100% sugar-free!


I am currently on assignment in Massachusetts – and we’ve had our share of snow in the last few weeks.  It certainly makes me long for Latin America..

on assignment in the northeast

on assignment in the northeast

But while I may be in the northeast for the next several weeks, it doesn’t mean that I am hiding under a rock – so I continue to talk / read/ and research issues in medical tourism.

One of the newest reports comes out of the United Kingdom.  The UK has embraced medical tourism to a greater degree that Americans have, and UK researchers are some of the forerunners in the field.  (There are multiple reasons for the ready adoption of medical tourism by large numbers of British citizens but that’s a different topic entirely.)

No candy coating!

No candy coating!

The latest news from the Yorkshire Post is a timely and necessary reminder for all potential medical tourists and facilitators out there.  The article discusses the recently published paper, entitled, “The three myths of medical tourism” as well as interviews with medical tourists.

Research into the medical tourism industry

The paper is based on results of a study conducted at York University.  Researchers at  York University have an ongoing medical tourism project looking at multiple aspects of medical tourism including financial/ economic, as well as quality and continuity of care issues.

Much of what the researchers at York are studying are topics we have discussed previously on our site:

Quality Control

– the lack of standardized guidelines for ensuring quality of care (and continuity of care from the moment the patient leaves home until recovery)

– the lack of accountability for facilitators/ tour operators/ medical tourism companies for patient safety and outcomes  (this means that companies can send you to the cheapest surgeon)

– the lack of recourse for patients who experience complications/ serious injury or inadequate care.  (It’s a black hole for medical malpractice at present).

– The potential financial costs of complications:  While some surgeons require their patients to purchase ‘complication insurance’ to cover treatment of complications (if they occur) in the home country, there is no universal requirement.

Papers in-press

Unfortunately, much of this work (by Lunt & Smith) is currently in-press.  I’m anxious to see their reports but I am also wondering what sort of regional differences may exist.  Medical tourism by British residents is often to neighboring areas of Europe, Eastern Europe, India and Israel.  I’d be fascinated to see how that compares with outcomes and experiences for medical travelers to Latin America, and different South American countries in particular.

In any case – it’s a timely report.  Hard scientific information is dearly needed since the majority of data over the last decade has been anecdotal in nature or statistical “projections/ estimates / guesstimates”.

Hard data is particularly important when it comes to allegations regarding poor post-operative care/ and increased incidence of infections (specifically in medical tourists from the UK who traveled to India).  Many of these complaints arise from local plastic surgeons and may have little supporting data.  If there is a problem, we need actual numbers, not case reports (particularly if we are dealing with antibiotic resistant infections).

The industry has also been plagued with numerous biases on both sides..  – Biases towards the perception that all overseas medical care is cheaper (not always the case)

and/or that cheaper = inferior

Quantitative data would also be helpful when discussing patient satisfaction and quality of care.  Most of the time, statistics are bandied about from the Deloitte Institute – but I want to hear what patients think from other sources.  How did patients rate their experiences in Britain?  In California?  Where were the patients going?  What countries?  What clinics were mentioned repeatedly?

Other issues – Patients poorly informed

Researchers also found that medical travelers were poorly informed or ignorant of the risks involved with medical tourism.

In some cases, patients were ‘willfully ignorant‘ and relied on social media and friends for all of their health information.  A subset of these patients also traveled for unproven/ unregulated medical treatments (such as bovine stem cell injections).

Many patients were ignorant of the risks or potential complications of the surgical procedures themselves (lap-band was specifically cited numerous times) as well as the problems that arise when your surgeon is thousands of miles away.

Patients were also unaware/ poorly informed about the financial implications of developing/ treating complications in their home country – (or the costs involved if they needed to return to their surgeon).  Some of the financial issues mentioned in this (and previous data I’ve encountered) is more specific to British residents with their National Health Services and it’s reimbursement structure.

However, it’s not unimaginable to picture similar circumstances for uninsured medical tourists, or tourists seeking aftercare at an “out-of-network” facility once they returned to the USA.

Ignorance of health care information – an ethical/ safety issue

Some of this ignorance may be directly attributed to the way that many medical tourism companies operate – with patients being funnelled overseas thru a “facilitator” versus referring physicians and nurses.  During a recent conference on medical tourism, I was astounded when a prominent American medical facilitator brushed aside my concerns about the lack of medically trained personnel, stating, “I’ve been a paralegal for 22 years in a malpractice office – I know all that anyone needs to know about surgery.”

But what about the ‘caregiver’?

Facilitators and medical tourism companies often tout the use of ‘caregivers’.  This  terminology is misleading in my opinion.

Since “doctor”, “registered nurse”, and other healthcare personnel are professions that require certification and educational degrees – companies often label their assistants ‘caregivers’ since it’s illegal to use the title of nurse.   In reality, the term ‘caregiver’ is more akin to ‘paid companion’.  These individuals have no medical or nursing training and may actually be a source of misinformation (as this paper states.)*

In the usual course of surgery – as part of the pre-operative process, patients receive information, education and instructions during their initial consultation/ and pre-operative visits.  This also gives patients a chance to ask questions, in-person to a medically knowledgeable person.  Skype, and email just can’t replace this critical component.

Many times, critical information is obtained (and given) by the surgical team during the physical examination and history-taking on the initial consultation.    If the referring service is a layperson, and the initial (in-person) consultation  takes place after the patient arrives in the destination country, these crucial education opportunities are lost.

Call for Regulation for patient safety

As readers know, I believe that regulation is both necessary and desirable to improve/ promote and grow the medical tourism industry.  This regulation needs to be undertaken by knowledgeable people/ institutions outside of the industry.

Other research in medical tourism –

Simon Fraser University – British Columbia, Canada

*In a related aside, one of the more popular Canadian medical tourism facilitators uses her unemployed sister in the role of ‘caretaker’.  While the sister has no medical or nursing training, the facilitator bragged that it allows her to put her family on the payroll and bill the client for these services.

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Start here…


This is a page re-post to help some of my new readers become familiarized with Latin American Surgery.com – who I am, and what the website is about..

As my long-time readers know, the site just keeps growing and growing.  Now that we have merged with one of our sister sites, it’s becoming more and more complicated for first time readers to find what they are looking for..

So, start here, for a brief map of the site.  Think of it as Cliff Notes for Latin American surgery. com

Who am I/ what do I do/ and who pays for it

Let’s get down to brass tacks as they say .. Who am I and why should you bother reading another word..

I believe in full disclosure, so here’s my CV.

I think it’s important that this includes financial disclosure. (I am self-funded).

I’m not famous, and that’s a good thing.

Of course, I also think readers should know why I have embarked on this endeavor, which has taken me to Mexico, Colombia, Chile, Bolivia and continues to fuel much of my life.

Reasons to write about medical tourism: a cautionary tale

I also write a bit about my daily life, so that you can get to know me, and because I love to write about everything I see and experience whether surgery-related or the joys of Bogotá on a Sunday afternoon.

What I do and what I write about

I interview doctors to learn more about them.

Some of this is for patient safety: (Is he/she really a doctor?  What training do they have?)

Much of it is professional curiosity/ interest: (Tell me more about this technique you pioneered? / Tell me more about how you get such fantastic results?  or just tell me more about what you do?)

Then I follow them to the operating room to make sure EVERYTHING is the way it is supposed to be.  Is the facility clean?  Does the equipment work?  Is there appropriate personnel?  Do the follow ‘standard operating procedure’ according to international regulations and standards for operating room safety, prevention of infection and  overall good patient care?

I talk about checklists – a lot..

The surgical apgar score

I look at the quality of anesthesia – and apply standardized measures to evaluate it.

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

I also write about new technologies, and treatments as well as emerging research.  There is some patient education on common health conditions (primarily cardiothoracic and diabetes since that’s my background).  Sometimes I talk about the ethics of medicine as well.  I believe strongly in honesty, integrity and transparency and I think these are important values for anyone in healthcare.  I don’t interview or encourage transplant tourism because I think it is intrinsically morally and ethically wrong.  You don’t have to agree, but you won’t find information about how to find a black market kidney here on my site.

What about hospital scores, you ask.. Just look here – or in the quality measures section.

Cultural Content

I also write about the culture, cuisine and the people in the locations I visit.  These posts tend to be more informal, but I think it’s important for people to get to know these parts of Latin America too.  It’s not just the doctors and the hospitals – but a different city, country and culture than many of my readers are used to.

Why should you read this?  well, that’s up to you.. But mainly, because I want you to know that there is someone out there who is doing their best – little by little to try to look out for you.

How the site is organized

See the sidebar! Check the drop-down box.

Information about surgeons is divided into specialty and by location.  So you can look in plastic surgery, or you can jump to the country of interest.  Some of the listings are very brief – when I am working on a book – I just blog about who I saw and where I was, because the in-depth material is covered in the book.

information about countries can be found under country tabs including cultural posts.

Issues and discussions about the medical tourism industry, medical safety and quality are under quality measures

Topics of particular interest like HIPEC have their own section.

I’ve tried to cross-reference as much as possible to make information easy to find.

If you have suggestions, questions or comments, you are always welcome to contact me at k.eckland@gmail.com or by leaving a comment, but please, please – no hate mail or spam.  (Not sure which is worse.)

and yes – I type fast, and often when I am tired so sometimes you will find grammatical errors, typos and misspelled words (despite spell-check) but bear with me.  The information is still correct..

Thank you for coming.

Talking with Dr. Gustavo Gaspar Blanco, plastic surgeon


Dr. Gustavo Gaspar Blanco, plastic surgeon

Gaspar 083

Dr. Gustavo Gaspar Blanco is a plastic surgeon in Mexicali (Baja California) Mexico.  He is well-known throughout Baja and Northern Mexico for his gluteal augmentation techniques using gluteal implants.  While this is one of the procedures he is most famous for, he also performs the complete range of body, facial plastic surgery procedures, and post-bariatric reconstructive surgery.

It was an engaging series of interviews as Dr. Gaspar is extremely knowledgeable and passionate about his craft.  “Plastic surgery is different from other specialties, it is an art.  The surgeon needs to have an eye for beauty and symmetry in addition to surgical skill.”

To read more about Dr. Gaspar in the operating room.

Gluteal Implants versus Fat Grafting

There are multiple methods of gluteal augmentation (or buttock enhancement).  Dr. Gaspar performs both fat grafting and gluteal implantation procedures.  He prefers gluteal implantation for patients who are very thin (and have limited fat tissue available for grafting) or for patients who want longer-lasting, more noticeable enhancements.   (With all fat injection procedures, a portion of the fat is re-absorbed).

He recommends fat grafting procedures to patients who want a more subtle shaping, particularly as part of a body sculpting plan in conjunction to liposuction.

Breast Implants and attention to detail

Like most plastic surgeons, breast augmentation is one of the more popular procedures among his patients.  The vast majority of his patients receive silicone implants (by patient request), and Dr. Gaspar reports improved patient satisfaction with appearance and feel with silicone versus saline implants.  He uses Mentor and Natrelle brand implants, and is very familiar with these products.  In fact, he reports that he has visited the factories that create breast implants in Ireland and Costa Rica.  He says he visited these factories due to his own curiosity and questions about breast implants**.

Once he arrived, he found that each implant is made by a time-consuming one at a time process versus a vast assembly line as he had envisioned.  He was able to see the quality of the different types of implants during the manufacturing process.  These implants, which range from $800.00 to $1200.00 a piece, go through several stages of preparation before being completed and processed for shipping.  He also watched much of the testing process which he found very interesting in light of the history of controversy and concern over previous silicone implant leakage in the United States (during the 1960’s – 1970’s).

Gaspar 061

Another aspect of breast augmentation that Dr. Gaspar discusses during my visits is the breast implantation technique itself.  While there are several techniques, in general, he uses the over-the-muscle technique for the majority of breast implantation procedures.  He explains why, and demonstrates with one of his patients (who had the under-the-muscle technique with another surgeon, and now presents for revision).

“While the under-the-muscle technique remains very popular with many surgeons, the results are often less than optimal.  Due to the position of the muscle itself, and normal body movements (of the shoulders/ arms), this technique can cause unattractive rippling and dimpling of the breast.  In active women, it can actually displace the implant downward from pressure caused by normal muscle movements during daily activities.  This may permanently damage, displace or even rupture the implant.”

Instead, he reserves the under-the-muscle implant for specific cases, like post-mastectomy reconstruction.  In these patients (particularly after radiation to the chest), the skin around the original mastectomy incision is permanently weakened, so these patients need the additional support of the underlying muscle to prevent further skin damage.

Not just about outcomes

While his clients, from all over North America, are familiar with his plastic surgery results, few of them are aware of his deep commitment to maintaining the highest ethical and medical standards while pursing excellence in surgery.

Commitment to ethical care of patients crosses language barriers

While Dr. Gaspar is primarily Spanish-speaking, his commitment to ethical practice is crystal clear in any language.  He explains these ethical principles while offering general guidelines for patients that I will share here (the principles are his, the writing style is my own).

Advice for patients seeking plastic surgery

Be appropriate:

– Patients need to be appropriate candidates for surgery: 

Around fifty percent all of the people who walk into the office are not appropriate candidates for plastic surgery, for a variety of reasons.  Dr. Gaspar feels very strongly about this saying, “Unnecessary or inappropriate surgery is abusive.”

– Plastic surgery is not a weight-loss procedure.  Liposuction/ Abdominoplasty is not a weight loss procedure.  Plastic surgery can refine, but not remake the physique.  Obese or overweight patients should lose weight prior to considering refining techniques like abdominoplasty which can be used to remove excess or sagging skin after large-scale weight loss.

fat removed during liposuction procedure

fat removed during liposuction procedure

  – Have surgery for appropriate reasons.  Plastic surgery will not make someone love you.  It won’t fix troubled relationships, serious depression or illness.  Plastic surgery, when approached with realistic expectations (#3) can improve self-esteem and self-confidence.

Realistic expectations – just as plastic surgery won’t result in a 25 pound weight loss, or bring back a wayward spouse, it can’t turn back the clock completely, or radically remake someone’s appearance.  There is a limit to what procedures can do; for the majority people, no amount of surgery is going to make them into supermodels.

Know the limitations

Not only are there limits to what surgery itself can do, there are limits to the amounts of procedures that people should have, particularly during one session.  “Marathon/ Extreme Makeovers” make for exciting television but are a dangerous practice.

Stay Safe:

Just as patients should avoid marathon or multi-hour, multiple procedure surgeries, patients should stay safe.

–          Avoid office procedures

As Dr. Gaspar says, “The safest place for patients is in the operating room.” With the exception of Botox, all plastic surgery procedures should be performing the operating room, not the doctor’s office.  This is because the operating room is a sterile, well-prepared environment with adequate supplies and support staff.  There are monitors to help surgeons detect the development of potential problems, life-saving drugs and resuscitation (rescue) equipment on hand. Should a patient stop breathing, start bleeding or develop a life-threatening allergic reaction (among other things), the operating room (and operating room staff) are well prepared to take care of the patient.

Communicate with your surgeon –

Give your surgeon all the details s/he needs to keep you safe, and have a successful surgery.  Talk about more than the surgeries you are interested in –

– bring a list of all of your medications

– know a detailed history including all past medical problems/ conditions and surgeries.

If you had heart surgery ten years ago – that’s relevant, even if you feel fine now.  Have a history of previous blood transfusions/ radiation therapy/ medication reactions?  Be sure to tell the doctor all about it.

Even if you aren’t sure if it matters, “My sister had a blood clot after liposuction” – go ahead and mention it.. It might just be a critical piece of information such as a family predisposition to thromboembolism (like the example above).

Lastly

Surgical complications are a part of surgery.  All surgeons have them – and having a surgical complication in and of itself is no indication of the quality or skill of the surgeon.  Complications can occur for a variety of reasons.

However, how efficiently and effectively the surgeon treats that complication is a good indicator of skill, experience and expertise.

As part of this, Dr. Gaspar stresses that medical tourism patients need to prepare to stay until they have reached an adequate stage of recovery.  This prevents the development of complications and allows the surgeon to rapidly treat a problem if it develops; before it become more serious.

“There is no set time limit for my patients after surgery, everyone is different.  But none of my patients can go [return home] until I give my approval.”  This philosophy applies to more than just medical tourists from far off destinations. It also applies to any patients have large procedures and their hospitalizations.  While many surgeons race to discharge clients as same-day surgery patients, Dr. Gaspar has no hesitation in keeping a patient hospitalized if he has any concerns regarding their recovery. “Hospitals are the best places for my patients, if I am concerned about their recovery.”

About Dr. Gustavo Gaspar Blanco, MD

Plastic and reconstructive surgeon

Av. Madero 1290 y Calle E

Plaza de Espana, suite 17 (second floor)

Mexicali, B.C

Tele: (686) 552 – 9266

If calling from the USA: 1 (877) 268 4868

Email: gustavo@drgaspar.com

Dr. Gaspar attended medical school at the Universidad Autonoma de Guadalajara.  He completed both his general surgery residency and plastic surgery fellowship in Mexico City at the Hospital de Especialidades Centro Medico La Raza.

He is a board certified plastic surgeon by the Mexican Society of Plastic and Reconstructive Surgery, license number #601.  He has been performing plastic surgery for over 20 years.  Surgeons from areas all over Mexico train with Dr. Gaspar to learn his gluteal implantation techniques.

** He has also visited the facilities in Germany where the Botulism toxin is prepared for cosmetic/ and medical use.

Why quality of anesthesia matters: who is administering your anesthesia?


Now that Colombia Moda is over – let’s get back to the stuff that really matters.. Let’s warm up but reviewing some older posts for our newer readers.

Guide to Surgery in Latin America

I know some readers find some of my reporting dry and uninspired, particularly when talking about methodology, measurements and scales such as Surgical Apgar Scoring.  But the use of appropriate protocols, safety procedures and specialized personnel is crucial for continued patient safety.

There is a saying among medical professionals about our patients.. We want them all to be boring and routine.   That is what I strive for, for each and every one of my readers – safe, boring and routine.

Excitement and drama are only enjoyable when watching Grey’s Anatomy or other fictionalized medical dramas.  In real life, it means something has drastically and horribly gone awry.  Unlike many of its fictional counterparts – outcomes are not usually good.

In a not-so-sleepy hollow of upstate New York, a medical tragedy serves to illustrate this point, while also bringing up questions regarding the procedure.  While we don’t know the circumstances behind this case – (and don’t really want to…

View original post 1,047 more words

In the operating room with Dr. Luis Botero, plastic surgeon


Please note that some of the images in this article have been edited to preserve patient privacy.  

Today, Dr. Luis Botero has invited me to observe surgery at IQ Interquirofanos in the Poblado section of Medellin.  He is performing full-body liposuction and fat grafting of the buttocks.

Dr. Luis Botero, in the operating room

Dr. Luis Botero, in the operating room

The facility: IQ Interquirofanos

Interquirofanos is located on the second floor

Interquirofanos is located on the second floor

IQ Interquirofanos is an ambulatory surgery center located on the second floor of the Intermedica Building across the street from the Clinica de Medellin (sede Poblado).  The close proximity of this clinic to a hospital is an important consideration for patients in case of a medical emergency.

The anesthesiologists estimate that 90% of the procedures performed here are cosmetic surgeries but surgeons also perform gynecology, and some orthopedic procedures at this facility.

The are seven operating rooms that are well-lit, and feature modern and functional equipment including hemodynamic monitoring, anesthesia / ventilatory equipment/ medications.  There are crash carts available for the operating rooms and the patient recovery areas.

There are fourteen monitored recovery room beds, while the facility currently plans for expansion.  Next door, an additional three floors are being built along with six more operating rooms.

Sterile processing is located within the facility with several large sterilization units.  There is also a pharmacy on-site.  The pharmacy dispenses prosthetics such as breast implants in addition to medications.

The only breast prosthetics offered at this facility are Mentor (Johnson & Johnson) and Natrelle brand silicone implants (Allergan).  In light of the problems with PIP implants in the past – it is important for patients to ensure their implants are FDA approved, like Mentor implants.

In the past seven years, over 31,000 procedures have been performed at Interquirofanos.  The nurses tell me that during the week, there are usually 30 to 35 surgeries a day, and around 15 procedures on Saturdays.

Prior to heading to the Operating Room:

Prior to surgery, patients undergo a full consultation with Dr. Botero and further medical evaluation (as needed).  Patients are also instructed to avoid aspirin, ibuprofen and all antiplatets (clopidogrel, prasugrel, etc) and anti-coagulants (warfarin, dabigatran, etc.) for several days.  Patients should not resume these medications until approved by their surgeon.

Complication Insurance

All patients are required to purchase complication insurance.  This insurance costs between 75.00 and 120.00 dollars and covers the cost of any treatment needed (in the first 30 days) for post-operative complications for amounts ranging from 15,000 dollars to 30,000 dollars, depending on the policy.   All of his clients who undergo surgery at IQ Interquirofanos are encouraged to buy a policy from Pan American Life de Colombia as part of the policies for patient safety at this facility. International patients may also be interested in purchasing a policy from ISPAS, which covers any visits to an ISPAS-affiliated surgeon in their home country.

Today’s Procedures: Liposuction & Fat Grafting

Liposuction – Liposuction (lipoplasty or lipectomy) accounts for 50% of all plastic surgery procedures.   First the surgeon makes several very small slits in the skin.  Then a saline – lidocaine solution is infiltrated in to the fat (adipose) tissue that is to removed. This solution serves several purposes – the solution helps emulsify the fat for removal while the lidocaine-epinephrine additives help provide post-operative analgesic and limit intra-operative bleeding.  After the solution dwells (sits in the tissue) for ten to twenty minutes, the surgeon can begin the liposuction procedure.  For this procedure, instruments are introduced to the area beneath the skin and above the muscle layer.

During this procedure, the surgeon introduces different canulas (long hollow tubes).  These tubes are used to break up the adipose tissue and remove the fat using an attached suctioning canister.  To break up the fat, the surgeon uses a back and forth motion.  During this process – one hand is on the canula.  The other hand remains on the patient to guide the canulas and prevent inadvertent injury to the patient.

fat being removed by liposuction

fat being removed by liposuction

Due to the nature of this procedure, extensive bruising and swelling after this procedure is normal.  Swelling may last up to a month.  Patients will need to wear support garments (such as a girdle) after this procedure for several weeks.

Types of liposuction:

In recent years, surgeons have developed different techniques and specialized canulas to address specific purposes during surgery.

Standard liposuction canulas come in a variety of lengths and bore sizes (the bore size is the size of the hole at the end of the canister for the suction removal of fat tissue.)  Some of these canulas have serrated bores for easier fat removal.

Ultrasound-assisted liposuction uses the canulas  to deliver sound waves to help break up fat tissue.  These canulas are designed for patients who have had repeated liposuction.  This is needed to break up adhesions (scar tissue) that forms after the initial procedure during the healing process.

Laser liposuction is another type of liposuction aimed at specifically improving skin contraction.  This is important in older patients or in patients who have excessive loose skin due to recent weight loss or post-pregnancy.  However, for very large amounts of loose skin or poor skin tone in areas such as the abdomen, a larger procedure such as abdominoplasty may be needed.

During laser liposuction, a small wire laser is placed inside a canula to deliver a specific amount of heat energy to the area (around 40 degrees centrigrade).  The application of heat is believed to stimulate collagen production (for skin tightening).  Bleeding is reduced because of the cautery effect of the heat – but post-operative pain is increased due to increased inflammatory effects.  There is also a risk of burn trauma during this procedure.

There have been several other liposuction techniques that have gone in and out of fashion, and many of the variations mentioned are often referred to by trademark names such as “Vaser”, “SmartLipo”, “SlimLipo” which can be confusing for people seeking information on these procedures.

Fat Grafting

Fat from liposuction procedure to be used for buttock augmentation

Fat from liposuction procedure to be used for buttock augmentation

Fat grafting is a procedure used in combination with liposuction.  With this procedure, fat that was removed during liposuction is relocated to another area of the body such as the buttocks, hands or face.

In this patient, Dr. Botero injects the fat using a large bore needle deep into the gluteal muscles to prevent a sloppy, or dimpled appearance.  Injecting into the muscle tissue also helps to preserve the longevity of the procedure.  However, care must be taken to prevent fat embolism*, a rare but potentially fatal complication – where globules of fat enter the bloodstream.  To prevent this complication, Dr. Botero carefully confirms the placement of his needle in the muscle tissue before injecting.

Results are immediately appreciable.

fat being injected for buttock augmentation. (Photo edited for patient privacy).

fat being injected for buttock augmentation. (Photo edited for patient privacy).

The Surgery:

Patient was appropriately marked prior to the procedure.   The patient was correctly prepped, drapped and positioned to prevent injury or infection.  Ted hose and sequential stockings were applied to lessen the risk of developing deep vein thrombosis.  Pre-operative procedures were performed according to internationally recognized standards.

Sterility was maintained during the case.  Dr. Botero appeared knowledgeable and skilled regarding the techniques and procedures performed.

His instrumentadora (First assistant), Liliana Moreno was extremely knowledgeable and able to anticipate Dr. Botero’s needs.

Circulating nurse: Anais Perez maintained accurate and up-to-date intra-operative records during the case.  Ms. Perez was readily available to obtain instruments and supplies as needed.

Overall – the team worked well together and communicated effectively before, during and after the case.

Anesthesia was managed by Dr. Julio Arango.   He was using an anesthesia technique called “controlled hypotension”.  (Since readers have heard me rail about uncontrolled hypotension in the past – I will write another post on this topic soon.)

Controlled Hypotension

However, as the name inplies – controlled hypotension is a tightly regulated process, where blood pressure is lowered to a very specific range.  This range is just slightly lower than normal (Systolic BP of around 80) – and the anesthesiologist is in constant attendance.  This is very different from cases with profound hypotension which is ignored due to an anesthesia provider being distracted – or completely absent.

With hypotensive anesthesia – blood pressure is maintained with a MAP (or mean) of 50 – 60mmHg with a HR of 50 – 60.  This reduces the incidence of bleeding.

However, this technique is not safe for everyone.  Only young healthy patients are good candidates for this anesthesia technique.  Basically, if you have any stiffening of your arteries due to age (40+), smoking, cholesterol or family history – this technique is NOT for you.  People with high blood pressure, any degree of kidney disease, heart disease, peripheral vascular disease or diabetes are not good candidates for this type of anesthesia. People with these kinds of medical conditions do not tolerate even mild hypotension very well, and are at increased risk of serious complications such as renal injury/ failure or cardiovascular complications such as a heart attack or stroke.  Particularly since this is an elective procedure – this is something to discuss with your surgeon and anesthesiologist before surgery.

The patient today is young (low 20’s), physically fit, active with no medical conditions so this anesthesia poses little risk during this procedure. Also the surgery itself is fairly short – which is important.  Long/ marathon surgeries such as ‘mega-makeovers‘ are not ideal for this type of anesthesia.

Dr. Julio Arrango keeps a close eye on his patient

Dr. Julio Arango keeps a close eye on his patient

However, Dr. Arango does an excellent job during this procedure, which is performed under general anesthesia.   After intubating the patient, he maintained a close eye on vital signs and oxygenation.  The patient is hemodynamically stable with no desaturations or hypoxia during the case.  Dr. Arango remains alert and attentive during the case, and remains present for the entire surgery.  Following surgery, anesthesia was lightened, and the patient was extubated prior to transfer to the recovery room.

He also demonstrated excellent knowledge of international protocols regarding DVT/ Travel risk, WHO safety protocols and intra-operative management.

Surgical apgar score: 9  (however, there is a point lost due to MAP of 50 – 60 as discussed above).

Results of the surgery were cosmetically pleasing.

Post -operative care:

Prior to discharge from the ambulatory care center after recovery from anesthesia the patient (and family) receives discharge instructions from the  nurses.

The patient also receives prescriptions for several medications including:

1. Oral antibiotics for a five-day course**. Dr. Botero uses this duration for fat grafting cases only.

2. Non-narcotic analgesia (pain medications).

3. Lyrica ( a gabapentin-like compound) to prevent neuralgias during the healing period.

The patient will wear a support garment for several weeks.  She is to call Dr. Botero to report any problems such as unrelieved pain, drainage or fever.

Note: after some surgeries like abdominoplasty, patients also receive DVT prophylaxis with either Arixtra or enoxaparin (Lovenox).

Follow-up appointments:

Dr. Botero will see her for her first follow-up visit in two days (surgery was on a Saturday).  He will see twice a week the first week, and then weekly for three weeks (and additionally as needed.)

* Fat embolism is a risk with any liposuction procedure.

**This is contrary to American recommendations as per the National Surgical Care Improvement Project (SCIP) which recommends discontinuation within the first 24 hours to prevent the development of antibiotic resistance.

Dr. Ivan Santos

Just another reason for Latinamericansurgery.com


Dr. Ivan Santos

Colombian plastic surgeons operating

because you need someone who is objective (and informed) that is looking out for you, the patient..

In this article, at International Journal of Medical Travel, Kevin Pollard talks about the need for regulation of medical tourism in cosmetic surgery.  I wholeheartedly agree – in fact, Mr. Pollard and I conversed about this very topic in a series of emails last week.

After all – it is why I do what I do, and publish it here for my readers.  The industry does need to be regulated – medical tourism companies shouldn’t pick providers by “lowest bidder” and patients need to be protected (from unsanitary conditions, bad surgeons, and poor care).  But what form will this regulation take?

Will it be Joint Commission certification – which covers facilities and not the physicians (and their surgical practices themselves)?

Will it require facilities to pay a lot of money for a shiny badge?

Or will it be someone like me, low-key and independent, going into facilities at the behest of patients; interviewing surgeons and actually observing the process and talking to patients?

and who pays for this?  The beauty of what I do – is that I am independently (read: self) funded.  True, it hurts my wallet but I have no divided loyalties or outside interests in doing anything but reporting the unvarnished truth.

and ultimately – will this be done in a fair, open and honest way?  Or it is really a witch hunt led by disgruntled American and British plastic surgeons?  Will they bother to discriminate between excellent surgeons and incompetent ones who will it be by geography alone?

I guess we will just have to wait and see.

In the operating room with Dr. Meza at Hospital General de Medellin


Dr. Meza, closing the chest

Dr. Meza, closing the chest

I apologize for the wordiness of this post – but much of what we discuss below is covered in the Bogotá, Cartagena and Mexicali books – the essential mechanisms of cardiac surgery; how procedures work, what is off-pump surgery, when do we use the bypass pump and other explanatory information.  But since I have am not writing a full book on Medellin, I wanted to offer a bit of a primer for my new internet readers here.  

Dr. Luis Meza

Cardiac surgeon, Hospital General de Medellin

After interviewing Dr. Meza and meeting many of the staff at Hospital General de Medellin, it was a pleasure to be invited to observe Dr. Meza and Dr. Urequi , the head of the cardiac surgery department in the operating room. Despite the patient’s young age, the surgery (for me as an observer) was knuckle-biting.  While the surgery itself was a fast, straight-forward and uncomplicated repair of an interauricular septal defect – it was the patient’s fragile condition that had me on the edge of my seat.

Complex patients The case was typical of many of the cases they see at public hospitals.  It was a young patient with newly diagnosed right-sided heart failure due to an uncorrected congenital defect.  The patient had traveled from another part of Colombia (one of the poorer regions) to have surgery.  The patient had initially presented to a local doctor after a syncopal event (passing out) and was found to have an enlarged heart, with a moderate sized pericardial effusion (fluid in the sac around the heart.)  After arriving at HGM, the patient was also diagnosed with a serious acquired coagulopathy (bleeding disorder).

drawing courtesy of Wikipedia (Creative Commons licensing)

drawing courtesy of Wikipedia (Creative Commons licensing)

Since the patient had a hole between the left atrium leading into the right atrium, blood was being pushed from the left atrium (which is under higher pressure) to the low pressure right atrium.  Over the course of many years, this had caused the right atrium to enlarge massively.  As the right atrium was continuously being overfilled (from blood from the left side), the right side of the heart was being forced to work harder, and harder.  As the atrium continued to be overstretched, and enlarged – it also caused blood to be forced back into the pulmonary arteries – causing pulmonary hypertension.  While pre-surgical tests (echocardiogram, and cardiac catheterization) showed the patient to have (only) moderate pulmonary hypertension (with PA systolic pressures of 65mmHg).

Pre-operative testing is only part of the story

However, when we looked down, into the patient’s chest – it was obvious that the patient’s pulmonary vasculature was engorged and enlarged.  The patient’s heart was massive, and floppy (which is a sign the heart is working way too hard).  The patient also had peripheral edema which is another sign that the heart was not working well.

Potential for badness*

So even though, the surgery itself (described below) is not terribly technically challenging (‘like darning socks’ one surgeon used to say) – a lot can go wrong because the patient’s heart just doesn’t work that well to begin with.

* a not-so-scientific term to describe the likelihood of potential complications, problems or adverse outcomes.  These may be unavoidable circumstances in many cases – but the term is a reminder to remain vigilant even during so-called “simple” procedures.

Nitric oxide on hand

This OR does have nitric oxide  – (which we didn’t need), but was available nearby, just in case. Nitric oxide, milrinone and other medications are critical to have on hand in patients with pulmonary hypertension.  Some patients will never need it – others can’t survive without it – and sadly, (in patients with severe fixed pulmonary hypertension),  nothing – not even an assist device is going to make much difference.  While we can try to predict which patients are going to tolerate surgery, it’s not always clear-cut.  Tests (echocardiograms, right heart caths) can predict, tests can give probabilities – but sometimes tests are wrong, and patients who appear to have only ‘mild’ disease do very poorly (and visa versa). Sometimes, we just have to hold our breath as the patient comes off bypass and see.

canisters of nitric oxide in OR #1

canisters of nitric oxide in OR #1

As I mentioned in a previous post – cardiac surgery procedures can be a bit more complicated than many other surgical procedures, and while having something like nitric oxide on hand doesn’t seem like a big deal – it is.  (I have worked in several facilities without these capabilities).   It also speaks to the general preparedness of the staff. But despite the ‘potential for badness’ everything proceeded beautifully with  Drs. Urequi and Meza.  The case seemed to speed by despite the patient’s fragile health.  The entire CPB (cardiopulmonary bypass run) was just 26 minutes with a total cross-clamp time of 31 minutes.)

A little bit about cardiopulmonary bypass – the “heart-lung machine”

In comparison to the congenital repair above, average CPB times for valve replacement run around 100 minutes, 60 to 90 minutes for bypass surgery.  Patients have a higher risk of CPB related complications from hypo/ altered perfusion after long pump runs  .  As the clock begins to exceed 120 minutes, the risk of renal failure, cognitive changes and bleeding problems (as blood cells are continuous smashed/ broken / damaged within the pump) increase.

Perfusionist operating bypass pump aka "hart-lung machine"

Perfusionist operating bypass pump aka “heart-lung machine”

What is “Off-pump surgery”?  Nowadays, lots of people get real excited about “off-pump” surgery because they think that by not using the heart-lung machine, they can avoid a lot of the problems we mentioned above.  But that’s oversimplifying the entire scenario – and one that I find is often used to “sell” a particular surgeon or surgical program.  Off-pump can be safer than CPB cases, for some patients.  But these are usually not the patients that the surgery is sold to.. So it’s important to know what some of the terminology really means.  Just because Hospital X has billboards announcing that they now perform off pump surgery – doesn’t mean that it’s something you may even need or want.

Off pump is not for everyone

Patients have to be fairly healthy to tolerate cardiac surgery without the pump.  People with a lot of the problems that we thought were worsened by the pump, actually fare worse when we try to do surgery without the heart-lung machine. For example, we initially thought that Off-pump surgery would be great for people with renal insufficiency or ‘bad kidneys’ – particularly people who have kidney problems but aren’t quite sick enough to be on dialysis yet. The hope was that by avoiding the bypass pump we could avoid any damage to the kidneys from artificial flow/hypoperfusion because one of the biggest risks of cardiac surgery in patients with bad kidneys is that surgery will cause their kidneys to fail entirely, and make patients dialysis dependent.  Unfortunately, the research from all of the off-pump surgeries being done hasn’t really shown the benefits that we thought it would. So like most things in medicine, it’s not quite the panacea we had hoped it was.  But we did learn an incredible amount  of information once surgeons started trying off pump surgeries for coronary bypass.   Surprisingly, we learned that many of the complications, and conditions that we had long blamed on the CPB pump – weren’t related to the machine at all. But much of this is still being argued by cardiac surgeons every single day – each with different research studies giving different results..

More importantly, Off-pump not possible for many types of cardiac surgery

It’s technically impossible to do some types of cases without the bypass pump.  Coronary bypass surgery (CABG) is very different from other types of surgery, for example.  During bypass, the surgeon is only operating on the outside of the heart – attaching new conduit (arteries and veins) to arteries on the surface of the heart.  So – it isn’t absolutely essential to have the pump circulating blood for him while he’s operating – in some patients – we can let their body do it for us during surgery.

But replacing diseased heart valves, or the great vessels (aortic aneurysms etc) is a completely different entity.  In those surgeries – the surgeon is cutting into the heart or great vessels themselves.  It’s not possible to lop off the top of the aorta, operate on the aortic valve and not have blood being re-directed mechanically during this process.   Otherwise blood would just literally spill out into the chest and never oxygenate the brain and the rest of the body. (The only time we ever do this kind of procedure without a pump is during organ retrieval – for obvious reasons). It’s important to know these distinctions so people understand how the surgery actually proceeds.

For the case today – the surgeon has to make an incision through the side of the atria (wall of the heart chamber) to get to the hole on the inside wall of the heart.)  The surgeon then closes the hole with suture (and a patch, in some cases).  Some doctors do this in the cath lab without surgery – but that’s also controversal because the patch used in the cath procedures in the past has caused a high incidence of stroke.  In a young patient like the one here – you certainly wouldn’t want to risk it – particularly since we don’t know how well those patches hold up in the long term.

Cardiac surgeons operate at Hospital General de Medellin (HGM)

Cardiac surgeons operate at Hospital General de Medellin (HGM)

Overall evaluation of today’s case:

Safety checklists, and all pre-operative procedures were completed.  Patient was prepped and draped in an appropriate sterile fashion.  Antibiotics were administered within the recommended window (of time).  Appropriate records were maintained during the case.

Surgery proceeded normally and without incident.

Due to an underlying coagulopathy the patient did require administration of nonautologous blood products (4 units of packed red blood cells, 3 packets of platelets, and abumin) while on pump.  While the facility does not have a ‘cell-saver’ for washing and re-infusing shed blood, patient did receive autologous(their own) transfusion from the CPB pump. This blood, from the CPB circuit was returned to the patient to limit the amount of blood needed after surgery.  Hemoglobin at the conclusion of surgery was 9.6mg/dl, which is within acceptable parameters.

Hemostasis was obtained prior to chest closure, with only a small amount of chest tube drainage in the collection chamber at the time of transfer to the intensive care unit.

Surgical Apgarsdo not apply for cardiac cases due to the nature of the case, and use of CPB.  Mean pressure while on CPB was within an acceptable range.  Patient’s urinary output was less than anticipated during the case (150cc) despite the use of mannitol while on pump, but the patient responded well  (1000+) with volume infusion and the addition of furosemide.

The patient was hemodynamically stable during the entire case.  The was a very brief transitory period of hypotension (less than 5 minutes) near the conclusion of the case, which was immediately noted by anesthesia and treated with no recurrence.

On transfer to the unit, the patient was accompanied by several members of the OR staff, including Dr. Meza, the anesthesiologist, and the perfusionist, each of which did a face-to-face “hand-off” report of the patient (and medical history) including the course of the surgical procedure (including medications given, lab values, procedural details) to the Intensivist (physician), with ICU nursing staff attending to the patient.

Transesophageal echo (TEE) was not performed during this case, but was available if needed.

Also, I am happy to report there were no smartphones or “facebooking” in sight.  No one appeared engaged in anything other than the surgery at hand.