Obesity Surgery in Spain

Special Article – Obesity Surgery in Spain

Austin J Surg. 2020; 7(2): 1243.

Obesity Surgery in Spain

Aniceto Baltasar*

San Jorge Clinic, 55 Oliver, Alcoy, Spain

*Corresponding author: Aniceto Baltasar, San Jorge Clinic, 55 Oliver, Alcoy, Spain

Received: February 06, 2020; Accepted: March 09, 2020; Published: March 16, 2020

Abstract

Gastric obesity surgery (OS) from the Greek bari = weight and iatrein = cure) treats obesity and began in Spain in 1977. Its greatest development occurs after the founding of SECO (Spanish Society of Obesity Surgery) in 1997. The purpose of this work is to reflect the changes that have occurred in these 23 years.

Keywords: Morbid obesity; Bariatric surgery; SECO

Abbreviations

VBG: Vertical Banded Gastroplasty; GB: Gastric Banding; RYGBP: Roux-en-Y Gastric By Pass;

OAGB: One Anastomosis GBP/mini GBP; BPD: Bilio-Pancreatic Diversion; ID: Intestinal Diversion; DS: Duodenal Switch; SADI: Single Anastomosis Duodenal-Ileostomy; SFG: Sleeve-Forming Gastrectomy; ABS: Adolescent Bariatric Surgery; ABS: Adolescent Bariatric Surgery; REV: Revision/Conversion of Prior Surgery; MO: Morbid Obesity; WL: Weight loss; %EWL: % Excess Weight Loss; L: Laparoscopic

Introduction

Obesity is a multifactorial epidemic ailment of environmental origin, affecting subjects from all countries. The surgical treatment represents a unique case of surgery to operate on healthy organs, which are not the cause of the disease and do not improve after the operation.

Kremen & Linner [1] and Varco & Buchwald in Minneapolis, MN teams began the malabsorptive intestinal diversion (ID) in 1954. Payne [2] and Scott [3] developed these ID techniques in the 1960s leaving only 14-4 inches (35-10 cm) as an absorptive zone and those were abandoned in the 1970s because of their serious metabolic (malnutrition) and hepatic (liver failure) complications.

Historical keynote

Cordoba (Qurtuba in Arabic) was the most civilized city in Europe in the 10th Century. Andalusia was home to the most famous physicians of the Middle-Ages, Averroes (1126-1198) and Maimonides (11351204). Sancho “the Fat”, King of León 956-958, was deposed due to his massive obesity that unable him to ride a horse. He found safety in Pamplona, in the Navarre Kingdom 400 km from León, where his grandmother, Queen Toda, ruled. Toda’s aim was to regain the kingdom of León for her grandson, but this was impossible unless Sancho the Fat lost his massive excess weight. Hasdai ibn Shaprut was a famous Jewish physician at Cordoba’s Abdurrahman III’s court. He travelled to Pamplona to evaluate Sancho super-super-obesity and decided that he would only treat him if he came to Cordoba. The 800-km trip was an ordeal because Sancho could not ride a horse or fit into a carriage. He remained semi-conscious for most of the trip and was carried in a special canvas tent, devised by Hasdai, between four mules. The queen, Toda (Abdurrahman III’s aunt), Garcia (her son, the king of Navarre) and Sancho lived in Cordoba for 6 months, during the time that the treatment lasted. The treatment consisted of suturing Sancho’s lips together and feeding him only through a straw. Sancho lost half his weight, returned to León riding a horse, and was able to regain his kingdom in 959 Baltasar (AB) [4].

First Spanish experience

Prof. Sebastián García Díaz of Seville carried out the 1st Scotttype Jejune-ileal diversion (JID) at Virgen Macarena Hospital on 11.19.1973. He began ID surgery in Spain with 12 cases [5-7] and then published 20 more, and the 1st work in English by a Spanish author [8] in 1981. His works went unnoticed for 40 years until we rescued them in 2013 [9] (Figure 1).

Figure 1: 

    

    
    

    

    Figure 1:

In 1964 Mason [10] initiates the GBP. It was a total change in strategy. Capella [11], álvarez-Cordero [12] (both 1st SECO Honorary Members) and Fobi [13] made very important contributions to this technique as well as many other authors in the 1970s. AB [14] performed in June 17, 1977 the 1st Mason-type GBP in Spain.

Scopinaro [15], a tireless researcher and clinician, initiated experimental and clinical gastrectomy with biliopancreatic diversion (BPD) in 1976 [16,17]. He is the leader and “father of European bariatric surgery” and participated in multiple congresses and publications. His combined mixed a technique of gastrectomy plus BPD as the most effective for treating obesity [18]. He is an Honorary SECO Member and the only foreign Outstanding Achievement Award winner (OAAW) of the American Association of Metabolic and Bariatric Surgery (ASMBS).

DBP became a very popular technique and was a commonly used in Spain. Larrad and Sánchez [19-21] published extensively on a modification of their own and other authors used this technique in Zaragoza [22-25] and Santander [26,27].

Mason [28] “father of BS” published in 1982 the vertical banded gastroplasty (VBG) in 18 patients and that was the 1st great revolution by making OS “easy and affordable”. AB [29] in 1984 broadcasts a VBG in RTVE and it was 1st Spanish documentary in obesity surgery in a man with BMI-52.Laporte [30] published the 1st Spanish VBG experience in 9 cases.

Reopening of the vertical staple-line was a serious disadvantage of the VBG because it cancels out the restrictive effect of the operation. AB [31] in 1989 described the separation with staples between gastric tube and the rest of the stomach and did not have a single recanalization in 100 cases. Alcoy’s Andreo [32] described the typical radiological “peanut deformity” of the VBG.

Many Spanish surgeons performed VBG [33-35]. AB [36] published his first 100 VBG cases in 1990 with excellent results, but 5 years later he reviewed the same patients and describes it as a “frustrated hope” [37,38]. Two years later this technique was abandoned.

Belachew [39,40] initiated in Belgium on 1/09/1993 the use of laparoscopy with the 1st laparoscopic adjustable gastric band (LAGB) operation and that was the 2nd revolution in bariatrics.

Favretti [41] performed on Sept 27.1995 the 1st LAGB operation in Spain at Madrid “La Paz” Hospital (Figure 3) assisted by Masdevall/ AB (Figure 2).

Figure 2: 

    

    
    

    

    Figure 2:

Figure 3: 

    

    
    

    

    Figure 3:

Carbajo [42] in 1986 published the 1st 12 LAGB in Spain and Alastrué [43] compared VBG with LAGB. More than 650.000 of LAGB were done all over the world and then the technique was abandoned due to poor long-term results.

Laparoscopy changed the way of doing surgery not only in bariatrics but in all general surgery. Advances in bariatric laparoscopy, being repetitive operations and performed on healthy organs were the greatest advance in XXI century surgery.

In the 90’s the American Society of Bariatric Surgery [ASBS] was the 1st national bariatric society created by Edward Mason on June 3,1983 in Iowa City, IO [44], the town he worked all his life. Deitel created Obesity Surgery, as the 1st obesity journal in 1990 [45] Figure 3.

The International Federation of Surgery for Obesity (IFSO) is founded in 1995 and the standards to report the results [46].

The Spanish Society of Obesity Surgery (SECO) was founded at Residencia Pérez Mateos, San Juan, Alicante by 26 surgeons on December 12.1976 (Figure 4-6).

Figure 4: 

    

    
    

    

    Figure 4:

Figure 5: SECO Founding members.

    

    
    

    

    Figure 5: SECO Founding members.

Figure 6: SECO Presidents.

    

    
    

    

    Figure 6: SECO Presidents.

SECO joined IFSO in 1998 and AB became IFSO-2002 president. He organized and preside IFSO-Salamanca-2003. Dr. A. Torres was the 2nd Spanish president of IFSO and organized IFSO-2019-Madrid, the world’s largest bariatric meeting. Spain is the 2nd country to organize this congress twice.

Wittgrove and Clark in October 27, 2003 [47-49] made the most significant step in performing the 1st laparoscopic gastric bypass (LGBP) in San Diego. This is the 3rd revolution of BS. AB was the San Diego 1st visitor in September 2007. Wittgrove [50], and at our proposal dropped the use of the huge circular #33 port to pass the circular stapler, and use no trocar, a very important step in those early times.

We performed the 1st LGBP in Spain on 1.14.1997 [51] and presented it [52] in Bruges IFSO-1998 as the 1st European to report it on video.Serra [53] published in 1999 the 1st world hernia after LGBP. Higa [54] made fortunately the 1st LGBPs with manual sutures.

AB [55] published the 1st book in Spanish on OS in 2000. Martínez [56] from Vitoria published a bilingual BS book (Spanish and Basque) on 2001. De la Cruz [57] published in 2006 the 1st Spanish book on LGBP and carried out the 1st surgical session in León. García-Caballero [58] published a book in English on diabetes surgery (Figure 7).

Figure 7: Books published by SECO members.

    

    
    

    

    Figure 7: Books published by SECO members.

In 1988, Hess [59] and Marceau [60] initiated the duodenal switch (DS), a Sleeve-forming Vertical Gastrectomy (SFVG) plus BPD and AB [61] started it on 3.17.1994.

Ren/Gagner [62] performed the 1st world LDS in October 1999 and AB on 5.10.2000 [63] the 1st LDS in Europe. (Figure 8). This difficult and controversial technique of LDS by the Switchers surgeons is rarely used today, in less than 1%.

Figure 8: 

    

    
    

    

    Figure 8:

AB [63] had a low mortality of 0.4% with LDS on 950 patients and he thinks [64] it is the most effective technique to lose weight.

There have been many technical variations in laparoscopy. In general, all viscera division is done with auto sutures. The anastomosis is done either with auto sutures or manual ones. We advocate the manual suture starting always with the sliding, self-locking sliding knot of Serra - Baltasar [65,66].

SECO members reported BS surgeries in the early years of OS and SOARD. Spain was the 2nd country with the highest number of publications after the USA in 2005 and 2006 and in 2013 was the 5th country with the highest number of publications in SOARD (Figure 9,10).

Figure 9: SECO Spanish pubs en Obes. Surg. 2005-6.

    

    
    

    

    Figure 9: SECO Spanish pubs en Obes. Surg. 2005-6.

Figure 10: Spanish publications in SOARD 2014.

    

    
    

    

    Figure 10: Spanish publications in SOARD 2014.

SECO members have been very active publishing in OS and SOARD (Figure 8 & 9). Among the SECO founding members there has been a high bibliographic volume (Alcoy-124, Carbajo-76, Belvitge-38, Alastrué-30, Martín-Duce-27, Martínez C.-22, Ballesta-9, Zaragoza-5). In 2003 SECO made the Salamanca Declaration on BS [67].

Laparoscopic Sleeve-Forming Gastrectomy (LSFG), the restriction part of DS, was described by several authors in 2005. AB paper on LSFG [68], is according to Ahmad [69] the 61st most cited article the bariatric literature. Angrisani [70] claims that the LSFG is today the most commonly performed operation in the world. We start the gastrectomy at the pylorus and suture the gastric anterior and posterior serosa, covering the staples, to prevent rotation of the sleeve and avoid leaks.

Rutledge described 1,274 cases of mini-gastric bypass in 2001 [71] and Spanish authors have developed two popular techniques. Carbajo [72] performs since 2004 the lesser curvature reservoir without gastric resection, the one anastomosis OAGB, a GBP with latero-lateral diversion to an intestinal loop. He presented more than 3,500 cases at the 1919 World Congress in valladolid and is today the fasters growing technique in the world (Figure 11).

Figure 11: 

    

    
    

    

    Figure 11:

Sánchez and Torres [73] at Madrid Clinic Hospital, describe in 2005 the one anastomosis DS or SADI in English. There is gastric resection in the form of SFG and the BPD is done end-to-side at the duodenum (D1). The operation is becoming very popular all over the world. Currently they have more than 350 cases (Figure 12).

Figure 12: 

    

    
    

    

    Figure 12:

BS at Barcelona Bellvitge hospital has organized 16 consecutive bariatric courses and Torres/Sánchez another 16 annual courses at Madrid Clinic Hospital.

We founded BMI-Latina Journal (Iberoamerican Bariatric and Metabolic) www.bmilatina.com in 2011 as an a online magazine published in Spanish, English and Portuguese. Adopted by SECO in 2015, it may play a valuable role in Spanish and Portuguese speaking BS societies.

In 2009, Scopinaro, Melissas, Fried and AB create the IFSO European Chapter of the Centers of Excellence Program (ECEP). Currently, several Spanish centers and surgeons use this prestigious quality control program.

SECO members have participated in numerous local, regional, national, and international meetings and congresses, especially in Latin American societies where SECO has always been very kindly well received. In May 1998 AB organized the 1st Symposium at the meeting of the prestigious course of Prof. Moreno González, with Drs. Cowan, Fobi, Scopinaro, Clark & F.de la Cruz.

In 2003, AB inaugurated the Spring (NYC) and Fall (Chicago) with two keynote lectures at the American Congress of Surgery with on DS. AB received the IFSO-Lifetime Membership Award in June 2011 and was a nominated finalist for the prestigious ASMBSOutstanding Achievement Award at the ASMBS meeting in Orlando, Florida (Figure 13).

Figure 13: 

    

    
    

    

    Figure 13:

Diabetes Surgery

Part of the BS is dedicated to diabetes as metabolic surgery. AB [74] published a successful 1st intervention in 2004 BPD-without- SFG.

Resa and Solano [75] describe 65 cases of gastro-ileal bypass as the simplest, quickest and safest technique to treat obesity. And then Resa [76] again publishes 1512 more cases. Alhambra [77], Vidal [78], Vilarrasa [79], García [80], Cruz [81] and Torres [82] have published on the same subject.

Laparoscopic OS in children and adolescents (ABS)

OS is increasingly used in children. AB [83,84] published the 1st national SFG in 2004 on a 10-year-old boy with excellent results 10 years later.

Carbajo [85] has a case with 5 years follow-up and then in 2019 again [86] reports the more extensive experience in ABS with 39 patients treated with OAGBP with excellent results.

Vilallonga [87] reports that the overweight rate in 4–24 years-old children has increased by approximately 10% in the last 20 years. It is estimated that today, 20% of boys and teenagers and 15% of girls are overweight.

Robotics bariatric surgery

Cadiere and Favretti performed the world’s 1st robotic bariatric operation at a distance in 1998. Diez and Blázquez perform the first 12 robotic Spanish bariatric surgeries in Vitoria-2013. Vilallonga (1st accredited robotics surgeon in Spain) and Fort from 2010 in the Hospital Vall d´Hebron in Barcelona develop robotic surgery [87] and performed more than 540 cases with the da Vinci (Figure 13) Surgical System® (Intuitive Surgical, Sunnyvale, CA) at the beginning with GV and them DG robotics [88] (Figure 14).

Figure 14: 

    

    
    

    

    Figure 14:

Morales [89] performs in Seville the complex single port surgery of since 2012 and today leads the European surgery [90].

A. Lacy initiated AIS-Channel as a pioneering worldwide on-line TV transmission and made the 1st BS remote operation by cellphone G5 from Barcelona Clinic Hospital on 4.14.2019 at the WORLDVIDEO Forum Barcelona-2019.

The biography of some members of the Spanish society [91-95] has been published in the Obes. Surg.

Surgeries performed in spain 2018

1st-Surgeries: 5.952; 2nd-Revision: 343.

Total Complications: LGBP-3.7% and LSFG-3.6%; LGBPLeaks- 1.2%, Bleeding-2.3%, PET-0.1% Re-op-2.3% Exitus-0.1% and in SFG-Leaks-1.5%, Bleeding-1.9% PET-0.1% 2.1% Deaths-0.1%. Extraordinary good results!

Private centers report multiple operations over the years with different techniques: Valladolid-4.255, Teknon-3.000, De la Cruz- 2.493, Zaragoza-2.649, Alcoy-1.729.

We should publish all serious complications such as malnutrition [96], leaks [97-99], total gastrectomy’s [100], liver failure [101-103], stapling of the bougie [104], emergency tracheostomy [105] and mistakes as the Journal of negatives or non-positive results (JNNPR) [106], since it is more likely to learn from negative results than positive ones.

BS is performed in public centers in all regions of Spain with very low leakage and complication rates. But it is not yet performed on an outpatient basis.

If OM is an epidemic pathology and if CB is the best solution, it should be accessible to more subjects. Duncan [107] performs ambulatory BS, and this will be the 4th great bariatric revolution. They have two-teams. Team A uses 2 operating rooms, 2 anesthesiologist nurses, 2 scrub nurses and an operating room technician as an assistant while team B have visiting and prospective patients. Team A and B switch duties in the afternoon cases. Operative times of 22´. The surgeon passes from OR-1 to OR-2 with the patient already anesthetized. He changes gloves and do 5 patients in total in the morning. In the afternoon, surgeon-B operates while team-A have consultations. Total 10 patients per day. 50 cases per week, 2, 2000 cases per year. No overnight stay. All morning patients are discharged before 14 hours. There is no hospitalization.

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