First-World Care at Third-World Rates: Pakistan, an Attractive Destination for Bariatric Tourism.

Introduction Obesity, a complex and multifactorial disease, is defined by a body mass index (BMI) greater than 30 kg/m². When the BMI exceeds 40 kg/m², it is classified as morbid obesity. This condition leads to excessive fat accumulation, which impairs normal body function and metabolism. For individuals grappling with morbid obesity and those who have faced significant hurdles in their quest for substantial weight loss, bariatric surgery emerges as a vital option. Purpose The study aims to explore the dynamics of bariatric surgical tourism in Pakistan, shedding light on factors influencing the choice of Pakistan as a destination for bariatric tourism. Materials and methods A retrospective cross-sectional study design was adopted. Data were gathered from the medical records database, including all patients who had undergone bariatric surgery from 2018 until 2022. The data collection process involved comprehensive patient outreach, where investigators conducted phone interviews and collected patient satisfaction assessments. During these phone interviews, valuable information was gathered by posing questions. These inquiries encompassed various aspects, including the patient's overall satisfaction with the surgical experience, their countries of origin, the specific bariatric procedures they underwent, the motivating factors behind their decision to travel abroad for surgery, their postoperative follow-up routines, and any complications they may have encountered. Results One hundred and nine patients traveled to Pakistan for bariatric surgery from 2018 to 2022. Out of 109 patients, 78 responded to the questionnaire by phone or email. The proforma was filled by 41 (52.5%) males and 37 (47.5%) females. Forty-seven (60.2%) of these patients underwent Roux-en-Y gastric bypass and 31 (39.8%) patients underwent sleeve gastrectomy. Out of 78 bariatric patients, 72 (92.3%) were satisfied with their surgery, five patients (6.4%) were neutral in their response and one patient (1.3%) was dissatisfied with the surgery. Most of the patients (26, 33.3%) declared money as the main driving force for traveling, with long waiting times being the close second reason (19, 24.36%) patients. Conclusion At least 2% of worldwide bariatric procedures are provided for medical tourists. Countries such as Mexico, India, Lebanon, and Romania dominate as providers for patients mainly from the USA, UK, and Germany. The lack of affordable bariatric healthcare and long waiting lists are some of the reasons for patients choosing bariatric tourism. The 92.3% satisfaction rate of patients with the surgery and its outcomes is a significant finding, as it suggests that bariatric surgery services provided in Pakistan are meeting or exceeding the expectations of international patients. The exceptionally high level of patient satisfaction speaks to the quality of care provided by the medical institutions in Pakistan. The data and analysis presented in this study shed light on the motivations and experiences of international patients traveling to Pakistan for bariatric surgery. These insights are invaluable for healthcare providers, policymakers, and the medical tourism industry as they seek to enhance the accessibility, affordability, and quality of healthcare services for domestic and international patients.

Effects of Restrictive Bariatric Surgery on Congenital Prader-Willi Syndrome: A Case Report.

Hyperphagia leading to obesity is the most common cause of mortality and morbidity in Prader-Willi syndrome (PWS). It has been classified as the most common genetic cause of the development of life-threatening obesity resulting from a defect in satiety, with an onset during early childhood. Abnormalities in the feedback from gut peptides, including ghrelin, may contribute to the satiety defect; autonomic dysfunction may also play a role in impaired satiety. Usually, pharmacological treatment is ineffective in managing obesity in these patients. A 19-year-old male child with Prader-Willi syndrome presented with morbid obesity, obstructive sleep apnea, and impaired glycemic control. The patient had complained of hyperphagia since early childhood, but food intake increased aggressively in the last few years, which resulted in morbid obesity. The patient was treated with laparoscopic sleeve gastrectomy, and the residual stomach volume was 100 ml. The intervention resulted in a 37.1% weight reduction after one year of surgery with well-controlled blood sugar levels. The patient also reported improved overall quality of life, mood, and functionality. Laparoscopic sleeve gastrectomy can be offered to obese Prader-Willi syndrome patients with heightened mortality, particularly because no other effective alternative therapy is available.

Decrease in Sperm Count After Bariatric Surgery: Case Reports.

Morbid obesity is associated with a large number of complications, including infertility; weight loss can help to improve fertility and increase the number of sperm in males. However, two of our patients developed azoospermia after bariatric surgery for weight reduction. A 30-year-old male presented to the outpatient department (OPD) with a BMI of 81.2 kg/m2 (258 kg) with no known co-morbidities. The patient had a normal sex life and one child. After bariatric surgery, he noticed a change in the consistency of his semen and azoospermia. In the second case, a 48-year-old man presented to the OPD with a BMI of 52 kg/m2 (189 kg) with no known co-morbidities. He had three children. He underwent bariatric surgery for weight loss and, after one year, he developed azoospermia. Bariatric surgery is a lifesaving procedure for morbidly obese patients and helps in restoring normal daily activities. This weight reduction surgery helps in decreasing blood pressure, increasing glycemic control and improving sexual activity. However, bariatric surgery may be followed by a further decline in semen parameters, resulting in azoospermia and severe oligoasthenoteratozoospermia. This is caused by the combined effects of two different processes: 1) the subduing of the negative effects of obesity, and 2) a deficiency of nutrients along with the release of some harmful substances. Bariatric surgery patients should be informed about the risk of complications and about the possibility for cryopreservation of sperm. In rare cases, bariatric surgery can result in a decrease in sperm count and infertility in males.

Laparoscopic Sleeve Gastrectomy versus Lifestyle Modification in Class I Obesity in Pakistani Population: A Prospective Cohort Study.

Introduction The American Society of Metabolic and Bariatric Surgery has stated that bariatric surgery is indicated in Class I obesity patients with one or more comorbidities. However, other weight loss options, such as diet plus exercise, are available to patients with a body mass index (BMI) ranging from 30 to 35 kg/m2. This study aimed to prospectively compare the results of Class I obesity patients undergoing laparoscopic sleeve gastrectomy (LSG) or using a weight control program (WCP). Methods A prospective analysis was conducted of patients with Class I obesity and comorbid diabetes and hypertension, with follow-ups at 6, 12, and 18 months. Subjects were divided into two groups: the LSG group of patients who had undergone LSG, and the WCP group who adhered to a WCP. The percentage of excess BMI loss (%EBMIL) and comorbidity remission (diabetes mellitus and hypertension) were tracked with measurements of hemoglobin A1C (HBA1C) levels and systolic blood pressure. Self-esteem was also tracked using the Rosenberg Self-Esteem Scale (SES) at 0 and 18 months. The overall patient satisfaction score was calculated using a visual analogue scale. Results Of the 150 patients enrolled in the study, 106 were included in the LSG group, and 103 were included in the WCP group. The reduction in HBA1C was more pronounced in the LSG group, and the differences between the two were statistically significant after 6, 12, and 18 months (LSG 5.6 ± 0.47 vs. WCP 6.5 ± 0.64, CI 1.04-0.73, P < 0.05). At 12 and 18 months, there were statistically significant reductions in systolic blood pressure after LSG (LSG 134.2 ± 7.16 vs. WCP 145.63 ± 5.94, CI 13.2-9.6, P < 0.05). Self-esteem levels measured by the Rosenberg SES increased for all participants, while patient satisfaction score was higher in the LSG group than that in the WCP group (P < 0.05). The %EBMIL at 6 months in the LSG group was 35.48%, compared to the WCP group at only 7.23%. At 12 months, the %EBMIL had increased twofold in the LSG group, at 68.19%, compared to 14.53% in the WCP group. At the final 18-month follow-up, the %EBMIL in the LSG group was 99.60% but was only 25.70% in the WCP group (P < 0.05). Conclusion Our study elucidates a clear superiority of LSG over any structured WCP with regard to weight reduction, improvement in glycemic control, and reduction in blood pressure in Class I obesity patients. Additionally, patients having LSG reported markedly improved self-esteem and satisfaction when compared with those who undertook a WCP.

Laparoscopic Sleeve Gastrectomy: To Suture or not to Suture Staple Line?

Objective To assess the outcome and safety of staple line over-sewing for patients undergoing laparoscopic sleeve gastrectomy (LSG). Study design and location Retrospective descriptive analysis conducted at Shifa International Hospital Islamabad. Materials and methods Consecutive patients undergoing LSG as a treatment for morbid obesity from October 2013 to December 2016 were included in the study after approval from the ethical review board. Patients were divided into two groups: group A who underwent reinforcement using Vicryl 2.0 and group B where no reinforcement was done. Results A total of 225 patients underwent LSG between October 2013 and December 2016, including 147 females (65.4%) and 78 males (34.6%). Both groups were comparable in terms of age, body mass index (BMI) and gender distribution (p-value more than 0.05). There was one leak in group A (1.36%), none in group B. The bleeding rate was 4.3% in group A and 2.7% in group B. Conclusion This was a retrospective analysis of all the patients who underwent LSG, and it was observed that there was no added benefit of sewing the staple line in terms of rate of bleeding and leak.

Early Laparoscopic Sleeve Gastrectomy Outcomes in Terms of Weight Loss.

OBJECTIVE: To investigate the outcomes of laparoscopic sleeve gastrectomy (LSG) in terms of weight loss. STUDY DESIGN: Descriptive cohort study. PLACE AND DURATION OF STUDY: Department of Surgery, Shifa International Hospital, Islamabad, from January 2009 to January 2015. METHODOLOGY: A total of 100 consecutive patients were included in the study through retrospective chart review. A5-port technique was utilized with the gastric sleeve being created using endostapler. Postoperatively, patients gradually progressed from clear liquid diet and oral rehydration salts to nutritional supplements over three days. By two weeks postoperatively, patients had progressed to a solid diet. SPSS was used for data entry and analysis. Body mass index (BMI) and weight in kg were determined. RESULTS: From 100 patients, 17 were lost to follow-up less than a week into the postoperative period. Of the remaining, average age of the patients was 34.7 ±11.3 years at the time of surgery. The majority of patients were females (72%). Mean preoperative and postoperative BMI was 45.3 ±10.4 kg/m2 and 35.0 ±10 kg/m2, respectively. Of the 83 patients, 62 were followed-up for longer than 1 month (average 419 days). For patients in this category, mean reduction in BMI was 10.3 ±6.5 kg/m2 with average weight loss of 34.3 ±18.2 kg. There were no mortalities associated with LSG. CONCLUSION: Laparoscopic sleeve gastrectomy is a safe and effective intervention in young Pakistani females with encouraging outcomes at a mean follow-up of over one year.

Outcome of laparoscopic cholecystectomy for gallstones disease in patients with liver cirrhosis.

BACKGROUND: Laparoscopic cholecystectomy (LC), a gold standard procedure for cholelithiasis, is associated with higher incidence of bile duct injuries and perioperative bleeding. These complications are of further concern when LC is carried out on patients with liver cirrhosis. Although LC is now increasingly being performed for cholelithiasis in cirrhotic patients, the safety of the procedure is debatable in this group of patients. METHODS: We retrospectively analysed 82 LCs, performed between January 2002 and December 2011. in cirrhotic patients with gall stone disease for perioperative complications. Patients were sub-classified into Class A, B and C based on child-Pugh classification of severity of liver cirrhosis. Intergroup comparisons were carried out using ANOVA, and p < or = 0.05 was considered significant. RESULTS: LC was successfully completed in all but 3 patients (3.7%). None of the cirrhotic patients had bile duct injury. Class C patients (n = 27) had higher frequency of perioperative bleeding than Class B and A (p = 0.03). Class C patients had comparatively longer stay (5.42 days: range 4-8 days) than Class B (3 days; range 2-6) and Class A (2.74 days; range 2-4), (p = 0.01). There was no mortality in our series. CONCLUSION: The outcome in Child A and B cirrhosis is comparable to noncirrhotic patients undergoing LC for gall stone disease. Conversion rate and perioperative bleeding in these groups of patients is acceptable in relevance to LC in non-cirrhotic patients. Child C patients however need careful assessment and determination of operative risk versus advantages.