Case Presentation: A 36 year old female presented to our hospital with septic shock following an elective laparoscopic sleeve gastrectomy performed in Mexico. She had undergone the procedure four months earlier, which she tolerated well, returning to her home in the United States four days later. Her post-operative course had been characterized by numerous complications, and this was to be her third hospitalization. She initially was hospitalized one week following her return with left upper quadrant pain for which she was treated with IV antibiotics, with improvement. She then re-presented while still on antibiotics one week later and was found to have a leak at the gastric sleeve anastomosis with a 5×5 cm abscess in her LUQ. She underwent upper endoscopy for stent placement and was discharged on IV antibiotic and antifungal therapy. At the time of her current presentation, she met criteria for septic shock with fever of 40.2, WBC 19.2, tachycardia and hypotension and she was admitted to the critical care unit where she was initiated on IV antibiotics and pressor support. Imaging showed interval progression of the known abscess with concern for trans-diaphramatic fistula, requiring several interventional procedures for abscess drainage and anastomosis closure. In addition, due to her multiple prolonged hospitalizations, recurrent infections, continued gastric leak, and severe nausea, she was maintained on total parenteral nutrition for several weeks, ultimately requiring a percutaneous endoscopic jejunostomy tube for enteral feeding. As of this writing, she has now been hospitalized for over 40 days over three separate admissions since her sleeve gastrectomy with ongoing need for antibiotics as well as future need for endoscopic device retrieval as well as need for re-initiation of oral feeding.
Discussion: It is currently estimated that 15 million Americans seek healthcare outside of the United States, but very little is known about patient outcomes following their overseas care. This case illustrates an example of an otherwise healthy young woman whose bariatric surgery performed abroad was complicated by anastomotic leak and subsequent abscess formation, diaphragmatic fistula and septic shock requiring prolonged hospitalization. As the medical tourism market continues to broaden, home nations are expected to see an increase in post-treatment complications, but due to the complex and varied treatments and medical expertise available to patients abroad, as well as relative lack of post-operative care, patient outcomes from medical tourism remain an under-reported and in need of further study.
Conclusions: Patients who are considering seeking surgical procedures abroad should be counseled regarding lack of data regarding patient outcomes as well as potential for prolonged hospitalizations and increased costs due to post-operative complications. Furthermore, while several reviews have attempted to analyze the known data regarding patients who seek medical care abroad, the literature overwhelmingly reveals that this is a large and growing industry with very little known about its implications for patient care, and it remains in need of further research and study.