Mortalità e morbilita liposuzione

Mortalità e morbilità da
liposuzione
Claudio Melloni
Anestesista libero professionista
Consulente per Villa Torri,Bologna,Villa
Chiara,Bologna,Poliambulatorio Gynepro,Bologna

PERUGIA: CONDANNATI MEDICI PER
PAZIENTE MORTA DURANTE
LIPOSUZIONE
PERUGIA, 11 MARZO - Si è concluso con la condanna

di tutti gli
imputati il processo davanti alla Corte d' Appello di
Perugia a 3 medici per la morte di una paziente dopo
un intervento di liposuzione.
In serata i giudici di secondo grado hanno infatti condannato ADG a 2 anni di
reclusione, S A a 1 anno e 4 mesi ed AP a 1 anno di reclusione.
Tutti sono stati ritenuti colpevoli di omicidio colposo.
Francesca De Tommaso morì nel 1993 dopo essersi sottoposta ad un
intervento di liposcultura per eliminare 3 chilogrammi di grasso. I 3 medici
erano stati processati in primo grado dal pretore di Ancona che aveva inflitto 2
anni di reclusione a DG ed A ed 1 anno e 4 mesi a P. La sentenza era poi stata
parzialmente riformata dalla Corte d' Appello del capoluogo marchigiano e
quindi annulla dalla Cassazione che aveva rinviato il processo alla Corte
d'Appello di Perugia.

Il chirurgo: «Una disgrazia»
Morte dopo la liposuzione. Il dottor P:in tv:
«L’intervento era perfettamente riuscito».
L’autopsia conferma: la giovane commerciante è stata uccisa da
un’embolia. Francavilla, tanti mazzi di fiori davanti al negozio di
Mariana .
Articolo di:
Il Messaggero, Cronaca, Provincia Chieti, 19-02-2002
FRANCAVILLA — E’ stata una tromboembolia polmonare ad
uccidere Mariana Bellomo, la giovane mamma deceduta a
Francavilla sabato mattina. A confermarlo è stato l’esame autoptico
effettuato dal dottor Armando Colagreco dell’istituto legale di Chieti.
Quattro, forse addirittura cinque, gli emboli killer che hanno
stroncato la vita di Mariana, 24 anni, madre di una bimba di appena
2 anni. E R P il medico che l’ha operata, va in tv e dice di non
sentirsi responsabile: «L’intervento era perfettamente riuscito, ed è
stato fatto rispettando tutte le procedure dal punto di vista
sanitario».

Chiesto il rinvio a giudizio per C G, il medico
fiorentino che operò Bernadette Fontana, uccisa da
un'infezione.Morta per liposuzione
"Omicidio volontario"
FIRENZE - Sapeva che avrebbe potuto uccidere. Sapeva che
qualcuno, prima o poi, sarebbe morto a causa sua. Ma il sapere tutto
questo non l'ha messa in guardia contro il pericolo che correva, e che avrebbe

fatto correre agli altri. Per questo CG, il medico di Firenze che lo scorso anno fece
un intervento di liposuzione su una donna che poì morì per un'infezione postoperatoria, è colpevole. Colpevole a tutti gli effetti. Per il pubblico ministero Paolo
Canessa che ha condotto l'inchiesta sul caso, si tratta senza ombra di dubbio di
omicidio volontario e per questo ne chiede il rinvio a giudizio: se il giudice accoglierà
la richiesta del pm, Costanza Greco dovrà rispondere dell'omicidio di Bernadette
Fontana, la donna di 48 anni morta per una grave infezione dopo essere passata
sotto i ferri del medico fiorentino.

Ma non è finita qui. La dottoressa G.è anche accusata di lesioni colpose e lesioni
volontarie gravi per aver provocato in quello stesso periodo di tempo, fra il 18 e il 20
marzo 1999, analoghe infezioni post-operatorie ad altre due pazienti, L. B., 39 anni,
e P. F., 44 anni. Anche loro andarono dalla G.nella speranza di togliersi quei chili di
troppo. Ma, dopo essersi sottoposte all'intervento di liposuzione al "Centro servizi
Edonè" di Firenze che, tra l'altro, secondo l'accusa, non aveva neanche
l'autorizzazione della Regione, se ne sono tornate a casa con un'infezione in eredità.
ILpm Canessa è arrivato a contestare il reato di omicidio e di lesioni volontarie al
medico dopo aver valutato anche altre ipotesi: la G.infatti inizialmente sembrava
avere avuto un comportamento colposo. Ma dopo l'infezione provocata alla prima
donna, L.B., la .G non prese precauzioni per evitare anche alle altre pazienti
conseguenze disastrose. E continuò a operare senza mascherina

chirurgica, a non sterilizzare la sala operatoria, a non prevedere
nessuna profilassi antibiotica, utilizzando infine cannule per
aspirazione e medicinali non adeguatamente sterilizzati. Per questo
alla colpa si è aggiunta nella convinzione degli inquirenti una responsabilità
volontaria della G.

By Damon Adams, AMNews staff.
March 1, 2004.
Florida puts limits on office
plastic surgery after 8 deaths.
State officials want to examine
surgical logs to see if more rules are
needed for such surgery.

August 10, 2000, Florida Board
August 10, 2000, Florida Board
of Medicine
of Medicine
90 days moratorium on Office
surgery
..."there is an immediate danger to
the health,safety and welfare of
patients"....
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

21 luglio 2000,UK.,eadings
21 luglio 2000,UK.,eadings

Vietata AG nello studio dentistico
18 mesi di tempo per la transizione in
ambiente ospedaliero.


Di che cosa stiamo parlando?
National USA Plastic Surgery Statistics
Cosmetic procedure trends.
400000
350000
300000
250000
200000
150000
100000
50000
0
2000

2002

2003


2004

mastoplast addit
mentoplastica
dermabrasione
otoplastica
blefaroplastica
lift facciale
lift frontale
trap capelli
liposuz
addominoplast

Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient
Safety in Accredited Office Surgical Facilities. Plast Reconstr Surg,
Volume 99(6).May 1997.1496-1500

Questionario inviato ai 418
AAAASF,uffici chir accreditati
Ripetizione del questionario alcune
settimane a dopo a chi non aveva
risposto
241 risposte :57.7 %
(organizzazione curata da una ditta
esterna , Chalana, Inc).

Eventi dannosi in ufficio
traumi da aghi
??

probl con farmaci Errori di dosaggio,allergia,IM
probl.attrezz
probl cardiovasc
Broncospasmo,depressione resp severa,ipossia,f
allita o errata intubaz,ostruzione…

eventi resp
0

10

20

30
%


40

50

Complicanze della office chirurgia plastica

From: Keyes: Plast Reconstr Surg, Volume 113(6).May 2004.1760-1770
Analysis of outpatient surgery center safety using an internet-based quality improvement and
peer review program


Keyes GR, Singer R, Iverson RE, McGuire M, Yates J, Gold A,
Thompson D.
Analysis of outpatient surgery center safety using an internetbased quality improvement and peer review program.
.Plast Reconstr Surg. 2004 ;113:1760-70.

411,670 interventi
2001-2002
2597 sequele,di cui 1378 significative
1 sequela/299 procedurs (incidenza 0.33 %)
7 morti ,1/ 58,810 procedure (0.0017 %.

Aritmie cardiache(2 arresti card.)

Alterazioni della PA Intraop.


Trombosi venosa profonda/embolia
polmonare:0.004%


Pneumotorace


Cause di morte durante liposuzione.

Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr
Surg 2000;105:436-46.

Embolia polmonare 23%
Perforazione visceri addominali 14,6%
Anestesiologiche 10%
Embolia grassosa 8,5%
Insuff cardioresp 5,4%
Infez massiva 5,4%
Emorragia 4,6%
Sconosciuta o confidenziale 28,5%
Mortalità globale 19,1

per
100.000,ossia 1/5000

Mortalità da liposuzione

. Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast
Reconstr Surg 2000;105:436-46.

sede

Morti tot

Morti %

Sede chir %

office

62

47,7%

45%

Day surg

39

30%

29%

Sala op
ospedale

22

17%

26%

sconosciuta

7

5,4%

Complicazioni delle liposuzioni per area trattata
Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast
Reconstr Surg 2000;105:436-46.

8

6
addome

14

natiche,estr.i
nf
estr sup

3

72

dorso sup
dorso inf

39

testa,collo

Rao,RB,Ely,SF,Hoffman,RS.DEATHS RELATED TO
LIPOSUCTION. NEJM;1999;340:1471
5 morti dopo liposuzione in tumescenza su 48,527 esaminate
dal Office of Chief Medical Examiner of the City of New York
tra il 1993 e1998.
I 5 paz avevano ricevuto lidocaina a dosaggi fra 10 - 40
mg/kg
Altri farmaci: midazolam,mep,isoflurane
3 morti improvvise con bradicardia ed ipotensione intraop
inspiegabili .Postmortem lidocaina ematica in 2 paz. era 5.2
e 2 mg/lt
1 decesso per sovraccarico idrico
1 decesso per dvt delle vene del polpaccio e PE dopo

Osservazioni sul lavoro di
Rao:
Chirurghi operatori;plastici,1 chir gen
Anestesista sempre presente
Rianimazione sempre effettuata
Quasi tutte procedure combinate di + aree

Teimourian B, Rogers WB A national survey of complications
associated with suction lipectomy: a comparative study. Plast
Reconstr Surg. 1989 Oct;84(4):628-31.
January 1984 -to January 1988 112,756 p rocedures :
major liposuction (75,591),
dermatolipectomy (10,603),
and abdominoplasty (26,562).

Pulmonary embolism in 9

4 anni di Florida MoratoriaAnn
Plast Surg. 2006 Jan;56(1):78-81. Office surgery safety and the Florida
moratoria. Clayman MA, Caffee HH.

Mark A. Clayman, M.D. Brent M. Seagle, M.D. Office Surgery Safety:
The Myths and Truths behind the Florida Moratoria–-Six Years of
Florida DataPlastic and Reconstructive Surgery • 2006;118:777-785

The authors reviewed all office surgical incidents
that resulted in death, injury, or hospital transfer in
Florida from January of 2000 to January of 2006.
Various methods were used to determine board
status, office accreditation, and hospital privileges.

Mortalità in Florida,2000-2006,da
office surgery
600.000 interventi

Procedure combinate:7/11
Addominoplastica:7/11

Conclusions: There were over 600,000
operations during the study period. The fact
that 11 office deaths were reported would suggest
that the location in which these procedures were
performed was not as much of a factor as the
regulators have suggested. The most frequent
cause of death after discharge was
thromboembolism.

Reduction of Lipoplasty Risks and Mortality: An ASAPS
Survey
Charles E. Hughes .A E S T H E T I C S U R G E R Y J O U R N
AL~MARCH/APRIL2001
lipoplasty morbidity and mortality
performed by members of the American Society for Aesthetic
Plastic Surgery (ASAPS) from September 1, 1998, through
August 31, 2000.
response rate of 53%.

94,159 lipoplasty procedures.
» 66% of the procedures lipoplasty only
» 20% lipoplasty without abdominoplasty but with one or more
additional procedures
» 14% lipoplasty with abdominoplasty, with or without any other

Mortalità della liposuzione:
da Hughes 2001

liposuzione da sola: 2.1 : 100.000
Liposuzione con altre procedure eccetto
addominoplastica:1 su 7314
Liposuzione con addominoplastica e altre procedure
1:3281


Complicazioni non fatali della lipoplastica con o senza
altri interventi combinati:da Hughees 2001


I chirurghi plast (ASAPS) che hanno
modificato la loro pratica ,in che cosa
l’hanno modificata?


Rischi della lipoplastica :
da Hughes 2001

» PONV :1.02%, 1 per 98 procedures.
» 245 major complications,for a rate of 0.2602%.

Conclusions: The ASAPS survey documents the
current safety of lipoplasty when it is performed as
an isolated procedure by properly trained surgical
specialists adhering to recommended standards of
clinical practice. Further studies are needed to
examine the factors that increase the risk in combined
procedures as well as the effectiveness of
prophylactic measures in avoiding complications

Cause della insufficienza
rianimativa
Attrezzature di rianimazione inadeguate
Monitoraggio insufficiente,specie
pulsossimetria
Errore umano
Lento riconoscimento dell’evento
Mancanza di esperienza
Sovradosaggio farmacologico
Inadeguata valutazione preop.
Inadeguata valutaz postop

Linee guida della ASA per la sedazione 1996

Practice guidelines for sedation and analgesia by nonanesthesiologists.Anesthesiology 1996; 84:459-471
Registrazione simultanea dei:
» livelli di coscienza
» funzione resp
» emodinamica
» prima,durante la procedura ad intervalli regolari,;nella fase di ripresa e al
momento della dimissione
Anche la chir maxillo faciale ha poi definito più precisamente I ciriteri per il
monitoraggio postop e la dimissione
Invece di “ segni vitali stabili prima della dimissione”
Ora specificamente raccomanda "determinazione e documentazione della
ossigenazione,ventilazione,circolazione e temperatura stabili prima della
dimissione”
Nel 2000 è stato stabilito che il chirurgo determini che “il paziente è ritornato al suo
stato basale fisico e mentale di prima dell’intervento e non è più a rischio di
depressione cardiorespiratoria”
In passato la formula era “il paziente risponde appropriatamente”

Personale aggiuntivo
1 persona preparata e competente per BLS
(il chirurgo deve essere ALS se somministra sedazione…)
2 persone con BCLS o equivalente in caso di AG
+ recentemente ASA e American Association of Pediatrics (AAP) hanno definito le
quqlifiche :AAPnelle linee guida ultime
Definisce la presenza oltre al chirurgo di una altra persona in caso di sedazione
profonda la cui unica responsabilità sia di osservare costantemente “i segni vitali del
paziente,la pervietà delle vie aeree e l’ adeguatzza della ventilazione e per
somministrare farmaci”
Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.
Pediatrics 1992;89:1110-1115

Nell’ ASA "Statement of Qualifications of Anesthesia Providers in the Office-Based
Setting," (1999),è scritto che"ASA believes that anesthesiologist participation in an
office-based surgery is optimally desirable as an important anesthesia safety standard
and will always support such a standard. It does not oppose however regulatory
requirements that, where necessary, speak merely in terms of `physician supervision‘”

Collaborazione su indicazioni per
pazienti in ambito OBS/OBA
ASA Committee on Ambulatory Surgical Care
Society for Ambulatory Anesthesia (SAMBA) stanno
sviluppando policies to safeguard the increasing numbers
Anesthesia Patient Safety Foundation
Dipartimenti della salute e società di anestesia locali per
creare dei legami con le società di accreditamento
interazione con American College of Surgeons (ACS).

Practice Advisory for Procedures in the Office-based Surgery
Setting, approved by the ASPS Board of Directors in November
of 2001

Elementi da considerare nella scelta della sede
più idonea:
Stress fisiologico:
»
»
»
»

Ipotermia
Perdite ematiche intraop
Liposuz di più aree
Durata della procedura

Misure di tromboprofilassi
problemi di ripresa postop
Qualificazione dei providers
Standard dell’ufficio chirurgico

Ipotermia
Ne parla il collega Zanello
Hypothermia can be a potentially serious complication of office-based surgery. Both regional and general anesthetics
markedly impair the normal precise regulation of core body temperature. Hypothermia develops because the typical
operating room environment is cold; however, it is anesthetic-induced impairment of thermoregulatory responses that
contributes the most to this condition. 3 The degree of hypothermia is a significant concern with regard to infection
and safety of anesthetic management. Studies indicate that hypothermia may directly impair neutrophil function or
impair it indirectly by triggering subcutaneous vasoconstriction and subsequent tissue hypoxia. 4
Recommendation: The office surgery suite must be equipped so that temperatures can be adequately monitored and
adjusted; equipment should be available to warm the patient, including such cutaneous warming devices as Bair
Huggers (Augustine Medical, Eden Prairie, Minn.), forced air warming blankets, and intravenous fluids warmers, as
necessary. Without such hypothermia prevention measures, the procedures performed should be of short duration (1
to 2 hours) and limited to no more than 20 percent of the body surface area.

Perdite ematiche
intraoperatorie
Possono portare ad una instabilità emodinamica
intra e postop
Possono portare al ricovero
Raccomandazione:

» Se le perdite anticipate sono dell’ordine
dei 500 ml o maggiori l’intervento è da
attuare solo in strutture ove sangue ed
emocomponenti sono prontamente
disponibili

Liposuzione combinata con
altre procedure
Multiple procedure effettuate nel corso
di un singolo intervento aumentano la
probabilità di complicazioni

Comunque la liposuzione ha visto
intervenire lo Stato della Florida
“Liposuction

may be performed in combination with
another separate surgical procedure during a single
level II or level III operation, only in the following
circumstances:
when combined with abdominoplasty, liposuction
may not exceed 1000 cc of aspirant;
when associated with or directly related to another
procedure, liposuction may not exceed 1000 cc of
aspirant;
major liposuction (in excess of 1000 cc aspirant),
may not be performed in a remote location from any
other procedure” (Florida Board of Medicine 64B8–9.009 Rule.

Some data support these limitations; however, the
data tend to be anecdotal or in studies lacking the
level of rigor necessary to establish clear standards of
practice. 5
Recommendation:
The presumed benefits of combining procedures, particularly
liposuction, must be weighed against the possibility of adverse events. It
is the position of ASPS that liposuction can be performed safely in the
office setting when done in accordance with ASPS recommendations to
limit total aspirant (supernatant fat and fluid) to 5000 cc or less. 6 When
large-volume liposuction is combined with certain other procedures,
such as abdominoplasty, serious complications have arisen. 5,6
Therefore, it is recommended that such combination procedures be
avoided.

Durata dell’intervento
Aumenta le complicanze postop e la frequenza di
ricovero ospedaliero:
– Mingus

Interventi che si prolungano > h15 del pomeriggio
hanno un aumentata incidenza di ricovero

Prevenzione dei problemi postop
PONV:tecnica anest,fattori di
rischio,profilassi,trattamento
Giramenti di testa
Confusione
Dolore
postop:prevenzione,trattamento,scorte a
casa…..
Chiare istruzioni

Qualificazioni mediche
Specializzazione
Partica ospedlaiera nella disciplina
Possibilità di ricovero?

Surgical Facility Standards
Plastic surgery performed under anesthesia, other than minor
local anesthesia and/or minimal oral tranquilization, should be
performed in a surgical facility that meets at least one of the
following criteria:
accredited by a national or state-recognized accrediting
agency/organization such as the American Association for Accreditation
of Ambulatory Surgery Facilities (AAAASF), the Accreditation
Association for Ambulatory Health Care (AAAHC), or the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO)
certified to participate in the Medicare program under Title XVIII
licensed by the state in which the facility is located.

Conclusioni
In ambulatorio non si puo fare di tutto
Selezione dei pazienti
Selezione delle procedure chir;
– Selezione degli operatori………

– Il rischio clinico e le possibili sequele
medico legali sono maggiori!

Per chi fosse interessato:
Patient Safety in Office-Based Surgery Facilities: II. Patient
Selection.[COSMETIC SECTION: COSMETIC SPECIAL
TOPIC].Iverson, Ronald E. Lynch, Dennis J. ASPS Task
Force on Patient Safety in Office-based Surgery Facilities
.Plast Reconstr Surg 2004 Apr 15;113(5):1478-90. [59
references]
American Academy of Dermatology Liposuction Guideline
Development Task Force .
American Academy of Dermatology Guidelines/Outcomes
Committee
NGC Clearinghouse 2001

Mortalità nella office surgery
Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient Safety in Accredited Office
Surgical Facilities. Plast Reconstr Surg, Volume 99(6).May 1997.1496-1500

7 casi ( 0.0017 %, 1 / 57,000)
1 decesso 3 gg dopo lifting facciale e frontale
2 decessi da occlusione della LAD ,1 durante mastoplast addit.e 1
4 h dopo rinoplastica.
3 decessi da complicanze intraop:1 /133,558
»

ipossia cerebrale durante addominoplastica ,con decesso dopo 11 gg:
– Un pnx iperteso durante mastoplastica con decesso 4 h più tardi
– Un arresto cardioresp (con decesso più tardi) durante decompressione
tunnel carpale

Casistica
Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient Safety in Accredited Office
Surgical Facilities. Plast Reconstr Surg, Volume 99(6).May 1997.1496-1500

400,675 interventi in 5 anni (Jan1, 1989 - Dec 31, 1993)
» 253,355 estetici (63.2 %) ,147,320 ricostruttive (36.8 %).

Complicazioni : 1877 (1/ 213 ), 0.47 %
»
»
»
»
»
»

Emorragie(ematomi intra-postop):965 ,1 /415 (0.24 %).
Episodi ipertensivi :414 ,1 /968 0.1 %).
Infezione (infezione maggiore o sepsi ) 350 , 1/1145 (0.09 %).
Ipotensione intra e postop :148 ,1 / 2707 (0.04 %).
Ritorno in sala op entro 24 h: 530 casi, 1/ 756 , (0.13 %, )
Ospedalizzazione precauzionale 126 casi, 1/ 3180 (0.03 %)


Incidenza di complicanze a confronto:office based vs day
surg.centers
Warner, M. A., Shields, S. E., and Chute, C. G. Major morbidity and mortality within 1 month of
ambulatory surgery and anesthesia.J.A.M.A. 270: 1437, 1993
Natof, H. E. Complications associated with ambulatory surgery. J.A.M.A. 244: 1116, 1980

emorragia infezione

Trasf in
ospedale

mortalità

Morello

0,24%

0.09%

0.03%

0,0017%
1/57000

Natof
Warner

0.55%

0.74%

0.12%

0
0,0087
1/11273

14 MI

7 SNC

5 emb polm

5 insuff resp


Dimensione del problema
Membership Audit, American Society for
Aesthetic Plastic Surgery, Inc., Spring
1993.
survey of members of the American
Society for Aesthetic Plastic Surgery
(ASAPS)

48.7 % of members perform their
aesthetic surgery in an office
surgical facility.

SMG Group: SMG Forecast of Surgical Volume in
Hospital/Ambulatory Settings: 1994‑2001. Chicago, SMG
Marketing Group, 1996
20
18

milioni e %

16
14
12
10

interventi chir
% interventi in OB

8
6
4
2
0
1984

1990


2001

Evoluzione della attività
sanitaria(USA???)
Anni 50-70
Gli ospedali posseggono le tecnologie più nuove ed i mezzi più potenti
Un professionista ,da solo, non potrebbe mai permetterselo
Ospedalizzazioni prolungate,prima e dopo l’intervento

Anni 90-2000Contenimento dei costi
Le tecnologie più avanzate costano sempre care,ma sono alla portata,per lo
meno come ingombro….
Enfasi sulla day surgery
Parcelle chirurgiche calanti( e quindi anche anestesiologiche)

Movimento dei pazienti verso l’ufficio
» Si riducono le spese per la struttura
» Si riducono le spese per i pazienti
» L’office che non sembra un ospedale fa meno paura al paziente?

Ann Plast Surg. 2006 Jan;56(1):78-81. Office surgery safety
and the Florida moratoria. Clayman MA, Caffee HH.

Department of Surgery, Division of Plastic &
Reconstructive Surgery, University of Florida
Health Science Center, Gainesville, Florida 32610,
USA. mclayman@ufl.edu
BACKGROUND: Office-based surgery has
become an important method of healthcare
delivery, but there is controversy about its safety.
Since 2000, a series of articles were published in
the lay media emphasizing the hazards of office
surgery, leading to the Florida Board of Medicine

1: Plast Reconstr Surg. 2006
Sep;118(3):777-85; discussion 786-7.
Links
Comment in:
Plast Reconstr Surg. 2007 Jun;119(7):2332-3; auth
Office surgery safety: the myths and
truths behind the Florida moratoria-six years of Florida data.
Clayman MA, Seagle BM.


Dermatol Surg. 2008 Mar;34(3):285-91;
discussion 291-2. Epub 2007 Dec 20.
Links
Office surgery incidents: what seven
years of Florida data show us.
Coldiron BM, Healy C, Bene NI.
Department of Dermatology, University
of Cincinnati, Cincinnati, Ohio, USA.
bcoldiron@gmail.com


Mortalità 2000-2007 nello stato della
Florida:dati sulla Office based surgery
In 7 anni :31 morti e 143 complicazioni degli
interventi con trasferimento in ospedale
18 morti (58% del totale) e 87 complicanze (61%) da
proceduree estetiche
Liposuzione e liposuzione con addominoplastica o
altro intervento cosmetico : 24 complicazioni e 8
decessi

CONCLUSION: Plastic surgeons were responsible for an inordinate number of
deaths and hospital transfers. Requiring physician board certification and physician
hospital privileges would not seem to increase safety, because most physicians
already have these credentials, and physicians without these credentials were not
responsible for a disproportionate share of incidents. These data do not show an
emergent hazard to patients from medically necessary office surgery. Liposuction
under general anesthesia deserves continued scrutiny because deaths due to this
procedure continue to occur and this procedure can be performed with dilute local
anesthesia, with which no deaths were reported. Mandatory reporting of office
incidents should be strongly supported, as well as reporting of incidents that occur
after surgery in the hospital outpatient department and ambulatory surgery center.
These data should be available for analysis after protecting patient confidentiality. A
national debate needs to occur to determine how many deaths and injuries are
acceptable from cosmetic procedures performed under general and intravenous
anesthesia.

Status degli uffici: 38.5% accreditati da una
agenzia indipendente, 92.5% dei medici specialisti
e 96.6% con privilegi ospedalieri.
A total of 78% (14/18) of these deaths were in
ASA Class 1 patients. Plastic surgeons were
responsible for 48% of all deaths (83% of
cosmetic surgery deaths) and for 52% of all
hospital transfers (83% of cosmetic surgery
complications and hospital transfers).

Thermodynamics, Liposuction, and Metabolism
Kelley D. E.
Extract | Full Text | PDF
N Engl J Med 2004; 350:2542-2544, Jun 17,
2004. Perspective


Metabolic Effects of Liposuction — Yes or No?
Esposito K., Giugliano G., Giugliano D.,
Arner P., Busetto L., Bassetto F., Nolli M.
L., Klein S.
N Engl J Med 2004; 351:1354-1357, Sep
23, 2004. Correspondence

American Academy of Dermatology Liposuction Guideline Development
Task Force
American Academy of Dermatology Guidelines/Outcomes Committee
NGC Clearinghouse 2001

The guidelines were provided to the entire
American Academy of Dermatology
membership. Upon request, the guidelines
have been sent to credentialing bodies.
Finally, the guidelines were provided to state
medical boards and/or state legislators


Physician qualifications
The physician performing liposuction
has completed residency training or is
board certified in a specialty that is
recognized by the American Board of
Medical Specialties, and that provides
education in liposuction and training in
cutaneous surgery.
Level of Evidence: L6


Facility in which the procedure is
performed and availability of
emergency care
Liposuction can be performed safely in a
physician's office surgical facility, an
ambulatory surgical facility, or a hospital
operating room.
Strength of Recommendation:


Preoperative medical and psychosocial
evaluation of the patient
Liposuction is contraindicated in patients
with severe cardiovascular disease, severe
coagulation disorders, including
thrombophilia, and during pregnancy.
Strength of Recommendation: Unanimous
Task Force opinion.
A thorough medical history that gives
special attention to any history of bleeding


Type of anesthesia employed and
perioperative administration of
anxiolytics, sedatives, and analgesics
Lidocaine is the preferred type of local
anesthetic.
Task Force opinion and weak evidence.
If a patient takes medications that inhibit
the metabolism of lidocaine, the


Surgical technique/procedure
including the performance of
concomitant additional surgery, the
size of the cannulae employed, the
length of time of the procedure, and
the volume of fat extracted per
session and by body weight
Performing liposuction with other
procedures should be done with caution,


Type of intra- and postoperative
monitoring
Baseline vital signs, including blood
pressure and heart rate, are to be
recorded pre- and postoperatively.
Strength of Recommendation:
Unanimous Task Force opinion.
For procedures removing >100 mL of
aspirate, there is the capability of


Postoperative compression
Specialized compression garments, binders,
and tape help to reduce bruising,
hematomas, seromas, and pain. Antiphlebitis support hose may be valuable for
cases involving the lower legs.
Task Force opinion.
The duration of compression is dictated by

POTENTIAL HARMS
Rare but serious surgical complications
include:
Mortality
Cerebrovascular accident or transient
ischemic attack
Pulmonary thromboembolism
Fat embolism

The Pursuit of Perfection: The Promise and Peri
Resnik D. B.
N Engl J Med 2004; 350:1368, Mar 25,
2004. B


Unraveling the Fat Embolism Syndrome
Fabian T. C.
Extract | Full Text
N Engl J Med 1993; 329:961-963, Sep
23, 1993. Editorials


American Society of Plastic Surgeons - Practice
advisory on liposuction,2004 Apr
Iverson RE, Lynch DJ. Practice advisory
on liposuction. Plast Reconstr Surg 2004
Apr 15;113(5):1478-90. [59 references]
PubMed
GUIDELINE COMMITTEE
American Society of Plastic Surgeons
(ASPS) Committee on Patient Safety
NGC Clearinghouse

Comparative Outcomes Analysis of
Procedures Performed in Physician
Offices and Ambulatory Surgery
Centers Hector Vila, Jr, MD; Roy Soto,
MD; Alan B. Cantor, PhD; David
Mackey, MD
Arch Surg. 2003;138:991-995.
Hypothesis This study compared


2003 Update: Outcomes Analysis of
Procedures Performed in Florida
Physician Offices and Ambulatory
Surgery Centers Hector Vila, Jr., M.D.,
Roy G. Soto, M.D., Rafael V. Miguel,
M.D., David C. Mackey, M.D.
Anesthesiology / Interdisciplinary
Oncology, H. Lee Moffitt Cancer Center
and Research Institute; University of
South Florida, Tampa, Florida.


FINE


Results: In 6 years of Florida data, a total of 46 deaths related
to office procedures were reported. Twenty of those were surgical
procedures that are within the scope of plastic surgery, although
non–board-certified plastic surgeons performed nine. Of those 20
related to plastic surgery, 11 died before discharge.
Although all 11 survived long enough to be transferred to a hospital,
we classified
them as office deaths. The other nine died after appropriate
discharge. Of the nine, seven deaths were from thromboembolism
and the others from unknown causes.


Thirty-five deaths were related to non–boardcertified plastic surgeons and specialists in other
fields. Board-certified plastic surgeons accounted
for less than one-fourth of the deaths. There were
no deaths from a board-certified plastic surgeon
since April of 2004.


Durata dell’intervento
In the selection of a plastic surgery procedure for the office setting, there are few prospective
data and mostly conflicting opinions on the importance of surgery duration alone as a predictor
of adverse outcomes. Most plastic surgery procedures typically performed in an ambulatory
setting take longer than 1 hour to complete. These procedures include face lifts, rhinoplasties,
breast reductions, mastopexies, liposuctions, and abdominoplasties. It is not uncommon for
several plastic surgery procedures to be performed during the same operative period, increasing
the total duration of the surgery. In some studies, the duration of surgery does seem to correlate
with adverse outcomes. In the anesthesia literature, Mingus et al. 7 suggest that any procedures
extending beyond 1 hour correlate with a higher rate of postoperative admission. This may be a
direct function of the procedure or it may relate to the procedure being more extensive than
initially anticipated.
Fogarty et al. 8 compared three categories of reconstructive plastic surgery that often last longer
than 6 hours: head and neck, breast reconstruction, and upper and lower limb surgery. Despite
having a similar mean duration of surgery, the differences in postoperative complications among
the three groups suggest that the duration of surgery alone is not a major determinant of
postoperative morbidity and that the type of surgery performed and the patient’s general health
are more important predictors of outcomes. More extended procedures are likelier to produce
postoperative nausea, vomiting, bleeding, and excessive pain, warranting overnight stay. 2,9,10
Several studies indicate that patients whose surgical procedure ended after 3 pm have a higher
incidence of unanticipated admission than those whose surgery ended earlier. 9
Recommendation: It is important to schedule long procedures sufficiently early in the day to
allow for adequate recovery time before discharge. 7 If possible, the surgery should be
completed by 3 pm to allow adequate time for recovery and discharge. Ideally, the overall

REf 7 e 8 di IVerson e AFPS task
forcePatient Safety in Office-Based
Surgery Facilities: I. Procedures in the
Office-Based Surgery Setting
[COSMETIC SECTION: COSMETIC
SPECIAL TOPIC]
Iverson, Ronald E. M.D.; and the ASPS
Task Force on Patient Safety in Officebased Surgery Facilities

Misure di tromboprofilassi
Identificazione dei fattori di rischio e classificazione dei pazienti a
seconda della entità del rischio
Fattori genetici o acqusiti
Sindrome antifosfoilipidi
Omocistinemia
Contraccettivi recenti o terapia sostitutiva ormonale postmenopausa
Storia di dvt
Anamnesi ed esame obbiettivo
.
Risk Rating for Thrombosis or Embolism
* Low-risk: Patients who face uncomplicated surgery and have no risk
factors. These patients are usually under 40 years of age, although
older patients undergoing short procedures may qualify.
* Moderate-risk: Patients 40 years and older who have no additional risk
factors but who face procedures longer than 30 minutes. Patients who

Tromboprofilassi a seconda della stratificazione del
rischio
* Low-risk: Comfortable positioning on the operating table with the knees
slightly flexed. Constriction of the extremities and external pressure should be
avoided.

* Moderate-risk: In addition to the recommendations for low-risk

patients, intermittent pneumatic compression devices of the calf or ankle and
frequent alteration of the operating room table are recommended. The devices
should be in place before the induction of general anesthesia, and their use should
be continued until the patient is awake and moving in the recovery unit

.

* High-risk: In addition to all recommendations for low-risk and moderaterisk patients, both a hematology consultation and preoperative/postoperative
pharmacologic antithrombotic therapy should be considered

.


Problemi potenziali postoperatori che
portano al ricovero ospedaliero non
programmato
Giramento di testa
Dolore
Nausea e vomito

Levin et al. 13 found that 9.5 percent of unplanned hospital
admissions resulted primarily from dizziness, pain, and
nausea/vomiting. In their study, these symptoms were not correlated
with the patient’s age.
Dolore:correlato a :
Tipo di liposuzione
BMI
Estensione della procedura
Durata della procedura:>120 min + dolore

Absence of an Effect of Liposuction on Insulin A
Klein S., Fontana L., Young V. L.,
Coggan A. R., Kilo C., Patterson B. W.,
Mohammed B. S.
Abstract | Full Text | PDF
N Engl J Med 2004; 350:2549-2557, Jun
17, 2004. Original Articles
ook Reviews

1: N Engl J Med. 2004 Jun
17;350(25):2549-57. Links
Comment in:
N Engl J Med. 2004 Jun 17;350(25):2542-4.
N Engl J Med. 2004 Sep 23;351(13):1354-7; author
Absence of an effect of liposuction
on insulin action and risk factors for


Losing Weight — An Ill-Fated New Year's Resolu
Kassirer J. P., Angell M.
Extract | Full Text
N Engl J Med 1998; 338:52-54, Jan 1,
1998.


Edito rials
Deaths Related to Liposuction
Rao R. B., Ely S. F., Hoffman R. S.
Abstract | Full Text | PDF
N Engl J Med 1999; 340:1471-1475,
May 13, 1999. Original Articles
Deaths Related to Liposuction
Ginsberg M. M., Gresham L., Vermeulen
C., Serra M., Roujeau J.-C., Talmor M.,


1: N Engl J Med. 1999 May
13;340(19):1471-5. Links
Comment in:
N Engl J Med. 1999 Sep 23;341(13):1000; author re
N Engl J Med. 1999 Sep 23;341(13):1002-3.


: Dermatol Surg. 2002 Aug;28(8):710-2;
discussion 713. Links
Office surgical incidents: 19 months
of Florida data.
Coldiron B.
brettcoldiron@hotmail.com
BACKGROUND: In 1999-2000 a series
of sensational articles were published in
the lay media emphasizing the hazards


Dermatol Surg. 2005 Jul;31(7 Pt 1):73343; discussion 743. Links
Erratum in: Dermatol Surg. 2005
Sep;31(9 Pt 1):1158. Review of the
liposuction, abdominoplasty, and
face-lift mortality and morbidity risk
literature.
Yoho RA, Romaine JJ, O'Neil D.
Department of Dermatology, Martin


Teimourian B, Rogers W. A national
survey of complications associated with
suction lipectomy: a comparative study.
Plast Reconstr Surg 1989; 84:628-631.
2. Grazer F, De Jong R. Fatal outcomes
from liposuction: census survey of
cosmetic surgeons. Plast Reconstr Surg
2000;105:436-446.
3. Teimourian B, Adham M. A national

Plast Reconstr Surg. 1989
Oct;84(4):628-31. Links
A national survey of complications
associated with suction lipectomy: a
comparative study.
Teimourian B, Rogers WB 3rd.
Department of Surgery, Suburban
Hospital, Bethesda, Md.
In March of 1988, a survey form was


complication rate for major suction
lipectomy was 0.1 percent, for
dermatolipectomy 0.9 percent, and for
abdominoplasty 2.0 percent. Fat emboli did
not prove to be a significant factor
associated with any of the three procedures.
However, of the 15 reported deaths (major
liposuction 2, dermatolipectomy 2, and
abdominoplasty 11), pulmonary
thromboembolism was the causative factor

1: Plast Reconstr Surg. 2006
May;117(6):1797-808. Links
Erratum in: Plast Reconstr Surg. 2007
Jan;119(1):426-7. Comment in: Plast
Reconstr Surg. 2007 Jan;119(1):426-7.
Abdominoplasty and abdominal
contour surgery: a national plastic
surgery survey.
Matarasso A, Swift RW, Rankin M.


Plast Reconstr Surg. 2006 Jul;118(1):207-12;
discussion 213-4. Links
Is it safe to combine abdominoplasty with
elective breast surgery? A review of 151
consecutive cases.
Stevens WG, Cohen R, Vath SD, Stoker DA,
Hirsch EM.
Marina Plastic Surgery Associates and the Keck
School of Medicine of University of Southern
California, USA. drstevens@hotmail.com
BACKGROUND: This study was designed to

PRATO Liposuzione, Nas sequestrano studio
non autorizzato

PRATO, 18 OTTOBRE 2002 - Un locale utilizzato per
interventi chirurgici di liposuzione è stato sequestrato
dai carabinieri del Nas di Firenze in uno studio medico
di Prato. Il locale - che era stato affittato da un
chirurgo di Pisa - non avrebbe avuto alcuna
autorizzazione per gli interventi di quel tipo. I
carabinieri hanno sequestrato anche tutte le
apparecchiature e le attrezzature e hanno denunciato
il medico e il rappresentante legale dello studio per
esercizio medico in locali non autorizzati.

In an attempt to crack down on problems with office-based surgeries, the Florida
Board of Medicine has imposed a 90-day ban on combination abdominoplasty and
liposuction procedures.
The board is responding to media reports and concerns about the deaths of eight
patients during office surgeries since the summer of 2002. Three of those deaths
involved combination liposuction and abdominoplasty.
The moratorium went into effect Feb. 11. It requires that liposuction and
abdominoplasty procedures performed on the same patient in an office setting be
separated by 14 days. Board officials said the combination of procedures increases
the risks of a deadly blood clot.
In 2000, patient deaths prompted the medical board to issue a 90-day ban on office
surgeries that required general anesthesia or heavy sedation. That led to new safety
standards for office surgery, including accrediting of offices, mandatory reporting of
adverse incidents and credentialing of surgeons.
But board Chair Lisa Tucker, MD, said the current regulations might not be enough to
protect patients. Board officials said they would evaluate office surgery logs to

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