Obesity Surgery in Spain

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.


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 10 th 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 1 st Scotttype Jejune-ileal diversion (JID) at Virgen Macarena Hospital on 11.19.1973. He began ID surgery in Spain with 12 cases [5][6][7] and then published 20 more, and the 1 st 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).
In 1964 Mason [10] initiates the GBP. It was a total change in strategy. Capella [11], Álvarez-Cordero [12] (both 1 st 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 1 st Mason-type GBP in Spain.
Scopinaro [15], a tireless researcher and clinician, initiated  [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).
Mason [28] "father of BS" published in 1982 the vertical banded gastroplasty (VBG) in 18 patients and that was the 1 st great revolution by making OS "easy and affordable". AB [29] in 1984 broadcasts a VBG in RTVE and it was 1 st Spanish documentary in obesity surgery in a man with BMI-52.Laporte [30] published the 1 st 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][34][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 1 st laparoscopic adjustable gastric band (LAGB) operation and that was the 2nd revolution in bariatrics. Carbajo [42] in 1986 published the 1 st 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. Wittgrove and Clark in October 27, 2003 [47-49] made the most significant step in performing the 1 st laparoscopic gastric bypass (LGBP) in San Diego. This is the 3 rd revolution of BS. AB was the San Diego 1 st 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 1 st LGBP in Spain on 1.14.1997 [51] and presented it [52] in Bruges IFSO-1998 as the 1 st European to report it on video.Serra [53] published in 1999 the 1 st world hernia after LGBP. Higa [54] (Figure 8). This difficult and controversial technique of LDS by the Switchers surgeons is rarely used today, in less than 1%. 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]. 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 61 st 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.    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). 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).

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

Laparoscopic OS in children and adolescents (ABS)
OS is increasingly used in children. AB [83,84] published the 1 st 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 1 st robotic bariatric operation at a distance in 1998. Diez and Blázquez perform the first 12 robotic Spanish bariatric surgeries in Vitoria-2013. Vilallonga (1 st 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).
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 1 st BS remote operation by cellphone G5 from Barcelona Clinic Hospital on 4.14.2019 at the WORLD-VIDEO Forum Barcelona-2019.
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 4 th 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.