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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
The Asia Pacific Chapter (IFSO-APC)
Harry Frydenberg and Lilian Kow
The Asia Pacific region was involved in the early stages of the development of metabolic bariatric
surgery (MBS) worldwide.
Dr Michael Long, an early initiator of MBS with a strong interest in weight-loss weight-loss surgery in
Melbourne, Australia performed the first MBS operation together with Dr Harry Frydenberg in 1974.
The procedure was a jejuno-ileal bypass. This early procedure was to be soon abandoned due to the
side effects of high morbidity and mortality associated with the blind-loop syndrome. Further MBS
operative procedures developed include the vertical banded gastroplasty (VBG) with the Australian
version of a long gastroplasty distinguished by a vertical staple line and stitches around the lower
end to create a stoma, rather than the American version wherein a hole was punched through the
stomach.
The popularity of the VBG persisted into the 1980s until the first fixed, and then later, adjustable
gastric band was introduced. The first Australian MBS society, the Obesity Surgical Society of
Australia and New Zealand (OSSANZ) was founded in 1984 with Dr. Ron Elmslie (Adelaide) as first
president. This inaugural meeting was held in Pokolbin, NSW, Australia with a small number of health
professionals from New Zealand and Australia interested in the surgical treatment of severe obesity.
OSSANZ continued to meet regularly to discuss developments in obesity surgery. In 1993, OSSANZ
hosted an international meeting in Echuca, Victoria with international visitors including Nicola
Scopinaro (Italy), Mitiku Belachew (Belgium), Mal Fobi (US), George Cowan (US), and Ingmar
Naslund (Sweden) cementing global friendship and collaboration. Thereafter, in 1995, when the
IFSO was formed in Stockholm, Sweden, OSSANZ was one of IFSO’s founding nation members.
Taiwan was the first of the other countries in the Asia Pacific region to become involved in MBS,
doing so as early as 1974; it was not until the early 1980s that the rest of the region followed. In
Japan, Taiwan, Korea, Malaysia, Singapore, and Hong Kong, the operations performed were gastric
partitioning or adjustable gastric banding. The adjustable gastric band was introduced by Dr.
Lubomyr Kuzmak, a Ukrainian-American surgeon, initially as an open procedure at the International
Bariatric Symposium held in Echuca, Victoria, Australia in 1993. This meeting was organised by Dr.
Andrew Jamieson, an early proponent of MBS from Melbourne, Australia. It was at this landmark
meeting that Asia Pacific surgeons were introduced to doyens of MBS from Europe and the US,
including Dr. Scopinaro, Dr. Fobi, and Dr. Naslund.
Laparoscopic adjustable gastric banding started in the Asia Pacific region after Dr. Belachew
performed the first human laparoscopic placement of the adjustable gastric band on 1st September
1993 at the CHU, Huy, Belgium. Professor Belachew went on to host numerous international gastric
band workshops and travelled the world teaching the surgical technique and presenting his data.
The adjustable gastric band became the most popular procedure in the Asia Pacific region for the
following two decades.
Professor Wei Jei Lee (Taiwan), in 2005, outlined in an article in Obesity Surgery (in the 2005
June-July issue) when MBS was performed in the Asia Pacific region: It was as early as 1974 in
Taiwan, followed by Japan in 1982 and Singapore in 1987. Dr. Kawamura (Japan) once said, “I
performed bariatric surgery in 1982 because such operations were necessary due to an increasing
number of severely obese people.” And he was right. Back in the 1980s, obesity was not considered
a disease. It was the epoch-making but much-needed surgery by Dr. Kawamura that changed the
status of research, and the development of surgical techniques for the treatment of severe obesity in
Japan and Asia. Countries like India, Hong Kong, Philippines, Korea, and Thailand did not start
performing MBS until after the turn of the century.

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