Hear a Patient Power interview with Dr. Stan Rogers, director of the Bariatric Surgery Center, and a patient Sheila Hardin, who underwent an incision-free, weight-loss procedure called transoral gastroplasty or TOGA.
NOTE — UCSF Medical Center no longer performs the TOGA procedure. This interview also addresses other bariatric procedures.
Obesity is a complex and chronic disease with many causes. In some cases, it's not simply a result of overeating. Research has shown that genetics often plays a role. Coming up, a prominent bariatric surgeon from UCSF Medical Center will discuss a new minimally invasive approach that's giving patients an incision-free option for weight-loss surgery, and you'll meet a woman who has benefited from just that. It's all next on Patient Power.
Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr. One of the daunting problems in America today is obesity. People try exercise, they try dieting, they try all the programs you see on television, and, yes, people can lose some weight. Unfortunately many people gain it back.
For some people, as hard as they try, their weight becomes quite substantial — 50 pounds, 80 pounds, more than 100 pounds overweight. Then, they consider surgery. There are many people who are what you call morbidly obese. They're at risk for so many serious conditions , even death, so they decide to have surgery.
There have been a variety of approaches developed over the decades that involve incisions. Now there is another option that is being studied in a clinical trial. Sheila Harden heard about it on television in the San Francisco Bay Area. Sheila, what did you see on TV and what did you do?
Well, I saw a local news show tease regarding the incision-free surgery for weight loss and it immediately caught my attention because I am considered obese.
Now, your weight at 5 foot 5 . . . was it about 225 pounds?
What size dress were you?
And years ago, let's go back to high school. What did your size used to be?
Oh, I was size 5 then.
Wow. So you had two boys who are grown now, and like so many women you go through pregnancy but getting the weight off is really tough.
Yes. I tried many diets, you know, Jenny Craig, Weight Watchers, Atkins, trying to go to the gym on my own, but nothing would help. It also turned out that I have a hypothyroid, so my thyroid is deficient. I have to take a daily medication for that.
And as you went on with your obesity, did you find you were tired?
Yes, I had trouble with low energy, and that just bogged me down.
So you hear about this. I think you were watching Oprah and then something came on in the commercial break that UCSF Medical Center was studying an incision-free or scarless approach that's called TOGA. We'll learn more about that because we're going to meet your doctor. You had the procedure. You had to go through a workup, if you will, to see if you were a candidate for this procedure. So beyond the hypothyroid problem, you found out you had another one. What was that?
I found out that I had sleep apnea. I did not know that I had sleep apnea, and so fortunately for me, sleep apnea was one of the co-morbidities that the TOGA study, that I was applying to, wanted you to have, since my BMI was lower than 40. My BMI was about 36. Sleep apnea then qualified me for the study because I did not have high blood pressure, did not have high cholesterol, no diabetes.
Sort of good news, bad news. The bad news is you have sleep apnea, although you had been tired so maybe that explains some of this. The good news is that you could be one of the first people to have what hopefully will be an approved approach for helping people deal with this overweight problem. How did it work out? Did you have the TOGA or scarless weight-loss surgery?
Well, as you know, the study was a double-blind study so I didn't know at the time. May 21st is when I went in to have my procedure.
That's correct. I didn't know whether or not I had it or I didn't. So I didn't find out until a year later whether or not I had the procedure or not.
But the answer and what you saw in your health . . . did you get your weight down?
Yes. I felt like I did have the procedure, and in fact it turns out that I did have the TOGA procedure on May 21, 2009 because it helped me lose weight.
All right. So you were a size 18. What are you now?
Now I'm a size 12.
Yaay. And what about fatigue?
Oh, I don't have any fatigue anymore. The greatest thing is that I no longer have sleep apnea. I was re-evaluated with a sleep study last month, August or July, and I no longer have sleep apnea. So that is the greatest thing because that can be life threatening.
And you feel you got good care?
Definitely. Dr. Rogers and Dr. Cello were great. They took great care of us. We also had nutritional visits. We met with a nutritionist all the time. Every time, we went to UCSF and initially before getting qualified, we had to see a psychiatrist, so they take good care of us.
Last thing I want to ask is, are you determined to keep the weight off?
Definitely. This has been a lifestyle change for me. It's no longer just a diet because with TOGA, I feel full sooner than what I have in the past, so it allows me to eat less than what I have in the past.
And I know you're determined to eat better too.
Definitely. I'm eating more fruits and veggies and all of that good stuff. I have my smoothies every day, and I make sure I get my daily movement as far as exercise and walking or dancing or whatever.
Good for you, Sheila. Let's meet one of the physicians you mentioned. That's Dr. Stanley Rogers, director of the Bariatric Surgery Center at UCSF and a bariatric surgeon. Dr. Rogers, what does this acronym TOGA stand for?
Greetings. TOGA stands for transoral gastroplasty, which means a procedure that's performed through the mouth and involves changing the anatomy of the stomach to some degree in order to achieve a desired outcome.
UCSF was one of just a handful of centers where this has been evaluated and we heard that Sheila found out she in fact had the procedure So, what are you doing exactly? You're going down through the mouth. Could you describe it for us and how it's different from what's been available so far.
This procedure is incisionless and involves two devices that are created by a local Bay Area company, Satiety. These devices are used endoscopically, so it's used while an endoscope is in place watching the procedure being performed. TOGA, which I mentioned stands for transoral gastroplasty, is a procedure that creates what's called a restrictive anatomy to the stomach. It creates a small pouch using a series of linear staple lines using titanium staples and then involves creating small restrictive pleats at the end of the sleeve that restrict outflow from this gastric pouch or gastric sleeve.
You can do all this by going down the throat?
This is all done by going down the throat. Exactly.
Sheila, you were held overnight. You were there a day, right?
That's correct. I was placed under general anesthesia.
Is the hope that you'll get to the point where this could be an outpatient procedure?
I think it will be an outpatient procedure at some point. As you know, a lot of the surgical procedures that we perform now that have incisions are performed as outpatient procedures. This is definitely within the realm of the outpatient procedure.
I guess the question is, is this a big deal? The idea of not having an incision is very desirable to patients. In your march for better bariatric surgery techniques, is this a real advance?
This is an advance. I think the goal of surgeons in general is to get a desired outcome with the least invasive procedure available, so this TOGA procedure and device represents a very minimally invasive approach to a bariatric procedure.
Let's talk about that. People are familiar with lap-band and a whole bunch of other procedures. Where could this fit in and who would it be right for?
The most commonly performed procedures currently are the gastric bypass and the gastric band. Sleeve gastrectomy is also performed but less commonly. The three major procedures again — gastric bypass, gastric banding and sleeve gastrectomy — are all considered restrictive procedures and they all involve, when performed laparoscopically, creating small incisions in the abdominal wall and performing the procedure with the use of long instruments, a video monitor, a camera and a scope in order to allow these procedures to be done.
The TOGA procedure is also a restrictive procedure similar to the others, though it does not involve incisions. As we mentioned, it is done with an endoscope through the mouth, and it will compare favorably with these other procedures. All of the restrictive procedures, including the TOGA procedure, involve a complex education of patients in order to achieve the greatest benefit from these procedures. No surgical procedure is foolproof, and they do require that all patients participate in the active dietary program to achieve the benefits that they desire.
How robust, if you will, is the program of support at UCSF. You can do your work as a surgeon but there are others who are supporting people like Sheila so they can be successful long-term?
We have a very robust program. We have a vigorous clinic that sees patients before surgery and after surgery. It involves evaluation by both nutritionists and psychologists as well other specialists in medical fields such as endocrinology for diabetic patients or gastroenterology for patients who might have gastrointestinal disorders. We also have cardiologists and pulmonologists who participate in our program and see patients before and after surgery.
After surgery patients are seen in our clinic on a routine basis and are evaluated both from a surgical and medical standpoint but also by nutritionists so that their dietary progress is being carefully observed, and patients receive counseling about how to improve their weight loss safely in our program with these specialists involved.
Sheila, what does it feel like to be restricted, if you will, in some ways surgically. They've made it tighter, I guess, or smaller. How important is that support in the program?
It is great because, as I stated before, it takes it from the realm of being a diet that I'm on to a lifestyle change that I have adopted. I no longer eat as much as what I used to. This is a tool that helps me monitor my diet so that I am not overeating because I was an emotional eater and may still be a little bit. But this helps me monitor and stay on track and lead a healthier lifestyle.
Dr. Rogers, we wondered about whether somebody would be a candidate for one procedure versus another. What about the TOGA procedure? Who would be a candidate?
Candidates for this surgical procedure as well as other surgical procedures have to qualify based on the standard criteria set forth by the NIH in their 1991 consensus panel, and that is specifically patients who have failed a supervised weight-loss program, patients who are well informed and motivated, those who have acceptable operative risks, and those who have a BMI, or body mass index, greater than 40 or between 35 and 40 with co-morbidities such as hypertension, diabetes, high cholesterol or sleep apnea.
It was sleep apnea that Sheila had and hypothyroidism as well. So although her BMI was a little bit lower , she had those conditions.
That's correct. Sheila's BMI was actually in the mid 30s, so she qualified based on the BMI of 35 or greater with a co-morbidity.
Dr. Rogers, do you see this as the next generation of bariatric surgery, the incision-free TOGA approach?
Yes, this would be a next generation procedure in general. A lot of the minimally invasive procedures that we perform now are becoming even less invasive with what's called NOTES surgery — natural orifice transluminal endoscopic surgery. These NOTES procedures, of which TOGA is one, is part of the new generation of surgical procedures.
That's certainly neat and sounds like real progress. Sheila, so somebody is listening to us, like you watched TV, and hears about this. What would you say to them? You had wondered about surgery and this sparked you to do something. What would you say to somebody else who is on the fence?
Well, I would say, if you have an opportunity to be a part of a clinical study like I did at UCSF for this TOGA procedure, I would jump on it. I would not hesitate. This procedure, TOGA, is a tool to be used for your weight-loss journey. It's not foolproof, as Dr. Rogers stated, and it's not magic. We have to do our part, and that means we have to make sure that we're eating correctly, eating smaller portions, getting our exercise, taking our vitamins and getting our daily exercise. So we have to do our part.
You can't get the TOGA and expect that, oh, everything is going to be fine. You still have to make your weight loss a success. And I still have some weight to lose and I'm still working on it, but this TOGA procedure has helped me significantly.
That really puts it into perspective. One last thing for you, Dr. Rogers. There's a lot of guilt people have when they're overweight and they try all these programs and they just can't either get the weight off or keep it off. There's a lot of research going on about the genetics of obesity too, right?
Yes. Clearly there is a genetic association with obesity as well as the development of medical problems associated with obesity.
Well, what I'd say to our listeners is don't beat yourself up about it. Nobody wants to have surgery if you can avoid it and you want to do whatever you can to control your weight, keep it from getting to a point of obesity. Clearly, there are some significant health risks, as Sheila mentioned. If you get to a point where you're what you call morbidly obese and you just can't get a handle on it, that's the time for a consultation. Am I right?
Exactly right. The time for the consultation is even before those co-morbidities present.
So in a person who does have obesity, being aware of options available is very important. Being aware that there are surgical as well as nonsurgical options to help lose weight, being aware that there are medical problems associated with obesity including diabetes and hypertension and hypercholesterolemia and sleep apnea, as Sheila mentioned, as well as other problems, early death being one of them, one of the problems associated with obesity. Pursuing a program to help lose weight — with either a nonsurgical or surgical option — is an important aspect to helping people lose the weight and avoid these medical problems.
And all of that can be discussed with qualified health care providers at the bariatric center at UCSF. If you want to find out more you can always just call the physician referral service at UCSF. That's (888) 689-UCSF. You're glad you called, right, Sheila?
Definitely. It's made a difference in my life.
We wish you well with your continued control of your weight, losing more. What size are you trying to get down to?
I guess about an 8 or a 10.
Well, you sound determined. Wish you luck with that. Dr. Stanley Rogers, thanks for the work you do. You're pioneering surgical techniques to help change lives. Congratulations on the work you're doing and thank you for being with us.
Thank you very much.
Thank you, Dr. Rogers.
Thank you, Sheila. Great job.
Thanks to UCSF Medical Center for the work they do and for sponsoring our Patient Power programs. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.
Recorded September 2010
Reviewed by health care specialists at UCSF Medical Center.
This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.
Bariatric Surgery Center
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