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Section 2: Father of IFSO: The Visionary from Genoa, Nicolo Scopinaro, MD

Francesco Saverio Papadia

Introduction: A Surgeon Who Lived Twice

When Nicola Scopinaro stood before the IFSO World Congress in Genoa in May 2000 and delivered
his one-hour opening lecture, he called it “My Way.” It was not arrogance but rather a quiet statement
of fact from a man who had already lived a life that would have filled several books. By the time he
turned fifty, he had invented the most effective operation for severe obesity, the biliopancreatic
diversion (BPD, the Scopinaro Procedure); became one of the first to recognize that MBS could cure
type 2 diabetes (T2D) even in patients who were not with severe obesity; survived two near fatal
accidents (one while parachuting, another while driving his car); earned his pilot’s license; traveled
the world as an invited speaker; and, importantly, founded a scientific society, the International
Federation for the Surgery of Obesity (IFSO). And yet, as Luigi Angrisani wrote, “for Nicola, this was
the second round.”
Scopinaro was a surgeon and scientist of broad culture and fierce passion. He was as much at home
reciting Dante from memory as leading a room of surgeons. To those who worked beside him, he
was much more than a list of achievements: he was a mentor, a friend, and a man who made
everyone around him believe that they, too, could contribute something meaningful. Nicola
Scopinaro was not only a pioneer of metabolic bariatric surgery (MBS), but the visionary who united
the world in the fight against obesity.

The Genesis of the Biliopancreatic Diversion (1973–1976)
The Failure of Earlier Approaches

In the early 1970s, the surgical treatment of severe obesity was caught between two inadequate
extremes. The jejunoileal bypass (JIB), introduced by Payne and DeWind in 1954, produced good
weight loss by creating massive, indiscriminate malabsorption, but it came at a terrible price: protein
malnutrition, electrolyte imbalances, liver failure, and bacterial overgrowth in the excluded bowel. By
the mid 1970s, the JIB was being abandoned worldwide. Scopinaro, trained in the rigorous
physiological tradition of the University of Genoa (where his father, Professor Domenico Scopinaro,
had been a renowned internist), saw the problem with unusual clarity. What was needed was
selective malabsorption: a way to reduce the absorption of calories from fats and starches while
preserving the absorption of proteins, vitamins, and minerals.

The Scopinaro Solution: Combining Restriction and Selective Malabsorption

Between 1973-1976, Scopinaro and his team worked systematically in the laboratory in the animal
model to understand and perfect the novel technique. The operation had two components, acting
at different times. First, a limited distal gastrectomy created a small stomach pouch of about 200-300
ml with a wide, non-restrictive stoma. This induced a temporary reduction in food intake, allowing
rapid initial weight loss. Unlike gastroplasty, the wide stoma meant that patients did not vomit if they
ate slightly more. After a few months, appetite returned to near normal.
Second, a long biliopancreatic limb diverted the duodenum and proximal jejunum so that bile and
pancreatic juices met food only in the distal ileum, 50 cm from the ileocecal valve. This meant that
fats and complex carbohydrates, which require bile and pancreatic enzymes for absorption, were
poorly absorbed, while proteins, water, minerals, and most vitamins were absorbed normally in the
proximal alimentary limb. Selective malabsorption was achieved. The first BPD in a human patient
was performed in May 1976 at the University of Genoa [1]. The weight loss was dramatic, 85% of

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