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Development of bariatric/metabolic surgery in Vojvodina

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Development of bariatric/metabolic surgery in Vojvodina
Развој баријатријске/метаболичке хирургије у Војводини SUMMARY The paper presents the chronological development of bariatric/metabolic surgery in Vojvodina, the region with the largest incidence of obesity in Serbia, and in which 13.2% of the population suffers from diabetes with a mortality of 15.7 / 100.000, which is one of the highest rates in Europe. Bariatric surgery began in the 1950s in the United States, with the consecutive development of various restrictive, malabsorptive, and combined procedures, which are intensified by the adoption of laparoscopic techniques. After initial, European knowledge and preparation of obese patients for surgery at the end of the 1970s, the first laparoscopic bariatric/metabolic interventions started in Vojvodina at the Clinical Center in Novi Sad in 2006. Next year, the multidisciplinary team for bariatric surgery is being prepared in Slovenia and Austria, and the first interventions are performed in 2008 at the Clinic for Thoracic Surgery of the Institute in Sremska Kamenica, in the first place -laparoscopic sleeve gastrectomy. Since then, bariatric/metabolic surgery at this Institute has been performed continuously. By establishing international cooperation, three courses were held with demonstration operations in bariatric/metabolic surgery and the participation of eminent surgeons and other experts from the country and abroad. Several bariatric surgeries were performed on children (Children's Surgery Clinic in Novi Sad), as well as in Sremska Mitrovica. Their own experience in this field has been published in the international literature and through several regional meetings dedicated to metabolic surgery.

INTRODUCTION
Bariatric surgery or weight loss surgery is considered different operative procedures with the aim of treating obesity. The word bariatric has origin from the Greek root of the two words which mean weight and treatment [1]. Obesity is a serious public health problem [2]. People who have elevated BMI have a significantly increased risk of developing cardiovascular, endocrine and infectious diseases, diabetes mellitus, cancer and asthma, as well as sleep apnea, musculoskeletal disease and sudden death [3,4,5]. In addition, obesity affects the social, economic and psychological function of a person in society. Although conservative treatment is first in the treatment of obesity and includes a diet, exercise, lifestyle change, and anti-obesity drugs, it is not successful in a long way [6]. Today, the surgical treatment of obesity and associated "metabolic syndrome" is recommended by the World Health Organization, but also by endocrine and other international associations [7,8]. Due to the effects on metabolism, primarily on the metabolism of glucose and fat, bariatric surgery is also called metabolic surgery. Vojvodina is according to the epidemiological and social medical indicators of the regions in Serbia and Europe, especially and most affected by obesity and associated metabolic syndrome, primarily diabetes and hypertension. According to the Institute of Public Health Institute in Serbia report of 2016, 13.2% of the adult population suffers from diabetes mellitus type 2, with a mortality rate of 15.7 / 100.000, which represents the highest rate in Europe.
Vojvodina and its "districts" (Bačka, Central-Banat and South-Banat district) have the highest incidence of diabetes, over 160:100,000 [9,10]. In the past decades sporadically and relatively constant in the last ten years, bariatric/metabolic surgery in Vojvodina has been performed.
The aim of the paper is to present the development of bariatric/metabolic surgery in Vojvodina.

THE HISTORY OF BARIATRIC/METABOLIC SURGERY IN THE WORLD
The development of open bariatric surgery began in the fifties of the last century, using the intestinal bypass [11]. In this procedure, the upper part of the intestine (jejunum) merged with the lower part of the small intestine (ileum), which left a large part of the small intestine to be excluded from digestion and caused weight loss by malabsorption [12]. Thereafter in the sixties years of twentieth century, a jejuno-colic bypass was made: the proximal small intestine is transected and anastomosed to the colon [13]. In 1967, on the basis of experiments in the laboratory, the "father" of bariatric surgery Edward Mason developed the original gastric bypass [14]. In 1977, following the work of Alden (who made gastro-jejunostomy -a surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum), Griffen introduced Roux-en-Y anastomosis into bariatric surgery and this procedure became a gold standard in bariatric/metabolic surgery [11,15]. As a combined restrictive and malabsorptive procedure, the Roux-en-Y gastric bypass was followed by dumping syndrome, iron deficiency and vitamin B12 deficiency. In the seventies and eighties in the last century, purely restrictive surgerygastroplasty -was brought to bariatric surgery [16]. The procedures on the stomach and its reduction were followed by the set of rings or staples [17]. These operations showed fewer complications but were accompanied by minor weight loss.
The modern era in bariatric surgery begins with the operation of the biliopancreatic diversion performed by the Italian surgeon -Nicola Scopinaro. The first report on 18 patients was published in 1979 [18]. He performed a horizontal hemi-gastrectomy with pouch drainage by a Roux limb of at least 250 cm length, joining a long biliopancreatic limb to form 50 cm long the common ileal segment, or channel. This procedure was converted by Picard Marceau et al. [19] in Canada to a vertical sleeve gastrectomy with cross-stapling of the duodenum and an approximately 100-cm common channel.
In 1998, Hess and Hess in the USA made a duodenal switch, by performing a sleeve gastrectomy, with pyloric preservation, duodenal division, a proximal duodeno-ileostomy, and a common channel of approximately 100 cm [20]. In this version of the biliopancreatic diversion called "biliopancreatic diversion with duodenal separation" (BPD-DS), which began to be performed laparoscopic, the volume of the stomach was reduced to about 200 millilitres, drawing the future sleeve gastrectomy.
Kuzmak introduced a silicone tape in 1986 that could be filled through the subcutaneous chamber and "adjusted" with clamping around the cardia area, preventing excessive filling of the stomach [21]. Forsell (1993) first set up a laparoscopic "adjustable gastric band" [22].
Laparoscopic sleeve gastrectomy (LSG) or vertical gastric resection was first performed by Michel Gagner in 1999 within the BPD-DS. In 2003, the same surgeon did the LSG as the first stage of two-stage Roux-en-Y gastric bypass (RYGB) surgery in patients at high risk and BMI higher than 50 kg / m2. Shortly after this description, the articles followed in which the LSG was performed as an independent and sufficient procedure for the treatment of obesity and metabolic disorders due to good results [23,24]. Today, this operation is the most commonly performed procedure in metabolic surgery in the whole world [25].

DEVELOPMENT OF BARIATRIC/METABOLIC SURGERY IN VOJVODINA
The first theoretical knowledge on bariatric surgery and the first preparation of patients were done in Novi Sad by the associate professor of surgery Borislav Savić, who worked in the Surgical Clinic from 1979 to 1981. He came from Germany as an affiliated surgeon and author of the book "Septic Surgery", published in Stuttgart [26].