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Conference report

1st noninva symposium

A look to the future - new technologies

After a rapid growth period, bariatric surgery has been entering a plateau phase. The “market” looks mature and the majority of the obese population still does not take advantage of the surgical possibilities, despite good public information and awareness in the medical community. This makes sense if one realises that most patients are afraid of the risks and adverse consequences of surgical treatments.

Hence, clinical research should be oriented towards less invasive procedures that could be accepted by the mainstream. In 2011, it is obvious that non invasive bariatric techniques are down the road. Although most of them are not yet standardized and sufficiently assessed, they are being constantly upgraded.


The purpose of this meeting was to elicit discussion among experts from worldwide, gather relevant information on new technologies that will make it possible to enlarge the vision of bariatric cares to a growing number of morbid obese and non morbid obese patients.


The program has been divided into five parts: 1. Procedures that aim at lowering the “ surgical trauma », mostly the single-trocar approach and the NOTES approach. They raise important questions, e.g. do we have the instruments we need? Is the upgrade relevant versus the typical lap-approach? 2. Techniques that are available through “ natural orifices », hopefully the most promising, provided they can prove satisfactory and long-standing. 3. New technologies, like neuro-modulation. 4. Transversal issues: the role of the anesthesiologist, the control that should exist from the gastro-enterologist, etc. 5. Round tables that will make it possible to reach a consensus on some matters, if not guide-lines for the anticipated evolutions. 


Goals of the meeting 


The gathering of the best international experts aimed at defining orientations in clinical research for less aggressive bariatric methods. Surgical procedures that are well established (gastric bypass, adjustable band, sleeve gastrectomy) have not been explicitly addressed as such, but only from the perspective of comparison and confrontation with less invasive procedures. 


Figuring out the transition from mini-invasive to non invasive may be described with the following steps: 


  • Picking-up procedures with medium aggressiveness such as SILS and NOTES, as well as parallel concepts like neuro-modulation. 

  • Seeking concept similarities: TOGA/VBG, endo-sleeve/BPD, endoplication/surgical plication, internal/external bands, etc. 

  • Organizing strategies: combining experimental and well-known techniques, stepping up the invasive degree; in this regard, endoscopic redo for failed procedures is a promising direction that has gained momentum recently. 


If one is convinced that the current offer is insufficient and too complex, and does not take into account the severe and morbid obesity issue with its public health dimension, then one understands that this symposium must become a regular event. 


The techniques that have been presented are not described in details here; a directory of these approaches is in preparation and will be available by the end of 2011.


Mixt techniques, state of the art


This first part has been dealing with the combination of less “surgical aggressiveness” and typical procedures that are performed according to the state-of-the art.


Routine gastric banding through the SILS approach was been addressed by Marie-Cécile Blanchet (France) and Jérôme Dargent, and SILS Lap-Band removal by Giovanni Dapri.


SILS Sleeve Gastrectomy was described by Alan Saber (USA) and Chih-Kun Huang (Taiwan).


The possibility of a SILS gastric bypass was been advocated by Roberto Tacchino (Italy), and Jean Cady (France).


Even the SILS bilio-pancreatic diversion seems to be worth it, according to Tacchino.


Andrew Zwolinski, an Ethicon engineer, described the evolution of surgical approaches, such as anticipated by company research (micro-trocars, magnets).


A NOTES-inspired Sleeve Gastrectomy was described by Manuel Galvao Neto (Brasil) and Elie Chouillard (France).


Chih-Kun Huang presented a novel reversible bariatric technique, and its results: Laparoscopic adjustable gastric banded plication, whereas gastric plication on its own has been often presented as the “sleeve killer”. 


Purely non invasive techniques


The road from hiatal hernia surgery to bariatric endoscopic surgery was described by Guy-Bernard Cadiere (Belgium).


Christopher Thompson (Boston, USA) was reviewed endoscopic therapy for Weight Regain after Gastric Bypass. 


The G-prox “ROSE” and “POSE” for morbid obesity and re-do is a promising technique, the current experience was reported by Gontrand Lopez-Nava (Spain), Karl Miller (Austria).


The endoscopic treatment of post-op complications after gastric bypass (bleeding, leaks, stenosis) was presented by Alfonso Torquati (Duke, USA).


Restrictive implants: 


The Barosense device might be an endoscopic band, according to Simon Biron (Canada).


The Endostapling TOGa device (technique and results) was analyzed by Daniel Blero (Belgium), and the TRIM procedure for obesity by Dean Mikami (USA), as well as the Flexible Endostitch. 


The possibility of injection at the GE junction was advocated by Jérôme Dargent, Frédéric Pontette (France).


Intra Gastric Balloon placement, removal, and state of the art, was reviewed by Manuel Galvao Neto.


Between mini and non invasive: results were presented from the experience from the adjustable gastric balloon: Giorgio Gaggiotti (Italy), and the SPATZ Balloon by Gontrand Lopez-Nava.


The duodeno-jejunal bypass sleeve represents a novel approach for type 2 diabetes, according to Jan Greve (Nederlands).


New technologies


Apollo overstitch and endoluminal bariatric by DDES were detailed by Christopher Thompson.


Evolution and perspective of neuromodulation in obesity treatments were summarized by Scott Shikora (USA)


Generalities


The position of the anaesthesiologist has two aspects: 1. Less invasive approach for anaesthesia in the obese patient – Jan Mulier (Belgium). 2. The anaesthesiology for non invasive bariatric surgery – Ashish Sinha (USA).


The cooperation between the bariatric surgeon and the endoscopist has been recommended by François Mion (France).


Panel sessions: Joint sessions with questions and answers from a panel 


N°1: Surgical approaches in bariatrics. Non-invasive procedures vs. NOTES vs. single trocar or needlescopy?


Elements of discussion: What surgical approach makes more sense today? Tomorrow? Is it worth investing money in defining new surgical approaches however mini-invasive they are (single trocars, very small instruments, magnets, etc.) given the rise of non-surgical approaches (endoscopy)? What are the preferences of patients, anaesthesiologists, GP?


N°2: What main concept will emerge concerning purely non-invasive techniques: Are we in an evolutionary or a revolutionary phase of bariatric surgery? Which current technique is the most innovative?


The elements of the discussion were: Can we apply “similarities of concepts” (or can we desire them!), such as surgical plication versus endoscopic plication, or vertical gastroplasty/sleeve gastrectomy versus TOGA technique, or BPD versus duodenojejunal sleeve, etc.? Are these techniques to be spread before clinical trials have been completed? Which ones of these concepts make more sense from the point of view of a patient, an anaesthesiologist, an endoscopist, etc.? Should we combine theses techniques with the current techniques, and/or define step-by-step strategies?


Conclusions


The field of bariatric surgery is rapidly and highly evolving. Less aggressive procedures are an absolute necessity since we cannot convince the vast majority of the obese population to get surgery. We have to propose alternatives, new options, but we have to it in a timely manner, such as stated in the ASMBS recommendations (Statements on emerging endosurgical bariatric interventions, SOARD, 2009).


The key-element does not seem to be the procedure itself, whether it staples, plicates, bypasses, injects, etc, whether it is metabolic or not… it will remain under scrutiny and debated; the key is the approach: the first bariatric revolution has been the move from invasive to mini-invasive procedures, the second revolution is going to be the move from mini-invasive to non invasive procedures.


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