This document discusses notes (natural orifice transluminal endoscopic surgery) bariatrics. It summarizes a study of 21 patients who underwent either transvaginal sleeve gastrectomy or transoral extraction of the remnant stomach. Key results include: - Average stomach volume extracted was 470cc. - Average OR time was shorter for TORE at 91 minutes compared to 135 minutes for transvaginal. - There were no post-operative complications. - Weight loss at 6 months and 1 year was identical to traditional laparoscopic sleeve gastrectomy. - Transvaginal and TORE approaches are concluded to be viable options for sleeve gastrectomy.

1. Notes Bariatrics Garth R Jacobsen, M.D. Surgical Program Director UCSD Center for the Future of Surgery Associate Residency Program Director UC San Diego Department of Surgery

2. Bias? Ethicon Honoraria: Speaking, Consulting, Research Grants, Fellowship Support W.L. Gore: Honoraria: Speaking, Consulting, Writing, Fellowship Support USGI: Honoraria: Speaking, Consulting, Research Grants, Proctoring Covidien Honorarium: Speaking LifeCell: Honorarium: Consulting Davol: Honoraria, Speaking, Consulting MTF: Honorarium, Writing Novus: Honorarium; Consulting

4. Decreased pain

5. Decreased risk of infection/seroma

7. Patient Characteristics Mean age of patients: 49 years (range 29-63 yrs) Mean pre-operative BMI: 46.1 (range 33-60)

8. CO-MORBIDITIES * PSH significant for laparoscopic hysterectomy in 1 patient in the transvaginal series.

9. Standardized technique for trans-oral extraction (TORE)

13. Post-op complications: NONE

14. No sexual dysfunction

16. SUMMARY - Transvaginal sleeve gastrectomy is a safe approach - Transoral extraction of remnant stomach is feasible - Weight loss is not compromised when compared to conventional laparoscopic techniques

17. CONCLUSION Transvaginal and Transoral Remnant Extraction (TORE) are viable options for sleeve gastrectomy This experience represents the first step towards a purely NOTES bariatric procedure

18. Primary Endoscopic Therapy Goal to build on utilization of durable anchors Notes Gastric Closure ROSE Target anatomic and physiologic effects Restrictive ? Suppression of Appetite Target Obesity epidemic with a low risk procedure

19. Clinical Application

20. Potential Feasibility Pilot completed with encouraging results Revision of Technology First generation G-prox to small for commercial viability Follow up with a prospective trial in patients with BMI between 28 and 35 Currently recruiting

21. Conclusions The first wide spread application of Natural Orifice Technology will be intralumenal The platform offers a durable intralumenal anchor Primary procedures may offer a solution to the obesity epidemic with minimal patient risk