Patients have been airlifted from Northern Ireland to London for last-ditch life-saving treatment following weight loss surgery in Turkey, it can be revealed.
Medics have warned of the catastrophic and life-threatening complications they have encountered in patients who have travelled abroad for bariatric surgery.
Belfast-based surgeon Graeme Macaulay said people have spent months recovering in hospital here after developing potentially fatal conditions, such as peritonitis and sepsis, and face multiple complex surgeries to reverse the damage done to their body.
Others have been left unable to eat solid food for the rest of their lives or have developed conditions more commonly associated with prisoners of war due to severe malnutrition and vitamin deficiencies after weight loss surgery abroad.
“I think the message is you have no idea what you’re going to get,” said Mr Macaulay, a consultant upper gastrointestinal surgeon with the Belfast Trust.
“In the days when you would book a holiday on Ceefax when we didn’t get the internet, you could end up in Spain in sometimes not a very good hotel.
“Your ability to vet foreign medical providers isn’t much better than that.
“This is complex, major surgery and the people in the UK who provide it have to undergo specialist training and fellowship training.
“You don’t necessarily have those same guarantees when you go abroad.”
Mr Macaulay said he has been treating people with complications from weight loss surgery abroad since he started working in Northern Ireland in 2008 but he and his colleagues have seen an increase in cases in recent years.
Family doctors in Northern Ireland have also reported more patients coming to them following surgery since the start of the pandemic, however, they have warned they are unable to provide the specialist post-operative care required.
Dr Michael McKenna, a GP based in west Belfast, said: “We’re getting patients come into us with a discharge letter written in Turkish, which is far from ideal.
“It means it isn’t necessarily clear what follow ups we should be doing and there is no bariatric surgery service in Northern Ireland so there isn’t a service we can refer those patients to.”
Medical tourism has become so popular that a number of firms now operate in Northern Ireland, sending people to Turkey for a range of surgical procedures, including gastric sleeve and gastric bypass surgery.
Clients can travel out to Turkey, undergo pre-operative assessments, have their surgery and return home within five days.
Mr Macaulay, who trained in bariatric surgery while working in Australia, described this as “definitely not best practice”, in particular raising serious concerns over the ability to complete a proper consent process in such a short space of time.
Where bariatric surgery is carried out in the UK, strict criteria is in place to ensure the safety and success of the operations, which only go ahead after patients go through a raft of psychological and physical assessments.
Patients are then monitored closely for a number of years after the surgery.
Mr Macaulay continued: “To have a good outcome from weight loss surgery, one of the most important things is the pre-operative assessment with a multi-disciplinary team, including psychologists and dietitians, so you know the patient is fully engaged with the process.
“Obesity is a complex disease related to hormones, related hormones, diet, lifestyle, socio-economic background, educational attainment, life events.
“The stress of work and eating too much, it’s easy for weight to creep on and one of the things is, if you remove food as a coping mechanism, the person may take on other maladaptive behaviours. So, if you look at the cohort after surgery, there are issues related to alcohol, gambling, drug use, infidelity and marriage break-up, if food is how you help control your emotions and that isn’t addressed.
“Then with gastric sleeves and gastric bypasses in particular, the long-term follow-up from a nutritional and metabolic point-of-view is so important.
“When your gut changes and your gut hormone changes, and your dietary intake changes, one of the things people sometimes struggle with is vitamin and mineral absorption.
“So, anaemia and lack of iron would be a very common side effect of those weight loss procedures. In the UK, there is a national guidance document for follow-up regimes depending on what procedure they have done.
“When I speak to patients who come to clinic after going abroad for weight loss surgery and ask them about what follow-up they’ve had, it is very, very variable.
“Some of them maybe have one or two phone calls from a dietitian in Turkey and that’s the limit of their follow-up, which is definitely not best practice.”
Mr Macaulay said he and his colleagues in Belfast have come across patients who are living on crisps and yoghurt after their surgery, leading to significant problems.
“A lot of these procedures will leave people unable to eat a full-sized plate of food, in reality most of the time you’re aiming for a saucer of food,” he explained.
“If you’re dealing with a person who has made bad food choices beforehand, they need to make very good choices afterwards.
“You can only have a meal the size of a saucer, but you have to get enough protein to maintain your muscle mass, all of your vitamins and minerals and some fibre, and that requires the involvement of a specialist dietetic team to go through all that before the operation and to maintain it afterwards.
“We’ve had patients who went abroad who I don’t think have had that same degree of counselling because they’re eating Doritos on the wards or think they can live properly on ice cream, custard and yoghurt, but that isn’t a realistic option for the next 40 years of your life. My colleagues have been involved in a number of patients who’ve had weight loss surgery where they’ve developed severe vitamin and mineral deficiencies and have rickets.”
Mr Macaulay also said patients have become dangerously unwell within a few days of their surgery and he is aware of cases where patients have disembarked their flight with the contents of their stomach leaking into their abdominal cavity.
“That might be associated with multi-organ failure with the patient needing support on a ventilator or kidney dialysis in the intensive care unit, with strong medications to support blood pressure,” he said.
“The last patient I had to operate on was delirious when she came off the airplane. We know there are very good outcomes if things are done properly but this is major surgery — a gastric sleeve involves taking away 80% of your stomach and a gastric bypass involves completely rearranging the intestines.
“It’s major surgery and the complications can be serious and life-threatening. We’ve transferred patients out to St Thomas’ in London to go on heart and lung bypass, which is the maximum level of support available to any human being. Sometimes these complications require emergency surgery or other complex procedures in the radiology department, or with our colleagues in gastroenterology to have special stents that need to be ordered in to cover leaks.
St Thomas’ Hospital in London. Credit: Dan Kitwood
“The patients may need artificial nutrition in a vein in their neck or a tube into their bowel and often you can’t fix it in one go and they may need one or two months in hospital and further revisional surgery once everything has settled down.
“For some patients there can be lifelong issues with reflux and some patients who never get to eat a solid meal again and who will eat a pureed diet for the rest of their lives.
“These are real people that myself and my colleagues have spoken to and looked after in Northern Ireland, they’re not textbook or hearsay.
“I know of patients who have returned from Turkey who have required further surgery in Northern Ireland because of a retained swab and on NHS terms, that would be considered a never event, it should never happen.
“I don’t know what sort of recompense or what ability those patients have to go back and follow up in terms of the legal position. There are success stories but for the people who do get severe complications, it’s really hard for them.
“You can see them really struggle psychologically from prolonged hospitalisation, the guilt and embarrassment, there is a real complex range of emotions aside from the physical effects on their body.
“From my point of view, it’s very hard to recommend that someone goes away because you can’t say that it’s going to be done safely and to the same standard you would expect from an NHS provider.”
In 2019, a working group was established to design a weight loss surgery service for Northern Ireland.
An expert multi-disciplinary team was being put together but progress on the matter has been stalled as a result of Covid-19.
Consultant hepatobiliary surgeon and director of the Royal College of Surgeons in Northern Ireland Mark Taylor said he believes people will continue to travel abroad until bariatric surgery is available here.
“There has been a definite increase in patients coming back from Turkey with complications and they can sometimes be very, very serious and even fatal,” he said. “I understand when the service isn’t available in Northern Ireland that people are going to go where they feel they can get that service, but it is the health professionals here who pick up the pieces when things go wrong.
“There is a public health message here about being careful over travelling to different types of countries for these types of surgeries.”
A Department of Health spokeswoman said: “The Department will shortly be recommencing developing proposals for an obesity management service.
“The timescales of work resuming will be dependent on the response required to stabilise elective care and support unscheduled care. Anyone considering travelling abroad for medical treatment should ensure they fully understand the risks involved, including the side effects of treatment and aftercare requirements.”
