Wednesday, October 22, 2008

Toga: Endoscopic Weight Loss Surgery

Weight loss surgery has turned into big business within medicine. Bariatric surgery has gone from the butt of a joke within surgery to a full-fledged subspecialty. Interesting article in the NYTimes today about what might possibly become the latest fad in bariatric surgery: endoscopic stapling.

The product described here, Toga, has not been approved yet in the United States, but it sounds intriguing:
On a recent Wednesday, Karleen Perez lay unconscious on an operating table in Upper Manhattan while her surgeons and two consultants from a medical device company peered at an overhead monitor that displayed images from inside her digestive tract.

The surgeons, Dr. Marc Bessler and Dr. Daniel Davis, had just stapled her stomach to form a thumb-sized tube that would hold only a small amount of food. The operation resembled others done for weight loss, with one huge difference. In Ms. Perez’s case, there was no cutting. Instead, the surgeons had passed the stapler down her throat and stapled her stomach from the inside.
What does the procedure itself entail, you ask?
The operation is not as simple as it might sound. To begin, Ms. Perez was given general anesthesia and put on a respirator. Then the surgeons pushed a dilator, a formidable-looking tube about three-quarters of an inch wide, down her throat to stretch her esophagus.
Next came another wide tube, this one about two feet long, containing the stapler. The surgeons inflated her stomach with carbon dioxide to create space in which to work. Dr. Bessler struggled for 5 or 10 minutes to position the stapler properly, and then activated controls that opened it, like a miniature spaceship, inside Ms. Perez’s stomach.
A sail and curving wire emerged from the stapler to help push aside the folds of her stomach. Then Dr. Bessler turned on a vacuum pump to draw parts of the front and back walls of the stomach into the device to be stapled together.
Three rows of staples were needed, but the stapler holds only one row, so the whole apparatus had to be withdrawn, rinsed, reloaded, pushed back down Ms. Perez’s throat and painstakingly repositioned for each row. The Satiety consultants stood close by to coach, at one point warning Dr. Bessler that if he inflated Ms. Perez’s stomach too much, her first row of staples could pop. The surgery took three hours.
I'm not sure about this whole esophageal dilation. Doesn't that put patients at risk for something like Boerhaave's syndrome (esophageal rupture)? Just wondering. And even if it does work reasonably well, can you say 'turf war'? My guess is that gastroenterologists and bariatric surgeons are going to have at it if this becomes the next big thing in weight loss surgery.

FYI the term 'Toga' comes from transoral gastroplasty.

On a related note, I came across this title and found it funny:

Not only are the readers overweight, but now you're calling them dummies too?! Those poor people!

Update: For more information on bariatric surgery, check out Houston Weight Loss Surgery


  1. Thanks for sharing the information on the latest fad in bariatric surgery...endoscopic stapling. Transoral gastroplasty, or Toga for short will help many obese people who wants to have a surgery , yet afraid of the knife. Lets hope Toga will help many.
    Learn more about bariatric procedures in our information guide, or consult with a bariatric surgeon in your area to find out if you qualify for the surgery and many more. Visit the link below
    click here to read more on Bariatric surgery

  2. im not entirely convinced too. 3 hours for endoscopic stapling? there are surgeons in Melbourne who can go a modified VBG (aka High Gastric Reduction) in 30minutes going by the open approach (either via midline or kocher incision). of course, the first publication will include optimistic comments like with time speed of operation will shorten. i say kudos to these pioneers who dare to try for without which there is no progress.

    on that note, the whole LES dilatation part also brings concern. perhaps more likely to get an iatrogenic Mallory-Weiss tear (partial)? remember the oesophagus and stomach are quite distensible.

  3. I had the toga precedure done on May 26th and the stapler didn't fire staples half way thru so ended up in surgery to fix the problem now have 6 incisions in the stomach as well as a sore throat. Hopefully all will be well, will follow up with the toga study even though I am not in it now since knowing I had procedure done.

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  6. Bariatric surgery to lose weight is very effective. Patients can lose a significant amount of weight and maintain it. However, in order to maintain this type of weight loss for life, patients should follow a post-operative diet program as well as an exercise program. Herbalife Diet



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