Transoral Gastroplasty - TOGA Procedure - The Future of Bariatric Surgery?

Bariatric Surgery has gone from an open surgery requiring a large abdominal incision to laparoscopic surgery requiring five or six tiny incisions to Single Incision Laparoscopic Surgery requiring a single abdominal incision. The future will be transoral or endoscopic bariatric surgery that involves no incisions. WD152

The Toga system developed by Satiety, Inc., a medical device company based in Palo Alto, California is one of the procedures currently undergoing clinical studies in the United States. The system is a flexible device that is inserted through the mouth into the stomach to staple the stomach.

The TOGA procedure is performed under general anesthesia by a bariatric surgeon. The surgeon then places the flexible stapler down into the stomach and inserts an endoscope, which is a flexible camera into the stomach to see the procedure on a television screen. The device then suctions the wall of the stomach into the stapler and forms a four-inch tube or pouch in the proximal stomach.

As a person eats after the procedure, they will feel full quickly. The food will pass into the newly created pouch and then slowly pass into the rest of the stomach and through the normal digestive system.

The TOGA procedure is not approved by the FDA and is presently under clinical studies in the United States. To qualify for the study patients need to have a body mass index (BMI) of 35 to 55. A BMI greater than 35 is considered severely obese. Enrollment in the study has been completed and the results are still pending.

The TOGA procedure has certain risks and potential complications as with any surgery. There is a risk the staple line can fail and come apart. Leakage is not a risk of transoral gastroplasty because the stomach is not cut. If the staple line comes apart the stomach reforms which can result in failure of the procedure.

The TOGA procedure is similar to other bariatric surgeries like the vertical banded gastroplasty (VBG). The VBG is no longer being performed in the US because of high failure rates. The most common cause of failure was disruption of the staple lines over time. The high incidence of staple line failure will most likely occur with the TOGA procedure as well. However the nice thing about the TOGA procedure as compared to a VBG is that it involves no incision, minimal risk, and minimal recovery time.

There are presently many endoscopic or transoral bariatric surgical procedures being developed. These procedures include endoscopic placement of a sleeve (Endobarrier) in the intestines by GI Dynamics, and POSE or Primary Obesity Surgery Endoscopically by USGI Medical.

Obesity is a growing epidemic in the United State and venture capital companies are investing large amounts of money to help find less invasive procedures to help cure this epidemic.

Steps of the TOGA Procedure

Shawn Garber, MD, FACS, FASMBS, is director of the New York Bariatric Group in New Hyde Park, NY. He is one of only a few surgeons in the Northeast using the new SILS technique for laparoscopic adjustable gastric banding.

November 2009