Unintended Souvenirs: Case Report of a Retained Foreign Body During Cosmetic Surgery Tourism

Abstract

 

Medical tourism has grown exponentially, spurred by incentives such as cost reductions, minimal wait times, and the allure of recuperative vacations. However, this trend carries substantial risks, as illustrated by the case of a 52-year-old female patient who underwent an abdominoplasty as part of a medical tourism package in Miami, FL, which resulted in a retained foreign body. The case highlights the broader issues of continuity of care, patient safety, and the legal and ethical ramifications faced by patients opting for medical tourism surgical procedures domestically and abroad. It also emphasizes the need for updated standards from professional societies and international cooperation to safeguard patient well-being in the expanding medical tourism sector. Lastly, it underscores the need for physicians and surgeons who manage these complications at home to recognize that prompt management and intervention are critical to avoid the escalation of complications and the increased risk of morbidity and mortality.

Level of Evidence: 5 (Therapeutic)

Medical tourism, defined as domestic or international travel for medical procedures, has become a major global industry. The global medical tourism market has been valued at ∼$50 billion in 2022, with an anticipated annual growth rate of 25% over the next decade, illustrating its increasing economic impact.¹ This is particularly prevalent in elective surgeries such as plastic surgery, orthopedic surgery, and dental procedures. Countries like India, Thailand, Brazil, and Mexico have emerged as popular destinations because of their combination of reduced wait times, enhanced privacy, the allure of cost savings (often offering medical services at a fraction of the cost seen in the United States or Western Europe), and the appeal of combining medical procedures with leisure travel.²

Despite its potential advantages, medical tourism has significant risks. Potential risks include issues related to the quality and accreditation of medical facilities and personnel, linguistic and cultural barriers, legal and ethical implications, and, particularly, the continuity and standard of postoperative care. Among the gravest concerns is the risk of postoperative complications.

We highlight these concerns through the lens of a particularly illustrative case: a 52-year-old female patient who experienced the retention of a surgical sponge postabdominoplasty, a severe and preventable complication. This case exemplifies the risks inherent in medical tourism, especially in the context of follow-up care and surgical accountability. Furthermore, we aim to shed light on the multidimensional challenges of medical tourism, emphasizing the need for comprehensive pretravel risk assessments, informed decision-making, and postoperative management of these complications by local surgeons after the patient returns home.

CASE PRESENTATION

A 52-year-old obese female with a BMI of 44.8 who underwent an elective primary extended lipoabdominoplasty and umbilical hernia repair in Miami, FL. She had not had any previous plastic surgery procedures on her abdomen but did have a remote history of laparoscopic abdominal surgery. The patient was cared for by a board-certified plastic surgeon; however, he did not undergo fellowship training through The Aesthetic Society. Furthermore, there was no information provided regarding the accreditation of the facility where the procedure was performed. The patient was discharged with 3 surgical drains in place but without a scheduled in-person postoperative follow-up and returned home to Illinois on postoperative Day 6. She had been experiencing severe abdominal pain since the surgery, prompting a refill of pain medications in Miami before returning home. By the seventh postoperative day, her abdominal pain continued to increase and was now accompanied by a fever of up to 102°F and purulent discharge from the left surgical drain.

Upon presenting to the local emergency department, the patient was found to be hypotensive and tachycardic. A computed tomography (CT) scan of the abdomen and pelvis revealed a rim-enhancing radiopaque fluid collection and foreign body along the left flank (Videos 1 and 2). Given these findings, the plastic surgery team was consulted, and the patient was urgently taken to the operating room to explore the left flank.

The patient was positioned in the lateral decubitus position (Figure 1). The left flank was incised, revealing a foul-smelling surgical sponge (Figures 2, 3). The presence of the foreign body had led to an abscess formation, requiring thorough irrigation. Subsequently, the remainder of the abdominal incision was opened to confirm that no additional objects were retained.

Figure 1.

Demonstration of the patient (a 52-year-old female) in the lateral decubitus position, with an obvious enlargement present over the left flank and purulent drainage from the incision line.

Figure 2.

Immediate exposure of the retained laparotomy sponge after opening of the surgical incision.

Figure 3.

The laparotomy sponge that was recovered from the patient. The sponge was foul-smelling and covered in purulent drainage.

After the removal of the surgical sponge, the patient was admitted for 5 days because of persistent pain, completion of antibiotics, and to work with physical therapy. After discharge, the patient received routine follow-up care in the clinic. Despite the resolution of the initial infection, the patient continues to suffer from chronic pain, impacting her quality of life. She underwent multiple postoperative CT scans to determine whether there was any residual cause for her pain; however, these were negative. She has worked with physical therapy in an attempt to improve her discomfort and continues to take over-the-counter pain medication daily.

DISCUSSION

The burgeoning phenomenon of medical tourism has emerged as a double-edged sword in global healthcare. Attracted by lower costs, shorter wait times, and the appeal of combining recuperation with vacation, more patients are traveling across state lines and international borders to undergo medical procedures. In the United States, states like Florida have become notable destinations for medical tourism, attributed to their lenient regulations allowing any physician to perform procedures with merely patient consent, regardless of specific training or experience in plastic surgery.³

However, this growing trend is not without risk, as underscored by our patient who suffered from a retained surgical sponge following an abdominoplasty procedure—a stark reminder of the potential dangers associated with medical tourism. This incident highlights several critical issues related to medical travel for surgery: inadequate postoperative care, the risk of serious complications, and the challenges surrounding the continuity of care upon the patient's return home.

Complication Rates

Based on data collected from a recent systematic review by McAuliffe et al, more than half of patients who undergo a plastic surgery medical tourism procedure experience at least 1 complication, the most common being infection (50.9%).⁴ Furthermore, these infections can be atypical, such as Mycobacterium, because of improper sterilization techniques and contaminated water, leading to delays in diagnosis, critically ill patient presentations, and infections that are resistant to treatment.⁵ Wound dehiscence, seroma, and chronic pain are additional complications that also occur in at least 30% of patients.⁴ More terrifying is the occurrence of severe and preventable complications such as perforated bowel in patients undergoing liposuction, retained foreign bodies or unwanted implants, pulmonary or fat emboli, or even death.^4,6 However, these percentages may be an underestimation as the total number of patients who undergo medical tourism procedures yearly is not precisely known. Nevertheless, over 1.3 billion dollars are spent annually in the United States to treat the complications that arise from medical tourism.⁷

Retained Foreign Bodies

Retained surgical items (RSIs), including sponges and instruments, are considered a “never event” in healthcare, a preventable complication with significant implications for patient safety and healthcare costs.^8,9 Our case underlines the grave consequences of such oversights, particularly in the context of cosmetic surgery abroad. However, given the lack of federal regulatory oversight, it is unsurprising that this complication occurs more frequently in medical tourism cases, with a rate as high as 5%.¹⁰ The subsequent impact is profound, leading to additional surgeries, prolonged hospital stays, and, in some instances, permanent harm or fatal outcomes.¹⁰ Furthermore, this estimated rate of retained foreign bodies may be underestimated given that the prevalence of RSIs as a complication of medical tourism is not well-documented, reflecting a broader issue of underreporting and a lack of centralized data collection.

Inadequate Postoperative Follow-Up

The lack of a postoperative follow-up visit with the operating surgeon significantly compromises a patient's care. Postoperative follow-up is crucial for ensuring a patient is healing correctly, allowing them to ask questions about their operation, and promptly identifying and managing complications. However, in medical tourism, logistical constraints often prevent adequate postoperative care. On average, patients return to their home state or country within a week of surgery, making attending follow-up visits with the operating surgeon impractical.¹¹ The current literature suggests that only 60% of medical tourists report having postoperative appointments, underscoring a critical care gap.^6,12 Although complications do happen even in the most prestigious and experienced practices, the ability to manage these complications with long-term follow-up is the critical differentiating factor from patients who undergo surgery through medical tourism.

Ethical and Legal Considerations

Medical tourism also raises significant ethical and legal questions. Patients may face considerable challenges in seeking recourse for unsatisfactory outcomes or complications because of the complex legal landscapes governing medical malpractice across jurisdictions. The difficulties in pursuing litigation against international surgeons and the unclear legal standing of medical referral agencies create a precarious situation for aggrieved patients.¹³ Moreover, the ethical implications extend beyond individual patient outcomes, encompassing concerns about the equitable distribution of healthcare resources, the exploitation of medical staff in host countries, and the potential for healthcare disparities.

It is critical to recognize, however, that just because a patient travels either internationally or domestically to have surgery does not always imply, they received suboptimal or unethical care. Many patients seek experts in other countries with the desire for a specific surgical outcome. Regardless of location, ethical surgeons work to mitigate patient risks, reduce surgical complications, and directly manage postoperative care. It is crucial to differentiate care from ethical surgeons performed abroad from medical tourism, which exploits patients.

Local Challenges in Managing Complications Postmedical Tourism

Managing postoperative complications in patients returning from medical tourism presents a growing, multifaceted challenge for local healthcare providers. An American Society of Plastic Surgeons (ASPS) survey study by Melendez and Alizadeh reported that 80.4% of plastic surgeon respondents had experience treating cosmetic surgery tourism patients.¹⁴ Physicians are often confronted with a lack of a comprehensive medical history and inadequate documentation, complicating the diagnostic process and subsequent management strategies.¹⁵ The absence of standardization in surgical practices across borders further exacerbates the difficulty in assessing and addressing postoperative complications, leading to delays in treatment and increased healthcare costs, ranging from $6000 to $26,000 for the treating hospital system.¹⁶ Moreover, the ethical dilemma home country physicians face, who must navigate the patient's compromised health status without previous involvement in the surgical decision-making process, adds another layer of complexity.

Improving Patient Safety in Medical Tourism

At this time, The Aesthetic Society, International Society of Aesthetic Plastic Surgery, and ASPS have provided guidelines, along with a patient safety checklist, to attempt to maximize patient safety for those who seek medical tourism opportunities. However, there is an urgent need to establish federally mandated international protocols for postoperative care and communication, as well as a requirement for pretravel consultations to ensure patients are fully informed of the potential risks and complications, given that informed consent has been reported in only 50% of medical tourism patients.¹¹ Addressing these challenges requires a collaborative approach, integrating ethical practice, patient education, and international healthcare policy to mitigate the risks associated with medical tourism and enhance patient safety. One avenue to improve the visibility of these dangerous practices is at national meetings, where cases such as this can be presented and discussed among the leaders of aesthetic surgery, to not only highlight that dangerous complications in medical tourism do occur but also provide a venue to create protocols for their management.

Furthermore, establishing a global reporting database for medical tourism complications could facilitate better understanding and management of associated risks. This would aid in patient decision-making and help healthcare providers in destination countries uphold high standards of care.

CONCLUSIONS

The case presented underscores the urgent need for comprehensive patient education, regulated oversight, and improved continuity of care to address the complexities and risks of medical tourism in plastic surgery. As the industry continues to grow, the medical community must prioritize patient safety and work collaboratively across borders to ensure that medical tourism does not compromise the quality of care.

By learning from cases like the one discussed, healthcare providers can better prepare to manage the complications associated with medical tourism. In conclusion, although medical tourism offers opportunities for patients, it also poses significant risks that require coordinated efforts to mitigate. The medical community's commitment to patient education, ethical practice, and international collaboration will be pivotal in shaping the future of safe and ethical medical tourism.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article, including payment of the article processing charge.