And so, one of the first procedures that tried to replicate the vertical banded gastroplasty was the endoluminal vertical gastroplasty, and this was performed by Roberto Fogel. And you can see in the video, he's using one long running suture to do this. And he starts with one stitch kind of approximately, and then he goes distally and places a second one. And he's going to alternate anterior and posterior surfaces of the stomach, kind of marching all the way up. And he's going to do that to, again, partition off that kind of lesser curve, a little tunnel along the lesser curve. So, he studied 64 patients, had 12 months of follow-up, and you can see here that the percent excess weight loss was 58.1% across the board, which isn't bad at 12 months, right? What was quite striking, though, is if you look at the BMI categories below that, patients with initial BMI of less than 35 had an E5% excess weight loss. And people with a BMI of over 40 still had about a 48 to 49% excess weight loss there. Quite encouraging. Problem was that these results really couldn't be easily replicated. Other centers tried, but they weren't getting the same results. And there was also issues with durability of these sutures because it was a suction-based suturing device. It wasn't very permanent. Another procedure that looked at recreating the DBG was the TOGA procedure by Satiety. This is a stapler that was placed para-orally into the stomach, and then the stapler would open up and a sail would emerge from it to divide the stomach into the greater curve and the lesser curve. And then tissues aspirated into the stapler from both greater and lesser size, or sorry, anterior and posterior surfaces. And then the stapler closes and fires several of the staples there. And then it's repeated, and then they have a smaller stapler that narrows down the outlet. So what you're getting here, again, looks very much like a DBG. So they did this study in two international centers, one in Brussels, one in Mexico City. They studied 62 patients. The primary endpoint there was really safety, but the secondary endpoint was weight loss. And you can see there's a 24% excess weight loss at six months. And the problem, again, once you start stapling here is that partial staple line breakdowns were present in 13 of the 21 patients, and really the weight loss was scattered all over. And they got very close to really hitting that FDA endpoint, but then the company sold off the IP and they didn't really pursue it. And finally, the most current of these procedures, now this is an active device, and there's a report from Gotran Lopez-Nava from Madrid last year. And this was a single center prospective series of 13 patients using a device they call the EndoZip. And it looks very much like an overtube with a little bulb here. And you can see that the device kind of aspirates tissue into it, again, similar somewhat to that TOGA procedure, and you run suture through this. So in this particular study, they placed 2.6 sutures. Procedure time was 35 to 120 minutes. So it can be on the longer side, some of these, but again, they're on their learning curve. This is the first 13 patients they had done. And here you see the percent total weight loss is 12% at three months and 42% excess weight loss at that time period. So very encouraging early results. Again, the question with these lesser curvature DBG analogs is durability. The DBG wasn't terribly durable in many centers. So will this be? But keep in mind, the SOS study did show some good results for that DBG out to 20 years.

vertical banded gastroplasty

endoluminal vertical gastroplasty

TOGA procedure

EndoZip device

SOS study