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The Alberta population-based prospective evaluation of the quality of life outcomes and economic impact of bariatric surgery (APPLES) study: background, design and rationale.

https://arctichealth.org/en/permalink/ahliterature140191
Source
BMC Health Serv Res. 2010;10:284
Publication Type
Article
Date
2010
Author
Raj S Padwal
Sumit R Majumdar
Scott Klarenbach
Dan W Birch
Shahzeer Karmali
Linda McCargar
Konrad Fassbender
Arya M Sharma
Author Affiliation
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. rpadwal@ualberta.ca
Source
BMC Health Serv Res. 2010;10:284
Date
2010
Language
English
Publication Type
Article
Keywords
Adaptation, Physiological
Adaptation, Psychological
Adult
Alberta
Bariatric Surgery - economics - methods - psychology
Body mass index
Cohort Studies
Cost of Illness
Cost-Benefit Analysis
Female
Follow-Up Studies
Health Care Costs
Humans
Male
Middle Aged
Obesity, Morbid - diagnosis - surgery
Patient Satisfaction - statistics & numerical data
Patient Selection
Postoperative Care - methods
Postoperative Complications - physiopathology
Preoperative Care - methods
Prospective Studies
Quality of Life
Risk assessment
Time Factors
Treatment Outcome
Waiting Lists
Weight Loss
Abstract
Extreme obesity affects nearly 8% of Canadians, and is debilitating, costly and ultimately lethal. Bariatric surgery is currently the most effective treatment available; is associated with reductions in morbidity/mortality, improvements in quality of life; and appears cost-effective. However, current demand for surgery in Canada outstrips capacity by at least 1000-fold, causing exponential increases in already protracted, multi-year wait-times. The objectives and hypotheses of this study were as follows: 1. To serially assess the clinical, economic and humanistic outcomes in patients wait-listed for bariatric care over a 2-year period. We hypothesize deterioration in these outcomes over time; 2. To determine the clinical effectiveness and changes in quality of life associated with modern bariatric procedures compared with medically treated and wait-listed controls over 2 years. We hypothesize that surgery will markedly reduce weight, decrease the need for unplanned medical care, and increase quality of life; 3. To conduct a 3-year (1 year retrospective and 2 year prospective) economic assessment of bariatric surgery compared to medical and wait-listed controls from the societal, public payor, and health-care payor perspectives. We hypothesize that lower indirect, out of pocket and productivity costs will offset increased direct health-care costs resulting in lower total costs for bariatric surgery.
Population-based prospective cohort study of 500 consecutive, consenting adults, including 150 surgically treated patients, 200 medically treated patients and 150 wait-listed patients. Subjects will be enrolled from the Edmonton Weight Wise Regional Obesity Program (Edmonton, Alberta, Canada), with prospective bi-annual follow-up for 2 years. Mixed methods data collection, linking primary data to provincial administrative databases will be employed. Major outcomes include generic, obesity-specific and preference-based quality of life assessment, patient satisfaction, patient utilities, anthropometric indices, cardiovascular risk factors, health care utilization and direct and indirect costs.
The results will identify the spectrum of potential risks associated with protracted wait times for bariatric care and will quantify the economic, humanistic and clinical impact of surgery from the Canadian perspective. Such information is urgently needed by health-service providers and policy makers to better allocate use of finite resources. Furthermore, our findings should be widely-applicable to other publically-funded jurisdictions providing similar care to the extremely obese.
Clinicaltrials.gov NCT00850356.
Notes
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PubMed ID
20932316 View in PubMed
Less detail

The cost of bariatric medical tourism on the Canadian healthcare system.

https://arctichealth.org/en/permalink/ahliterature104354
Source
Am J Surg. 2014 May;207(5):743-6; discussion 746-7
Publication Type
Article
Date
May-2014
Author
Caroline E Sheppard
Erica L W Lester
Shahzeer Karmali
Christopher J de Gara
Daniel W Birch
Author Affiliation
Centre for the Advancement of Minimally Invasive Surgery, Room No. 502 CSC, 10240 Kingsway Avenue, Royal Alexandra Hospital, Edmonton, Alberta T5H 3V9, Canada; University of Alberta, 2-590 Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta T6G 1C9, Canada.
Source
Am J Surg. 2014 May;207(5):743-6; discussion 746-7
Date
May-2014
Language
English
Publication Type
Article
Keywords
Adult
Bariatric Surgery - economics
Canada
Female
Health Care Costs - statistics & numerical data
Humans
Male
Medical Tourism - economics
Middle Aged
Postoperative Care - economics
Postoperative Complications - economics - therapy
Abstract
Medical tourists are defined as individuals who intentionally travel from their home province/country to receive medical care. Minimal literature exists on the cost of postoperative care and complications for medical tourists. The costs associated with these patients were reviewed.
Between February 2009 and June 2013, 62 patients were determined to be medical tourists. Patients were included if their initial surgery was performed between January 2003 and June 2013. A chart review was performed to identify intervention costs sustained upon their return.
Conservatively, the costs of length of stay (n = 657, $1,433,673.00), operative procedures (n = 110, $148,924.30), investigations (n = 700, $214,499.06), blood work (n = 357, $19,656.90), and health professionals' time (n = 76, $17,414.87) were summated to the total cost of $1.8 million CAD.
The absolute denominator of patients who go abroad for bariatric surgery is unknown. Despite this, a substantial cost is incurred because of medical tourism. Future investigations will analyze the cost effectiveness of bariatric surgery conducted abroad compared with local treatment.
PubMed ID
24791638 View in PubMed
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A deficiency in knowledge of basic principles of laparoscopy among attendees of an advanced laparoscopic surgery course.

https://arctichealth.org/en/permalink/ahliterature137353
Source
J Surg Educ. 2011 Jan-Feb;68(1):3-5; quiz 5.e1-2
Publication Type
Article
Author
Carlos A Menezes
Daniel W Birch
Andrey Vizhul
Xinzhe Shi
Vadim Sherman
Shahzeer Karmali
Author Affiliation
Center for Advancement of Minimally Invasive Surgery, University of Alberta, Edmonton, Alberta, Canada.
Source
J Surg Educ. 2011 Jan-Feb;68(1):3-5; quiz 5.e1-2
Language
English
Publication Type
Article
Keywords
Alberta
Analysis of Variance
Clinical Competence
Colorectal Surgery - education
Curriculum
Education, Medical, Continuing - organization & administration
Educational Measurement
Female
Humans
Internship and Residency - statistics & numerical data
Laparoscopy - education - standards
Male
Medical Staff, Hospital - statistics & numerical data
Needs Assessment
Questionnaires
Abstract
Advanced laparoscopic courses serve as a comprehensive and popular Continuing Medical Education (CME) activity. Knowledge of basic laparoscopy is an assumed prerequisite for attendance at these courses.
To determine the baseline laparoscopic knowledge of attendees at an advanced laparoscopic surgical course.
A.17-question examination was designed using data from the basic laparoscopic quizzes on the Society of American Gastrointestinal Surgeons (SAGES) website (http://www.sages.org/education/quiz). The questions covered 4 realms of basic laparoscopy: access, pneumoperitoneum, camera navigation, and surgical instrumentation. The questionnaire was distributed to all attendees at an advanced laparoscopic course at the 2009 Canadian Surgical Forum organized by the Canadian Association of General Surgeons.
Forty-three respondents completed the survey. Fifty-three percent (53%) of responders had been in practice for more than 10 years and 65% had over 5 years experience. Fifty-five percent (55%) [24/43] of respondents listed laparoscopic courses as the sole means of laparoscopic training. Sixty-one percent (61%) [28/43] were performing > 50 laparoscopic cases per year. The median score on the knowledge-based questions was 70.6% [12/17]. In terms of overall score, respondents with more than 5 years experience performed similarly to respondents with less than 5 years experience (73% correct answers). Interestingly, in a subgroup analysis, respondents performed well in camera skills and pneumoperitoneum-themed questions (84% correct answers) but performed poorly on questions pertaining to instrumentation or access (52% correct answers).
Basic laparoscopic knowledge among the attendees of an advanced laparoscopic course is suboptimal. A review of basic principles of laparoscopy particularly pertaining to instrumentation and access should form part of these CME activities.
PubMed ID
21292207 View in PubMed
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Distribution and determinants of critical illness among status Aboriginal Canadians. A population-based assessment.

https://arctichealth.org/en/permalink/ahliterature167371
Source
J Crit Care. 2006 Sep;21(3):243-7
Publication Type
Article
Date
Sep-2006
Author
Kevin B Laupland
Shahzeer Karmali
Andrew W Kirkpatrick
Lindsay Crowshoe
S Morad Hameed
Author Affiliation
Department of Critical Care Medicine, Calgary Health Region, University of Calgary, Calgary, Alberta, Canada T2L 2K8. kevin.laupland@calgaryhealthregion.ca
Source
J Crit Care. 2006 Sep;21(3):243-7
Date
Sep-2006
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Age Factors
Aged
Aged, 80 and over
Canada - epidemiology
Cohort Studies
Critical Illness - epidemiology
Female
Hospital Mortality
Humans
Incidence
Indians, North American - statistics & numerical data
Intensive Care Units - statistics & numerical data
Length of Stay
Male
Middle Aged
Risk factors
Sex Factors
Socioeconomic Factors
Treatment Outcome
Abstract
The aim of the study is to determine the incidence, demographic risk factors, and outcomes of critical illness among all adult status Aboriginal Canadians (SACs) admitted to intensive care units (ICUs).
A population-based cohort was conducted among adult residents of the Calgary Health Region admitted to ICUs between May 1999 and April 2002. Patients were classified as SAC based on an alternate premium arrangement field within their Alberta personal health number.
The annual incidence of critical illness among SACs of 620.6 per 100,000 was significantly higher than the non-SAC population of 302.6 per 100,000 (RR, 2.1; 95% CI, 1.78-2.35); this was due to a 3-fold higher admission rate to the multisystem ICUs among SAC (579.6 per 100,000/y) as compared with non-SAC patients (210.7 per 100,000/y; RR, 2.75; 95% confidence interval [CI], 2.37-3.17). The highest risk for ICU admission among SAC patients was observed in those aged 20 to 49 years, and the incidence was higher in males than females (772.3 vs 479.8 per 100,000/y; RR, 1.6; 95% CI, 1.21-2.14). Although the in-hospital case-fatality rate was only slightly higher among SAC (18%, 38/212) as compared with non-SAC patients (922/7,159; 13%; RR, 1.39; 95% CI, 1.04-1.87), the annual mortality rate was much higher (146.4 per 100,000 for SAC vs 60.9 per 100,000 for non-SAC; RR, 2.40; 95% CI, 1.78-3.19).
This study demonstrates that SACs have an increased burden of critical illness as compared with the general non-SAC population and supports further research aimed at exploring means to reduce its adverse impact in this population.
PubMed ID
16990090 View in PubMed
Less detail

Epidemiology of severe trauma among status Aboriginal Canadians: a population-based study.

https://arctichealth.org/en/permalink/ahliterature175314
Source
CMAJ. 2005 Apr 12;172(8):1007-11
Publication Type
Article
Date
Apr-12-2005
Author
Shahzeer Karmali
Kevin Laupland
A Robert Harrop
Christi Findlay
Andrew W Kirkpatrick
Brent Winston
John Kortbeek
Lindsay Crowshoe
Morad Hameed
Author Affiliation
Department of Surgery, University of Calgary, Calgary, Alta.
Source
CMAJ. 2005 Apr 12;172(8):1007-11
Date
Apr-12-2005
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Alberta - epidemiology
Female
Humans
Incidence
Indians, North American - statistics & numerical data
Male
Middle Aged
Risk factors
Trauma Severity Indices
Wounds and Injuries - classification - ethnology
Abstract
Aboriginal Canadians are considered to be at increased risk of major trauma. However, population-based studies characterizing the distribution, determinants and outcomes of major trauma in this group are lacking. We sought to measure the impact of ethnicity, as reflected by Aboriginal status, on the incidence of severe trauma and to broadly define the epidemiologic characteristics of severe trauma among status Aboriginal Canadians in a large health region.
This population-based, observational study involves all adults (people > or = 16 years) resident in the Calgary Health Region between Apr. 1, 1999, and Mar. 31, 2002. Stratification of the population into status Aboriginal Canadians and the reference population was performed by Alberta Health and Wellness using an alternate premium arrangement field within the personal health care number. Injury incidence was determined by identifying all injuries with severity scores of 12 or greater in the Alberta Trauma Registry, regional corporate data and the Office of the Medical Examiner.
Aboriginal Canadians were at much higher risk than the reference population in the Calgary Health Region of sustaining severe trauma (257.2 v. 68.8 per 100,000; relative risk [RR] 3.7, 95% confidence interval [CI] 3.0-4.6). Aboriginal Canadians were found to be at significantly increased risk of injuries resulting from motor vehicle crashes (RR 4.8, 95% CI 3.5-6.5), assault (RR 11.1, 95% CI 6.2-18.6) and traumatic suicide (RR 3.1, 95% CI 1.4-6.1). A trend toward higher median injury severity scores was observed among Aboriginal Canadians (21 v. 18, p = 0.09). Although the case-fatality rate among Aboriginal Canadians was less than half that in the reference population (14/93 [15%] v. 531/1686 [31%], p
Notes
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Comment In: CMAJ. 2005 Apr 12;172(8):1023-415824407
PubMed ID
15824405 View in PubMed
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Health status, quality of life, and satisfaction of patients awaiting multidisciplinary bariatric care.

https://arctichealth.org/en/permalink/ahliterature123629
Source
BMC Health Serv Res. 2012;12:139
Publication Type
Article
Date
2012
Author
Raj S Padwal
Sumit R Majumdar
Scott Klarenbach
Daniel W Birch
Shahzeer Karmali
Linda McCargar
Konrad Fassbender
Arya M Sharma
Author Affiliation
Department of Medicine, University of Alberta, 2F1,26 Walter C, Mackenzie Health Sciences Centre, 8440-112th Street, Edmonton, AB T6G 2B7, Canada. rpadwal@ualberta.ca
Source
BMC Health Serv Res. 2012;12:139
Date
2012
Language
English
Publication Type
Article
Keywords
Adult
Alberta
Bariatrics - methods - psychology
Cross-Sectional Studies
Female
Health Services Research
Health status
Humans
Interdisciplinary Communication
Linear Models
Male
Middle Aged
Pain Measurement
Patient satisfaction
Prospective Studies
Quality of Life
Watchful Waiting
Abstract
Protracted, multi-year wait times exist for bariatric care in Canada. Our objective was to examine wait-listed patients' health status and perceptions regarding the consequences of prolonged wait times using a cross-sectional study design nested within a prospective cohort.
150 consecutive consenting subjects wait-listed for multi-disciplinary bariatric assessment in a population-based medical/surgical bariatric program were surveyed. Health status was measured using a visual analogue scale (VAS). A Waiting List Impact Questionnaire (WLIQ) examined employment, physical stress, social support, frustration, quality of life, and satisfaction with care. Multivariable linear regression analysis adjusted for age, sex and BMI identified independent predictors of lower VAS scores.
136 (91%) subjects were women, mean age was 43?years (SD 9), mean BMI was 49.4 (SD 8.3) kg/m2 and average time wait-listed was 64?days (SD 76). The mean VAS score was 53/100 (SD 22). According to the WLIQ, 47% of subjects agreed/strongly agreed that waiting affected their quality of life, 65% described wait times as 'concerning' and 81% as 'frustrating'. 86% reported worsening of physical symptoms over time. Nevertheless, only 31% were dissatisfied/very dissatisfied with their overall medical care. Independent predictors of lower VAS scores were higher BMI (beta coefficient 0.42; p?=?0.03), unemployment (13.7; p?=?0.01) and depression (10.3; p?=?0.003).
Patients wait-listed for bariatric care self-reported very impaired health status and other adverse consequences, attributing these to protracted waits. These data may help benchmark the level of health impairment in this population, understand the physical and mental toll of waiting, and assist with wait list management.
Clinicaltrials.gov NCT00850356.
Notes
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PubMed ID
22681857 View in PubMed
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The impact of laparoscopic sleeve gastrectomy on plasma ghrelin levels: a systematic review.

https://arctichealth.org/en/permalink/ahliterature112833
Source
Obes Surg. 2013 Sep;23(9):1476-80
Publication Type
Article
Date
Sep-2013
Author
Blaire Anderson
Noah J Switzer
Ahmad Almamar
Xinzhe Shi
Daniel W Birch
Shahzeer Karmali
Author Affiliation
Department of Surgery, University of Alberta, Edmonton, AB, Canada.
Source
Obes Surg. 2013 Sep;23(9):1476-80
Date
Sep-2013
Language
English
Publication Type
Article
Keywords
Biological Markers - blood
Body mass index
Canada - epidemiology
Female
Gastroplasty - methods
Ghrelin - blood
Humans
Laparoscopy
Male
Obesity, Morbid - blood - epidemiology - surgery
Treatment Outcome
Weight Loss
Abstract
Within the last decade, several authors have proposed laparoscopic sleeve gastrectomy (LSG) as a potential definitive treatment for morbid obesity. While initially perceived as being a solely restrictive procedure, it is now theorized to have additional hormonal effects (primarily the reduction of circulating levels of plasma ghrelin). However, there is limited supporting evidence for this claim. Therefore, the purpose of our study is to conduct a systematic review of the literature to clarify the effects of LSG on modulation of postoperative ghrelin concentrations. A comprehensive literature search for published or unpublished studies of sleeve gastrectomy (SG) and ghrelin written in English prior to February 2013 was performed using Pubmed, EMBASE, the Cochrane database, and Scopus. Gray literature was also searched through Google. Inclusion criteria for searches were: randomized controlled trials, non-randomized clinical trials, retrospective and prospective cohort studies, or case series. Seven studies were deemed suitable for analysis. The mean patient age was 43?±?8.8 years and female percentage was 74.4?±?15.3 %. The mean initial BMI was 46.2?±?7.8 and mean follow-up time was 9.5?±?15 months. The mean postoperative BMI was 37.3?±?5.8 over the same follow-up period. Pooled mean preoperative ghrelin levels were 698.4?±?312.4 pg/ml and postoperative levels were 414.1?±?226.3 pg/ml (P?
PubMed ID
23794092 View in PubMed
Less detail

Laparoscopic sleeve gastrectomy with staple line buttress reinforcement in 116 consecutive morbidly obese patients.

https://arctichealth.org/en/permalink/ahliterature127848
Source
Obes Surg. 2012 Apr;22(4):560-4
Publication Type
Article
Date
Apr-2012
Author
Richdeep S Gill
Noah Switzer
Mike Driedger
Xinzhe Shi
Andrey Vizhul
Arya M Sharma
Daniel W Birch
Shahzeer Karmali
Author Affiliation
Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
Source
Obes Surg. 2012 Apr;22(4):560-4
Date
Apr-2012
Language
English
Publication Type
Article
Keywords
Adult
Anastomotic Leak - epidemiology - etiology - prevention & control
Canada - epidemiology
Female
Follow-Up Studies
Gastrectomy - adverse effects - methods
Humans
Laparoscopy - methods
Male
Medical Records
Obesity, Morbid - complications - epidemiology - surgery
Postoperative Hemorrhage - epidemiology - etiology - prevention & control
Retrospective Studies
Surgical Stapling - methods
Treatment Outcome
Weight Loss
Abstract
Obesity rates have reached epidemic levels with over 300 million obese individuals worldwide. Laparoscopic sleeve gastrectomy (LSG) as a primarily restrictive bariatric surgical procedure has been shown to be effective in producing marked weight loss. However, LSG-associated gastric leakage and hemorrhages remain the most important challenges postoperatively. Staple line buttress reinforcement has been suggested to reduce these postoperative complications. Our objective was to assess staple line buttress reinforcement via the Duetâ„¢ tissue reinforcement stapler system in morbidly obese patients undergoing LSG as part of a comprehensive weight management strategy, focusing on postoperative complications.
Between January 2008 and April 2011, we retrospectively reviewed the medical records of 116 consecutive patients that underwent LSG with staple line buttress reinforcement at an academic teaching hospital with advanced bariatric fellowship.
The mean age of patients was 44.3?±?9.5 years, with mean preoperative BMI of 44?±?7 kg/m2. The mean operative time to perform LSG was 96?±?25 min. Postoperative weight was significantly lower following LSG at 1-year follow-up compared to baseline (104?±?25 vs. 125?±?27 kg, P?
PubMed ID
22258197 View in PubMed
Less detail

Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity.

https://arctichealth.org/en/permalink/ahliterature122039
Source
Can J Surg. 2012 Oct;55(5):329-36
Publication Type
Article
Date
Oct-2012
Author
P S Griffith
Daniel W Birch
Arya M Sharma
Shahzeer Karmali
Author Affiliation
The Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
Source
Can J Surg. 2012 Oct;55(5):329-36
Date
Oct-2012
Language
English
Publication Type
Article
Keywords
Adult
Anastomotic Leak - etiology - surgery
Canada - epidemiology
Constriction, Pathologic - etiology
Evidence-Based Medicine
Female
Gastric Bypass - adverse effects - methods
Gastrointestinal Hemorrhage - etiology - surgery
Humans
Intestinal Fistula - etiology - surgery
Intestinal Obstruction - etiology - surgery
Jejunum - pathology
Laparoscopy
Length of Stay
Male
Malnutrition - etiology
Middle Aged
Obesity, Morbid - epidemiology - surgery
Postoperative Complications - etiology - surgery
Surgical Stapling - adverse effects
Ulcer - etiology
Weight Gain
Abstract
Obesity has become a major health concern in Canada. This has resulted in a steady rise in the number of bariatric surgical procedures being performed nationwide. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. With this in mind, it is imperative that all gastrointestinal surgeons understand the LRYGB and have a working knowledge of the common postoperative complications and their management. Early postoperative complications following LRYGB that demand immediate recognition include anastomotic or staple line leak, postoperative hemorrhage, bowel obstruction and incorrect Roux limb reconstructions. Later complications may be challenging to differentiate from other gastrointestinal disorders and include anastomotic stricture, marginal ulceration, fistula formation, weight gain and nutritional deficiencies. We discuss the principles involved in the management of each complication and the timing of referral to specialist bariatric centres.
Notes
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PubMed ID
22854113 View in PubMed
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Source
Am J Surg. 2010 May;199(5):604-8
Publication Type
Article
Date
May-2010
Author
Daniel W Birch
Lan Vu
Shahzeer Karmali
Carlene Johnson Stoklossa
Arya M Sharma
Author Affiliation
Center for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, 10240 Kingsway, Edmonton, Alberta, T5H 3V9 Canada. dbirch@ualberta.ca
Source
Am J Surg. 2010 May;199(5):604-8
Date
May-2010
Language
English
Publication Type
Article
Keywords
Adult
Bariatric Surgery - adverse effects - methods
Body mass index
Canada
Female
Follow-Up Studies
Gastric Bypass - adverse effects - methods
Gastroplasty
Humans
Laparoscopy - adverse effects - methods
Medical Tourism - statistics & numerical data - trends
Middle Aged
Obesity, Morbid - diagnosis - surgery
Postoperative Complications - epidemiology - surgery
Reoperation
Retrospective Studies
Risk assessment
Sampling Studies
Treatment Outcome
Young Adult
Abstract
The number of Canadians who self-refer for bariatric surgery outside of Canada or to private clinics within Canada remains undefined. The outcomes from this questionable practice have not been evaluated systematically to date.
We completed a chart review of known cases referred to our center for complications related to medical tourism and bariatric surgery.
We present a series of patients who have experienced complications because of medical tourism for bariatric surgery and required urgent surgical management at a tertiary care center within Canada. Complications have resulted from 3 commonly used procedures: adjustable gastric banding, gastric sleeve resection, and Roux-en-Y gastric bypass.
Because of this review, we propose that a medical tourism approach to the surgical management of obesity-a chronic disease-is inappropriate and raises clear ethical and moral issues.
PubMed ID
20346442 View in PubMed
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