THE PLACE OF ULTRASOUND ASSISTED MEGALIPOSUCTION IN THE ROMANIAN OBESITY THERAPY DEDICATED PROGRAMS

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2012 vol. 116, no. 4 INTERNAL MEDICINE - PEDIATRICS ORIGINAL PAPERS THE PLACE OF ULTRASOUND ASSISTED MEGALIPOSUCTION IN THE ROMANIAN OBESITY THERAPY DEDICATED PROGRAMS Laura Maria Curic 1, Carmen Vulpoi 2 University of Medicine and Pharmacy Grigore T. Popa - Iasi 1. Ph.D. student Faculty of Medicine 2. Discipline of Endocrinology THE PLACE OF ULTRASOUND ASSISTED MEGALIPOSUCTION IN THE ROMANIAN OBESITY THERAPY DEDICATED PROGRAMS (Abstract): Obesity global epidemic and increasing number of super obese people requires a firm stand on the need for medical education of the general population and the need for aggressive therapeutic, but effective, methods, as its consequence is growth rate of comorbidities. The treatment of obesity is a combined treatment worldwide: lifestyle changes, medication and surgery. The aim of this article was 1) to highlight the obesity therapy in the world and the Romanian experience regarding bariatric surgery and the UAM (Ultrasound Assisted Megaliposuction) technique, 2) to underline the necessity of implementation of all new methods of obesity treatment in Romania and the possibilities to do that and 3) to determine the knowledge and the compliance of the Romanian obese patients regarding the new surgical obesity therapy technique. Material and methods: We conducted a personal single center survey on 30 obese persons in order to demonstrate the necessity of adjusting the obesity treatment in Romania to the European standards and the complete Romanian patient compliance regarding the new surgical obesity therapy technique. Responses to two questionnaires were evaluated. Results: Interpretation of the scores of the first questionnaire revealed a significant impairment of life quality. Evaluation of the second questionnaire results revealed that 60% of people studied had morbid obesity. These people may theoretically benefit from bariatric surgery techniques and UAM. Conclusions: The implementation of all new methods of obesity treatment in Romania, as an UE member state, is not an illusory idea, but a reality and it should be a matter of national interest. Keywords: OBESITY, ULTRASOUND ASSISTED LIPOSUCTION, MEGALIPOPLASTY. Obesity is often neglected but is a very severe illness by morbid complications associated with it. Obesity global epidemic (GLOBesity) and increasing number of super obese people (BMI> 50 kg/m 2 ) requires a firm stand on the need for medical education of the general population and the need for aggressive therapeutic methods, but effective, as its consequence is the growth rate of comorbidities: cardiovascular (hypertension, cardiac overload, tachycardia), respiratory (breathing muscle wasting due to increased work needed for ventilation, sleep apnea syndrome), metabolic (glucose intolerance, diabetes, dyslipidemia), mobility (joint strain), endocrine (hormonal disorders) (1, 2) and premature death (3, 4) in this population. Worldwide, 1 billion adults are overweight and 475 million are obese, leading 951

2 Laura Maria Curic, Carmen Vulpoi to more than 2.5 million deaths per year. In Europe, 260 million adults and 12 million children are overweight or obese. In Romania, 20% of men and 30% of women are obese. Over time were proposed several ways to treat obesity. The aim of this study was: 1) to highlight the obesity therapy in the world and the Romanian experience regarding bariatric surgery and the UAM technique; 2) to underline the necessity of implementation of all new methods of obesity treatment in Romania and the possibilities to do that both technically, economically and in terms of housing and 3) to determine the knowledge and the compliance of the obese Romanian patients regarding the new surgical obesity therapy technique. MATERIAL AND METHODS We conducted a single survey center in Iaşi University Center, included 30 persons, 10 men and 20 women, aged between 16 and 60 years old (36.7+/-13.9) and a BMI between 30.1 and 55, 1 kg/m2 (38.6+/-6.3). The aim of this survey was to underline the necessity of implementation of all new methods of obesity treatment in Romania and to determine the patient compliance regarding the new surgical obesity therapy technique. Responses to two questionnaires were evaluated. This survey was approved by the Ethical Committee of the University of Medicine and Pharmacy Grigore T. Popa - Iasi and every person who participated in the survey has signed an informed consent. The first questionnaire is a quality of life questionnaire, proposed by George Parkerson et al. in 1990 (5). The second questionnaire is a personal questionnaire that included 20 questions and try to emphasize knowledge of the studied persons about treatment methods of obesity and their compliance on UAM technique. The questionnaire was accompanied by an information sheet on bariatric surgery techniques and UAM. For the rest of the data presented, the Internet was the source of information. RESULTS AND DISCUSSION Worldwide, the treatment of obesity is a combined treatment. Basically there are three major therapeutic principles: lifestyle changes, medication and surgery (bariatric and plastic surgery). Surgery is the most effective way to combat morbid obesity after the U.S. National Institutes of Health (6). Surgery is dedicated to only selected cases, when other treatment methods have been exhausted: diet, sports, psychotherapy, anorexogenics, lipase inhibitor, behavioral therapy, therapy for possible endocrine disorders. After bariatric surgery, the patient may benefit from a series of plastic surgery procedure to reshape the body: liposuction, dermolipectomy, brahioplasty, abdominoplasty. UAM is a liposuction technique based on the use of ultrasonic energy, which allows the selective destruction or fat emulsification, which is then aspirated. With this method the blood loss are minimal (7,8) and the amount of lipoaspirate that can be eliminated in a single session can reach up to 20 liters. For this reason UAM can be used in the treatment of obesity. Unlike traditional liposuction, UAM selectively destroys only target adiposity and spares support structures of the skin and dermis, such as vessels, nerves, collagen matrix and elastic fibers, thereby preserving the elasticity of treated areas (9). It has been hypothesized that liposuction should not only have a remodeling role but also a functional one, removal of large 952

3 The place of ultrasound assisted megaliposuction in the Romanian obesity therapy quantities of fat lead to increased lipase activity, leading through a feedback mechanism, to a continuous reduction in body weight, linked to inhibition of hunger center (10, 11, 12). For this reason, liposuction is performed not only for aesthetic reasons but also for therapeutic purposes to improve the quality of life of obese patients. UAM can be practiced in combination with bariatric surgery in the treatment of morbid obesity, but it may represent a reliable alternative to this. In Romania, there are about 300,000 obese patients who should benefit from such interventions. Of these, only 4,500 were operated in the last 20 years, over 2,500 by Dr. Catalin Copaescu and his team, at BariXL Center, the only center of excellence in the treatment of obesity and metabolic diseases in Romania, center accredited by specialized forums in Europe and the United States (IFSO- EC). In Romania, laparoscopic gastric bypass, gastric banding and gastric sleeve procedures are performed in Bucharest, Timisoara, Cluj Napoca, Târgu Mures. In Romania, the first laparoscopic gastric bypass surgery was performed in 2002 (13, 14). Since then, 170 operations of this type were performed. This experience is a priority in Romania. The experience of Romanian surgeons in the laparoscopic treatment of obesity approaches 1,000 patients, thus constituting one of the most important experiences in the Balkans. However, it cannot be said the same about their experience in terms of UAM technique. There are no publications concerning the application of this method in Romania. Technically and in terms of housing, UAM can be introduced in the Romanian obesity therapy dedicated programs in centers where there is an interdisciplinary group involved in the study and treatment of obesity (table I) and only after surgeons were familiarized and trained in performing this surgical techniques, in order to minimize intraoperative and postoperative complications. The learning curve of this technique is long (15,16), it involves a minimum of 30 patients and it requires careful attention to detail in terms of volume of tumescent solution infiltrated and ultrasound aspiration time (17). TABLE I Interdisciplinary group involved in the study and treatment of obesity NUTRITION AND METABOLIC DISEASES Bariatric Medicine Control of Diabetes GENERAL SURGERY Bariatric Surgery PLASTIC AND RECON- STRUCTIVE SURGERY Body reshaping surgical techniques U.A.M. PSYCHIATRY PSYCHOLOGY Treatment of eating disorders From an economic perspective, in the year 2000 it was published a comparative evaluation of systemic effects, efficacy and cost for SAL, PAL and UAM (16). Cost analysis (table II) showed that UAM is the most expensive technique. The choice of the ideal technique depends always on the surgeon. Thus, UAM is the technique preferred by surgeons for patients with morbid obesity, being the only method that allows liposuction of a large amount of adipose tissue in one surgical session, with minimal blood loss (7,8). UAM equipment is indispensable for the complex treatment of obesity and it should be found in all specialized centers. 953

4 Laura Maria Curic, Carmen Vulpoi Nowadays, the public health sector in Romania is going through a difficult period. Not the same can be said about private medical services, which are more present than ever. The number of private hospitals, increased from 12 in 2006 to 84 in 2012, are able to raise to the necessary UAM application requirements in the treatment of obesity. Thus, the implementation of all new methods of obesity treatment in Romania, as an UE member state, is not an illusory idea, but a reality and it should be a matter of national interest and a priority of the Ministry of Health. TABLE II Total cost of a single procedure (1 unit = 500 USD) (adapted from 16 ) Cost (units) SAL PAL UAL Hospitalization Surgery room Equipment Total Our survey was approved by the Ethical Committee of the University of Medicine and Pharmacy Grigore T. Popa - Iasi and every person who participated in the survey has signed an informed consent. Interpretation of the scores of the 10 scales of the Duke Health Profile questionnaire revealed a significant impairment of life quality both physically (43.3+/-24.4), mentally (55.3+/-40.1) and from the socioprofessional point of view (51.6+/-30.5). Most people have a real perception (45+/- 37.9) of their general poor health condition (50.06+/-25.6). For this reason we notice a decrease in the self-esteem score (53.3+/- 35.7) and depression-anxiety installation (Duke-Ad Score 44.4+/-32.05). Duke Health Profile questionnaire assessment results emphasized once again that obesity is a disease often overlooked due to the lack of pain (Pain Score 38.3+/-33.9) but very severe and associated with morbid complications (Disability Score 60+/-33.2). Resolution of co-morbidities and regaining of self-esteem would improve dramatically the quality of life. By evaluating the responses to the 20 questions of the personal questionnaire, we reached the following results: 30% of people had a I st grade obesity (BMI kg/m2); 30% of people had a II nd grade obesity (BMI kg/m 2 ) of which 20% of people show associated comorbidities and 40% of people had III rd grade obesity (BMI> 40.1 to 55.1 kg/m 2 ). In conclusion 60% of people had morbid obesity. In our study, 40% of people, 30% with I st grade obesity and 10% with II nd grade obesity but without associated comorbidities, can benefit from medical treatment and only for inefficiency of this therapy after 1 year, we can discuss a UAM technique, not having bariatric surgery indications in these cases. Only half of them (1 man and 5 women) had medical therapy instituted: 1 man and 1 woman had diet associated with sports and drug therapy and 4 women had diet associated with sports and psychotherapy. Although all 5 young people (2 men and 3 women) aged between 16 and 19 years old had a form of depression, only 2 women of 16 and 18 years old have received medical psychotherapy. The medical treatment was of minimum one yearin 4 cases and of 6 months in 2 cases. Its efficiency could be observed only in 3 cases of the 4 who benefited from therapy more than one year. The patient who received this therapy for one year and to whom it proved ineffective, can benefit from UAM. The other two cases should continue therapy for at least one year and 954

5 The place of ultrasound assisted megaliposuction in the Romanian obesity therapy for the 6 cases who remained untreated, it can be established a complex medical therapy for at least 1 year. In case of its inefficiency after one year (30% of people), UAM may be considered for patients without contraindications. From all the patients, 60% of people with morbid obesity, 20% with II nd grade obesity and associated comorbidities and 40% with III rd grade obesity, can theoretical benefit of bariatric surgery techniques and UAM as conservative therapeutic methods (diet, exercise, medications) are effective in patients who do not have severe forms of obesity (BMI < 35 kg/m 2 ). In the case of morbid obesity results are poor, but conservative treatment methods must be applied for at least one year before surgical techniques. Obesity surgery is considered today the most effective treatment for morbid obesity. Only 30% of people with morbid obesity had indications for bariatric surgery and 16.6% for UAM. Contraindications were represented by depression (23.3%), varices (10%), inguinal hernia (6.6%), and weight > 140 kg without weight loss diet (6.6%), effective gastric banding (3.3%), diagnosis of less than 5 years (3.3%). In conclusion, assessment of the second questionnaire results revealed that in the moment of the study only 30% of people with morbid obesity had indications for bariatric surgery and 16.6% for UAM. In case of inefficiency of the one year medical therapy in the case of the 30% people with no morbid obesity, 46.6% had indications for UAM. With regard to information held by 30 people, only 36.6% (age 16-29) had summary information about bariatric surgery and only 13.3% (age 25-36) about UAM. The source of information was represented by the physician in 16.6% cases and by Internet in 33.3% cases. Given this situation, people compliance on this technique was very low 16.6%. The people compliance on this technique has increased 3.6 times after reading the information sheet attached to the questionnaire concerned. All patients have shown interest in being included in a therapeutic program for obese patients, including: diet, sports, psychotherapy, bariatric surgery, UAM, body shaping and other techniques. It should be noted that our survey, being accomplished in a single center, can be only a mere guide, thus it is necessary a multicenter study to define the result. CONCLUSIONS Obesity is a serious medical condition. Co-morbidities related to obesity are responsible for decreased life expectancy by nine years to women and by 12 years to men. In Romania, one of two people is overweight and one of four is obese. Treatment of obesity should be a combined treatment: diet, sports, psychotherapy, drug therapy, bariatric and plastic surgery. Surgery is the most appropriate therapeutic option for patients with morbid obesity. UAM has metabolic effects and significant morphological effects, improving quality of life of patients who maintained a constant body weight (12). UAM can be practiced both in combination with bariatric surgery in the treatment of morbid obesity, but it may represent a reliable alternative to this, when patients refuse it. In addition, UAM represents an attractive alternative for patients with BMI kg/m 2 and surgical recommendation, who are not candidates for bariatric surgery and are unresponsive to other forms of therapy. UAM is also a solution in the case of juvenile obesity (young people up to 18 years old, not having a bariatric surgery indica- 955

6 Laura Maria Curic, Carmen Vulpoi tion, for which other treatment methods have failed). The experience of Romanian surgeons in the laparoscopic treatment of obesity is one of the most important experiences in the Balkans, but there are no publications concerning the application of UAM method in Romania, although it has become in Europe and the United States one of the basic techniques of body reshaping methods arsenal since For the UAM technique to become a reality also for obese patients in Romania and for obese patients to be included in a specific therapeutic program, several conditions must be taken in consideration: - creation of centers adequately equipped in the existing private hospitals, with an interdisciplinary group involved in the study and treatment of obesity (nutritionist, general surgeon, plastic surgeon, anesthesiologist, psychologist); - organization of UAM learning technique trainings for surgeons; - creation of a grant program for patients with indications for operation, given the precarious pecuniary situation of the population; - organization of information programs both for population and for family physicians (brochures, radio, TV, internet, conferences, symposia, etc.). REFERENCES 1. Pi-Sunier FX. Medical hazards of obesity. Ann Intern Med 1993; 119: FosterWS, Burton BT, Van Itallie TB. Health implications of obesity: NIH consensus development conference. Ann InternMed 1985; 103(Suppl 2): Calle EE, Thun MJ, Ptrelli JM, et al. Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med 1999; 341: McGinnis JM, FoegeWH. Actual causes of death in theunited States. JAMA 1993; 270: Parkerson GR Jr, Broadhead WE, Tse CK. The Duke Health Profile. A 17-item measure of health and dysfunction.med Care 1990; 28(11): Gastrointestinal Surgery for Severe Obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr1992; 55: 615S 619S. 7. Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg 1992; 16: Zocchi M. Ultrasound-assisted lipoplasty. Adv Plast Reconst Surg. 1998; 11: Di Giuseppe A. Ultrasonic Assisted liposculpture. Presented at the World Congress on Liposuction. San Francisco, May 3 5, Bastard JP, Jardel C, Bruckert E, et al. Elevated levels of interleukin-6 are reduced in serum and subcutaneous adipose tissue of obese women after weight loss. J Clin Endocrinol Metab 2000; 85: Arner P. Not all fat is alike. Lancet 1998; 351: Busetto L, Bassetto F, Zocchi M et al. The effects of the surgical removal of subcutaneous adipose tissue on energy expenditure and adipocytokine concentrations in obese women. Nutrit Metab Cardiovasc Dis 2008; 18: Copaescu C. Laparoscopic sleeve gastrectomy for morbid obesity. Chirurgia 2009; 104(1): Copaescu C, Munteanu R, Prala N, Turcu FM, Dragomirescu C. Laparoscopic mini gastric bypass for the treatment of morbid obesity. Initial experience. Chirurgia, Bucureşti 2004; 99(6): Matarsso A. Ultrasound-assisted lipoplasty: is this new technology for you? Clin Plast Surg 1999; 26(3): Scuderi N, Paolini G, Grippaudo FR, Tenna S. Comparative Evaluation of Traditional, Ultrasonic, and Pneumatic Assisted Lipoplasty: Analysis of Local and Systemic Effects, Efficacy, and Costs of These Methods. Aesth Plast Surg 2000; 24: Zukowski ML, Ash K. Ultrasound-assisted lipoplasty learning curve. Aesth Surg J 1998; 18(2):