Endoluminal Treatment of Obesity: First Case Report of Transoral Gastroplasty in the US
Comments: The obesity epidemic now affects 30% of the adult population in the U.S., approximately 60 million Americans. Bariatric surgery remains the most effective treatment to date.
Endoluminal therapies present an opportunity for a less invasive approach.
Transoral gastroplasty, or TOGA, combines two flexible, endoscopic staplers that can be used to create a restrictive gastric pouch, giving patients a feeling of satiety after a small meal. This device is not currently FDA approved but is being studied in a sham-controlled, multicenter study.
Early experience in Mexico and Europe with this device has been favorable. We present the first case report of endoscopic gastroplasty using TOGA in the United States.
The first stapler using vacuum pods to acquire tissue prior to closing and deploying a serosal –to serosal staple line.
A restrictive stapler is passed to clamp gastric folds together within the pouch, decreasing the diameter of the pouch outlet.
A 30 year old woman is referred for obesity treatment after failing diet and lifestyle modification. After informed consent, she agrees to undergo endoluminal gastroplasty. At the time of her procedure, her BMI was 48.2.
After endotracheal or nasal intubation is performed under general anesthesia, a 60 French Savory dilation of the esophagus is performed. The flexible endoscope stapler is gently advanced into the body of the stomach. Once inserted, an 8.6 mm gastroscope is advanced through the stapler and retroflexed in the distal stomach to visualize the alignment of the gastric fundus with the stapler. This highlights the surgeon on the right, controlling the endoluminal stapler while the gastroenterologist, on the left, directs the gastroscope for optimal visualization.
The jaws of the stapler are opened and the device is repositioned under endoscopic visualization at the gastroesophageal junction. A retracting wire and sail, noted by the arrow, are extended to retract the body of the stomach. This facilitates the stapler's alignment in the fundus prior to tissue acquisition from opposing sides. The retracting wire and sail are then pulled back into the stapler and the lumen is collapsed through suction from the gastroscope as well as vacuum pods within the endoscopic stapler. The collapsed lumen is shown in the left upper quadrant while the surgeon's control of the stapler is in the left lower quadrant. This animation highlights the stapler as it is retracted. Next, the cartridge is closed and the stapler fired to plicate opposing walls of fundus.
Once the lumen is distended, you can appreciate the placation, which extends approximately 4.5 cm below the gastroesophageal junction. The stapler is carefully removed, and the procedure is repeated after the device is reloaded with a second stapler cartridge.
After the pouch is extended with a second pilcation, the surgeon advances the restriction stapler into the stomach. A pediatric gastroscope is advanced alongside the restriction stapler to inspect the pouch and optimally position the device. Here you can appreciate the staple line extending from the GE junction almost to the level of the incisura.
Once the restriction stapler is positioned to allow tissue acquisition on the opposite wall of the staple line, the gastroscope is removed. Similar to the initial stapler, suction is applied prior to clamping, and deploying the stapler.
This step is repeated a second time. The 8.6 mm gastroscope is reinserted to inspect the gastric pouch. A retroflexed view demonstrates an intact staple line extending approximately 6 cm from the gastroesophageal junction. On direct inspection immediately distal to the Z line, the restriction pouches are seen on opposing walls, creating a pouch diameter of approximately 15 mm.
In summary, post-procedure endoscopy reveals a gastric pouch extending to the level of the incisura with two restrictions to reduce the pouch outlet. Upper GI series performed one day later demonstrates no leak as barium passes from the gastroesophageal junction through the gastric pouch or sleeve, into the distal body.
Potential advantages of this technique include the ability to create a restrictive pouch or sleeve using an endoluminal stapler that creates a full thickness or trans-serosal placation. With average procedure times between one and two hours and minimal post-endoscopy symptoms, this is likely to evolve into an ambulatory intervention.
Several obstacles remain, some of which may be addressed in an ongoing sham-controlled tiral. In addition to issues of device safety, how effective is the gastric pouch in producing significant weight loss and obesity-related co-morbidities? Importantly, will the weight loss be sustained several years after the initial intervention?
At her three month follow-up, out index patient denies symptoms of nausea, dysphagia or abdominal pain. She has lost 29 pounds, or 22% of her excess body weight, and her BME is currently 42.9.
Thank you to the ASGE and the video editing scholarship program for their support of this project.
| Contributed by: |
Gregory A. Cote, MD, MS University of Washington |
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Citation: Cote, MS, GA (Jun 01 2009). Endoluminal Treatment of Obesity: First Case Report of Transoral Gastroplasty in the US. The DAVE Project. Retrieved Sep, 2, 2010, from http://daveproject.org/viewfilms.cfm?film_id=856 Times viewed since Feb 2006: 3316 |
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