Obesity Surgery (2023) 33:665–667
https://doi.org/10.1007/s11695-022-06407-z
LETTER TO THE EDITOR
The Questionable IFSO Position Statement
Sergio Santoro1   · Almino Ramos2
Received: 21 October 2022 / Revised: 21 November 2022 / Accepted: 30 November 2022 / Published online: 19 December 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022
The recent IFSO Position Statement [1] contains misun-
derstandings, omissions, and some mistakes that deserve
discussion. First, it declares that Metabolic and Bariatric
Surgeries (MBS) are rising. Available IFSO [2] (not signifi-
cant increase) and ASMBS [3] (decrease) last numbers do
not allow this statement.
There is no reason to include approved procedures as One
Anastomosis Gastric Bypass (OAGB) and Single Anastomo-
sis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-
S) in a statement related to investigational MBS. The alleged
reasons were to recommend RCTs for them. But why were
Roux-in-Y gastric bypass (RYGB), sleeves (SG), and bands
excluded, if these procedures are also IFSO approved?
The Statement [1] also recommended that SG plus antire-
flux procedures, should be done under IRB approval because
of high complications rate. Can we expect to decrease
complications rate just by having the surgery done under
IRB approval? What MBS surgery was entirely developed
under IRB approval before clinical utilization? What sur-
geons should do for patients with gastroesophageal reflux
with indication for MBS presenting some contraindication
for RYGB? Would not it be more interesting to have IFSO
working towards discussions, education, and collecting data
on these procedures?
Gastric plications positive results are insufficient. But
gastric bands also underachieves, and it continues as a reg-
ular procedure, accepted by IFSO. Should the rules not be
applied to all surgical procedures?
On the topic “Gastric Bipartition,” lot of mistakes
occurred, starting by the name of the procedure. No publica-
tion ever referred to that name, especially because there is no
* Sergio Santoro
sergio@santoro.med.br
1
Hospital Israelita Albert Einstein, Av. Albert Einstein, 627,
São Paulo 05652‑900, Brazil
2
GastroObesoCenter – Institute for Metabolic Optimization,
Rua Barata Ribeiro, 237 8th Floor, 01308‑000 São Paulo,
Brazil
gastric bipartition; there is a sleeve gastrectomy associated
to an intestinal transit bipartition (TB).
The supposed author, Sanet, if he exists, is not mentioned
in the reference cited, and that reference had no relation to
transit bipartition. Wrong surgery, wrong author, and wrong
reference: a bad start for a review that gives support for an
IFSO Position Statement.
SG-TB was first presented in 2002, as part of a protocol
aimed to dismiss mechanical restriction and malabsorp-
tion aiming only at neuroendocrine improvements instead.
That protocol was groundbreaking, introducing the concept
of pure metabolic surgery [4]. First published in 2004 [5],
SG-TB appeared in Obesity Surgery Journal in 2006 [6] and
2008 [7], and in Annals of Surgery, 2012 [8]. No author ever
wrote, as published, that “the majority of the food consumed
will exit the sleeve through the pylorus,” neither that it “was
initially developed as a metabolic procedure to treat diabetes
mellitus”: mistakes!
There were important omissions. First, there was an RCT
[9], conducted in a major Brazilian Center, where hormones
(including FGF-19) were re-measured and results confirmed.
The best studies published by other authors, comparing
SG-TB with other surgical procedures were omitted [10–12].
The First Brazilian Emerging Surgeries Forum (https://​
www.​sbcbm.​org.​br/​forum-​sobre-​cirur​gias-​emerg​entes/), a
3-Society collaborative effort among the Brazilian Society
of Bariatric and Metabolic Surgery (SBCBM), Brazilian
College of Surgeons (CBC), and Brazilian College of Diges-
tive Surgery (CBCD) also was omitted. They concluded that
there is enough evidence to include SG + TB as an accepted
procedure in Brazil. The recognition of the second largest
obesity surgery society in the world is too important to be
omitted.
The IFSO statement still declares: “this procedure may
achieve excellent results solely on the bases that it is a
malabsorptive procedure.” Well, if excellent results can be
obtained through malabsorption without any exclusions, it
would already be a progress. But fortunately, SG-TB is not
based in malabsorption, neither in its initial concept nor
its results depend on malabsorption. Malabsorption is a
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disease (ICD K.90) that causes weight loss, while SG + TB
is a treatment that improves gut signals. Researchers in the
field acknowledge that it is not malabsorption that does
the good job [13]. SG-TB is clearly more potent than just
a sleeve and obviously less complicated than a DS, since
it does not include duodenal section, does not exclude
segments, and is made with less and simpler steps. How
can IFSO, in 2022, say that results come exclusively from
malabsorption, when diabetes improvement is immediate
and important gut hormones (PYY, GLP-1 and FGF-19)
are enhanced [9], showing the existence of “something
beyond malabsorption”?
In logical grounds, SG-TB should not need special
approval, because it stays between two recognized proce-
dures, the sleeve and the DS.
However, the most serious mistakes are these last state-
ments: “there is no proof that an enterohormonal imbalance
is related to obesity” and “there is no published evidence to
confirm a gut hormonal imbalance in patients with severe
obesity” [1].
Let us examine the statements. The production of gut
hormones occurs during nutrient absorption [14]. High-
glycemic index diets absorbed faster in the proximal parts
progressively reduce distal gut hormones [15, 16]. Confirm-
ing this idea, GLP-1 [17], PYY [16, 18], FGF-19 [19] are
relatively low in obesity, and the additions of any of them
or their agonists cause improvement in both, obesity and
metabolic syndrome.
On the other hand, proximal gut endocrine activity seems
elevated. “Fasting levels of GIP were significantly elevated
in the obese group. After meals, the overweight subjects
showed a significantly greater response of GIP than the
controls”: it was published as early as 1978 [20]. In type
2 diabetes (T2D), there are similar findings: “In patients
with type 2 diabetes, there is a moderate degree of GLP-1
hyposecretion. GIP is secreted normally or hypersecreted in
type 2 diabetes” [21].
K cell hyperplasia and increased production of GIP were
observed in obesity. Studies showed that GIP deficiency or
ablation of K cells, GIP receptor antagonism or knock out,
antibodies, or vaccine against GIP all promote protections
against high fat diets [22]. There is plenty of biochemical,
physiological, anthropological, and evolutionary [23] evi-
dences for a hyperactive proximal gut and a hypoactive distal
gut.
Abundant, high-glycemic index diet is probably the main
inductor of this imbalance [15, 16], conferring to obesity an
environmental origin, besides a genetic propensity. SG-TB,
in spite of avoiding mechanical restriction and malabsorp-
tion by eliminating exclusions, was shown to correct this
imbalance [9] by shifting some food from the proximal to
the distal gut, as many other effective procedures do through
exclusions.
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Obesity Surgery (2023) 33:665–667
This explains why very different procedures have positive
effects. But all procedures that work well have one com-
mon trait: they somehow deactivate the proximal gut or they
hyperactivate the distal gut. A proximal gut resection (but
not a distal) provokes insulin sensitivity [24], as well as sim-
ple nutrient infusion in the ileum [25].
Enhancing distal absorption rather than malabsorption
seems to be the important. Distal gut signals produce satiety
and elevations in energy expenditure, and, by diminishing
the gastric emptying, they provoke a physiological restric-
tion that differs from the static mechanical obstacles to the
food passage. Metabolic and not mechanical elements guide
us to better procedures.
SG-TB is a paradigm breaker as it is the first procedure
to ever to be designed not to provoke mechanical restric-
tion and malabsorption but to correct the signals of food
perception.
To conclude, we ask if this kind of overregulation should
be considered an IFSO members’ best interest. Is this our
mission? To educate, learn, and teach or to prohibit and sug-
gest punishment? To unite or divide? In the federation, we
have more than 70 associated countries. Rules about bari-
atric and metabolic practice are different according to the
region. Positions like this create problems, not solutions.
IFSO should work with every country’s society looking to,
according the local circumstances, point to the best paths
and practices in MBS.
Declarations 
Ethics Approval  This article does not contain any studies with human
participants or animals performed by any of the authors.
Consent to Participate  Informed consent does not apply.
Conflict of Interest  The authors declare no competing interests.
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