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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


14 Comment(s)
Comment by [Anonymous] on Oct 30, 2009 at 06:10am
The no incision part sounds fine, until you get to the line that says "the high incidence of staple line failure will most likely occur with the TOGA procedure as well". Who wants to go through that if the doctors expect it to fail?
Comment by KRWaters on Oct 30, 2009 at 02:56pm
So it is a pouch then like the gastric bypasas, just no incision? I still think the duodenal switch far exceeds the expectations of this TOGA thing.
Comment by [Anonymous] on Oct 30, 2009 at 03:58pm
This looks like stomach stapling done from the inside. A sleeve gastrectomy seems like it would be more effective since it reduces ghrelin secretion and this procedure does not.
Comment by [Anonymous] on Oct 30, 2009 at 05:45pm
Who wants to go through all this if it has the same high failure rate as the VBG? Just because it doesn't leave a scar doesn't mean it's a successful long term surgery to cure S/MO! I think the DS sounds like a much better option since it actually removes most of the grehlin (hunger) secreting hormone, and has a proven track record of high excess weight loss AND long term maintenance of EWL! I'll take a few lap incisions for that kind of success thank you!
Comment by [Anonymous] on Oct 30, 2009 at 08:02pm
I see a high failure rate with this one. We are a long way off from a WLS with no incisions that ACTUALLY works.
Comment by Ms_Swoosh on Oct 31, 2009 at 05:47am
Ya, Im gonna pass on this one.... My band frustrates me some...but I think I will stick with it. Besides 33titanium staples....INSIDE ME? Ya, I think not :)
Comment by [Anonymous] on Oct 31, 2009 at 06:33am
why would anyone subject themselves to any procedure that is EXPECTED to have a high failure rate. even if the restriction works, what is the patients chances of maintaining their weight loss with NO malabsorption. i will take my the scar from my open DS with its success over a procedure with the expectations of the TOGA procedure.
Comment by panda_q_bear on Oct 31, 2009 at 04:22pm
No thanks. I really like not having a "stoma" for food to get stuck in, or worse, fall through. This surgery does not seem to address that ubiquitous problem in RNY and Lap Band. Additionally there is no malabsorptive component, which appear from the statistics to be a key factor in long term success from WLS> Given the choice, I'd choose the DS again over this one.
Comment by [Anonymous] on Nov 07, 2009 at 07:14am
Yeah, the reason my Sleeve has worked so well is because I don't get hungry (and still haven't over one year out) - this procedure offers none of the important parts of weight loss surgery: hunger reduction by loss of stomach, malabsorption by loss of intestine, or even the trauma of WLS that I think we all need to "reset" our bodies (I know I physically didn't want to eat for weeks - I don't see that happening with this). I think this is a waste of time!
Comment by WILL0630 on Nov 15, 2009 at 08:37am
This may do well for people with lower bmi's or a lot of self control who do not want a band. My biggest concern is the staple line failure rate being an unknown over the long term. Like with all wls you need to understand why you are fat to begin with as well as what your post op lifestyle expectations are. I've met many succesful vbg'ers despite the stats. With discipline, this can possibly work for many.
Comment by [Anonymous] on Dec 07, 2009 at 01:26am
The idea is good, but the long term is the issue. I can see rich/famous people doing it so they can lose weight radically on a "temporary" basis, without the invasion, complication risks, pos-op recovery,scars, etc... They can get fit for the next summer or movie... and I say rich because they dont need to have a BMI higher that 35 to be approved by the insurance companies... their credit card will do all the approving !
Comment by [Anonymous] on Jan 06, 2010 at 07:10am
IS this a clinical study?
Comment by [Anonymous] on Apr 08, 2010 at 07:06am
I had the TOGA and it only works if we follow the rules. You don't have to take extra vitamins because the food goes into the stomach and sits there. Your full all the time. I liked this ove Bypass because of the risks & they all have drawn saggy faces from losing weight too fast. The duodanal or whatever switch is horrible. You smell like a sewer all the time. Gas is horrible. As with any procedure..its as good as we are..Bypass patients gain the weight back all the time..
Comment by [Anonymous] on Nov 12, 2011 at 10:24pm
Are there any TOGA patients with results 2 years out? I got the TOGA in 2009 and I am currently seeking revision to sleeve going the MX route as my insr does not cover bariatric surgery. Anyhow I was curious to see how everyone else is doing as there were such high hopes for this one. The trial was discontinued this year as the investors backed out because of poor results. I personally lost 45 lbs initially, plateaued, and it crept back up. My TWL has actually been 15 lbs which I've kept off for the past year. It's sad and dissapointing really, but apparently many of you saw that coming.
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