate figures for that. But for the things we don't.
Okay. And do we know what the most common procedures people are having abroad are?
So it seems like the most common procedures are procedures for excess weight, procedures for cosmetic procedures, plastic surgery and reconstructive surgery and dental procedures. They seem to be the top three.
Okay. And what sort of complications are you seeing then?
So we're seeing a range of complications. Any operation can carry complications, but travelling abroad adds extra risk. And so some of the sorts of complications we're most concerned about are things like clots, DVTs and pulmonary embolus. They can be life threatening complications. They're much more common following air travel and they're also more common after an operation.
So those additive risks are of a concern. We're also seeing significant infections with bacteria that we don't always see here. So most of your listeners will have heard of superbugs. And so in some countries, there are greater numbers of superbugs. They're more endemic in their health systems. And so we're seeing infections that can be serious and some of them can be really difficult to treat.
OK, I want to bring Helen in here. Helen, good morning to you. Good morning, David. Bariatric surgery, as Deborah has mentioned, is one of the things that people travel for. And it's one of the things that you're seeing complications arising from those surgeries abroad.
Yes, David, and I guess the reason people feel the need to travel abroad for surgery is the delay or the lack of access to services here. So, you know, obesity treatment services have been grossly underfunded for decades in Ireland and the legacy of that is a very lengthy waiting list for treatment now.
So whilst we do have excellent, high quality services, certainly for obesity care in Dublin and in Galway, It's not enough to meet the demand such as the prevalence of obesity around the country. So I understand why people feel the need to go abroad. And similarly, if people are to seek surgery privately here and to self pay for it, it is more expensive.
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Chapter 3: What are the most common surgical procedures performed abroad?
And how many people would you be seeing that coming to you with complications arising from surgery abroad?
So that has changed over the last three to four years, David. So when, and Alan might speak to this, the time Alan went abroad for surgery just after COVID and there was a surge of people travelling then. As a result of what Professor McNamara mentioned, really direct and targeted aggressive advertising to patients when they had time, they were at home and could travel.
Despite the travel restrictions and lockdowns, people were allowed to go for medical procedures. So there was a surge there where we were seeing back two to three patients a week in certainly our hospital in St. Vincent's. And that happened around the country with complications such as leak, bleeding.
complications and leading to sepsis and that has changed the pattern of complications we're seeing now is related is is later complications so people who've had sleeve gastrectomy and now have bad reflux as a result some people are regaining weight and some people have malnutrition because they didn't really have any they have no follow-up care no wraparound care that's so important to the success of bariatric surgery okay um i want to bring alan kyo in alan good morning to you
Tell us a bit about your story. Take us back to where you first started thinking about having some sort of surgery and why. And how did you get on with your GP?
Well, my GP, he was fine. But any time you go to a GP in Ireland and you're overweight, you're sick because you're overweight. So you go in with a chest infection, it's because you're big. You go in with a bad ankle, it's because you're big. So anytime you're looking for support, unless you have a GP who knows a lot about bariatric stuff, you're not going to get support.
And how big were you, if you don't mind me asking at the time? I was about 270 kilos, which is about 42 stone. And so I was extremely big and I was only getting bigger. And if I had waited the Irish waiting list, I don't think I'd be here today. Like at the time, I only had the energy to work. So I used to work five, six days a week and I'd go to work.
I'd come home and I'd be there asleep on the couch within 10 minutes of being home. and not have any energy for my kids at the weekends. Couldn't exercise because my knees, my hips were all blown out because I was just so big. Even standing at the cooker to cook, my back was in pain. So everything was just leading towards one thing.
To go privately to get bariatric surgery was about 18,000, 19,000 plus in Ireland. Waiting list was between four and six years. I'd still be waiting today for the surgery. And you tried every other option, I presume, at that stage. Sure, I'd been to every weight loss class. I'd been to every gym. I'd tried everything. I genuinely had tried everything. I had...
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Chapter 4: What complications can arise from surgeries performed overseas?
I thought like if I was to have surgery in Ireland, it was a huge risk. At my weight, any surgery anywhere is going to be a huge risk. Like going in to have any anesthetic is a massive risk at that weight. And when I went to Turkey, the first hospital, even though they knew how big I was, when I got over there, the doctor refused.
And they then, the clinics started to scramble to find a different professor to help.
He refused to do the operation? Yeah. Okay. And did that give you any worries? No. Okay. So they found a second surgeon who was prepared to do the operation. And how did that go?
The surgery went well, but when I got home, it went wrong.
so when i got home and i had a yogurt because that was the next stage that i was to go to from liquid to kind of thick fluid right um so i had a yogurt for a spoonful got an awful pain in my stomach and uh turns out i had burst open all the stitches in my stomach so my stomach was completely open so from my anything that i swallowed just leaked into my abdomen
And it was in a position that couldn't be closed. So I ended up in Connolly Hospital. They did a scan, discovered it was the hall was there and transferred me over to Vincent's under the care of Helen. Yeah. And then I spent guts of nine, ten months in hospital. My God. The hole I had for two years. I couldn't eat, I couldn't drink. Nothing went down my mouth.
I couldn't swallow a tablet, couldn't have a glass of water, couldn't do anything. I was completely peg-fed for two years. My God, that's horrendous. Yeah. It is what it is. You can't cry about it. You're very phlegmatic. Well, you can't cry about it. There's no point. If I cry about it, I have two kids and a wife at home that I have to look after and keep going for. I lost 130 kilos if I hadn't.
It's quite the diet.
It's a bit extreme Alan, it's a bit extreme. But I mean clearly the level of care you got in that clinic or hospital in Turkey was not the standard that you'd get here.
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Chapter 5: Why do patients feel the need to seek bariatric surgery abroad?
You need to know exactly what is going to happen. You need to mentally have have have come to terms with what it's going to involve. And it doesn't sound like any of that was done in Turkey.
Yes, and the multidisciplinary team, both assessment and follow up afterwards is really what's key to the success of bariatric surgery. So, you know, all our patients here, you know, part of our high quality service is a full multidisciplinary assessment to ensure a few things. Some people should never have bariatric surgery, just it wouldn't be the safe thing for them.
and that we identify that well in advance or early in the assessment. And then some people will be ready but need some preparation either with dietitian or psychology or both and medical preparation to optimize them for safe surgery. So a lot of preparation that would sometimes take up to nine months here and on occasion it can be done faster in two to three months. But it's really important.
That's a kind of a joint preparation process between the patient and the multidisciplinary team. Then aftercare is really important as well. And that's completely missing when people have traveled abroad for surgery, unless they instigated themselves with the GP or a service at home. So looking for, you know, and Alan may not have had as difficult course if his problem had been identified earlier.
Often when people have problems like a leak or bleeding, there are, if you look back, very early signs of it in the first toot. even 24, 48 hours after surgery. And if you intervene early, a lot of the long terms are the sequelae. It can be fixed easier and people won't have as challenging a recovery. So in hospital care is really important to pick up problems early.
And then after discharge, making sure someone is losing weight in a safe way, not losing too much muscle mass is really important to durable results in the long term as well and to not leading to malnutrition.
Deborah, when you hear Alan's story and just what appears to be a complete lack of care offered to him and lack of aftercare, as a professional, it must horrify you.
Yeah, it's very distressing to hear, actually. And, you know, I think every surgeon has an ethical obligation not just to do operations, but to look after their patients afterwards. And that is part of surgery. And that sort of wraparound care is an essential component of surgery. And as you've rightly said, preoperative assessment is part of that, looking after patients early.
What we call rescuing patients from complications that promptly is really important to getting best long term outcomes. And then, as Professor Hinehan has mentioned, long term care for patients who may have long term sequelae. So, yes, I think it's very concerning.
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