So, there are of course many different types of surgery, and they're all fairly effective. You can see above here we have the gastric procedures, which really focus on reducing the volume of the stomach, either the sleeve gastrectomy on the upper left or the adjustable gastric band on the upper right. So they're creating a smaller stomach. And then below we have the procedures that also involve an element of bowel bypass. So you still in all of these have a partitioning or resection part of the stomach, but you now have an element of bowel bypass, and that's thought to confer an additional metabolic component to the procedure, you know, good for the treatment of diabetes and comorbidities. The Swedish Rebuse Subject Study is a longitudinal prospective match study. It wasn't a randomized controlled trial, but they had over 400 primary health care centers involved and 25 surgical departments, and they looked at several different surgical procedures longitudinally. So the circle here is banding, adjustable gastric banding. The triangle is vertical banded gastroplasty, and the square is gastric bypass. And you can see the gastric bypass, of course, is associated with the greatest percent total weight loss out to 20 years here, you know, nearly nearly 30 percent. But you see that even just those gastric procedures where they make the stomach volume smaller, either the adjustable gastric band or the BBG, you get pretty decent weight loss out to 20 years. Right. So that's very encouraging for our procedures and more in the 15 to 20 percent range there. So endoscopic, bariatric, and metabolic therapies, or EBMTs, really break down broadly into two categories, either gastric procedures or small bowel. The gastric procedures involve various devices. You have the space occupying devices, such as the intragastric balloons here. You have gastric remodeling, which is suturing or gastric placation procedures, aspiration therapy, and then a variety of other procedures as well. And those focus on treating obesity first and foremost. They're triggering weight loss. And then whatever other resolution you have in comorbidities is probably due to the weight loss. Then we have the small bowel procedures, okay, and these have more direct metabolic effects or anti-diabetic effects. And you can see there's various sleeves or liners, if you will, and anastomosis technologies as well as adenaline mucosal resurfacing, where you're kind of ablating the mucosal lining of the duodenum. Now they all kind of have different proposed mechanisms of action, and some of these are really trying to mimic the surgical analogs. And that's really what a lot of the suturing procedures do, right? The small bowel devices are focusing on hindgut mechanisms, trying to spike TLP1 and doing a variety of things there. The suturing procedures were thought to potentially delay gastric emptying and suppress grellins. That's one mechanism by which they can work. Or maybe they act like a sleeve gastrectomy and they cause more rapid gastric emptying. And then you can also get into that scenario where you're spiking GLP1 and triggering some of the hindgut mechanisms that you see with the small bowel devices. So one thing to keep in mind here with suturing and placating is that the devices are FDA cleared. However, they don't have a specific weight loss claim. So they're an approved device, if you will. They're cleared through the FDA, but without that claim. So keep that in mind, unlike some of the other procedures or devices like a balloon that's actually specifically approved for weight loss. So a suturing has been available since 2000. This is when the first suturing device was approved in the United States. And it was really focusing on anti-reflux procedures. I became involved in this space in 2003, right after fellowship, and started focusing on obesity. And we had a patent for this, and we did various procedures, including closing fistula, revising failed gastric bypasses, and some primary obesity therapy as well. And again, what we were looking at is the surgical alternatives that we could replicate. So we have the vertical banded gastroplasty here on the left of the VBG. That was kind of commonly performed for a while, and then was quickly replaced by adjustable gastric bands, because it had a high failure rate due to staple line breakdown. So that was just a problem with the procedure. But it did work, provided that the staple line wouldn't break down, and they didn't get complications like reflux. And then the other analog would be gastric imbrication, which was done more in South America, but there were some centers doing that in the United States as well, where they fold in that greater curvature of the stomach, again, reducing gastric volume. So these were the two targets for endoscopic suturing.

weight loss surgery

obesity treatment

gastric procedures

bowel bypass

endoscopic bariatric and metabolic therapies