1. Phil Schauer, MD Bariatric and Metabolic Institute

2. Education and Research Support, Consulting NIH/NIDDK Ethicon Endosurgery Stryker Corporation Invacare Corporation Covidien Gore Corporation Bard/Davol Corporation Baxter Corporation Cardinal Health Surgical Excellence Barosense ReMedyMD SurgiQuest Quadrant www.ccf.org

3. Laparoscopic Gastric Plication  No stomach stapling or removal  low leak risk, low bleeding risk  No bypass  minimal nutritional risk  no bowel re-routing  No foreign body (i.e. band)  no prolapse or erosion risk  Potentially reversible or modifiable to another procedure if needed  Minimally invasive; short stay  Lower cost

4. LGCP Normal Endoscopic Appearance Invagination of the greater curvature results in decreased intraluminal gastric volume Normal, intact plication results in lobular contour abnormalities and intraluminal filling defects on imaging

5. LSG vs. LGCP

6. Variations in Technique Laparoscopic Greater Curvature Plication Suture Type Suture Pattern Suture Spacing Depth of Fold Calibration Use of Endoscopy

7. Video - Technique

8. Clinical Studies - Outcomes

9. OUTCOME OF LAPAROSCOPIC TOTAL VERTICAL GASTRIC PLICATION IN MORBID OBESITY Talebpour M, Amoli B. J Laparo Adv Surg Tech 2007; 17:793-798 94p 72p 51p 23p 10p 57% 61% 60% 57% 55% N=150, Mean BMI 47

10. – N = 100 – Age 15-64 y – BMI 31.64 - 45.09 kg/m 2 Mean=37.47Kg/m 2 – Results at 1 year: – Mean weight loss 26.4 +/- 8.7 kg (13-51 kg) – Mean %EWL 69.6 +/- 7.44 (6.2 – 95.6) – No reported complication or mortality

11. Laparoscopic Greater Curve Plication Ramos et al. Obes Surg 2010 Jul;20(7):913-8 42 patients Mean BMI 41 kg/m 2 Mean operative time 50 minutes Mean length of stay 36 hours No major complications Mean 62% EWL at 18 months

12. Brethauer SA et al. SOARD 2011 7:15-22

13. Laparoscopic Gastric Plication for the Treatment of Severe Obesity METHODS IRB approval obtained for this investigational procedure 15 patients (three male) Mean preop BMI 43.5 (36.9 – 49.0) 9 patients underwent anterior surface plication 6 patients underwent greater curvature plication (gcp) Brethauer SA et al. SOARD 2011 7:15-22

14. Anterior Plication

15. Greater Curvature Plication

16. Anterior Plication 6 months 12 months

17. 6 months 12 months Greater Curvature Plication

18. Weight Loss Procedure Three MonthsTwelve Months NΔ BMI%EWL NΔ BMI%EWL Anterior 9 -4.8 +/- 1.4 23.0 +/- 6.4 7* - 4.3 +/- 4.5 19.8 +/- 19.3 ** Greater Curvature 6-7.8 +/- 1.538.9 +/- 8.2 6-10.9 +/- 5.5 53.9 +/- 22.3 * 2 patients lost to follow-up ** Data from 2 patients collected after scheduled 12 month visit

19. Comparison to Other Studies

20. Complications No bleeding or infectious complications First GCP patient required reoperation and plication reduction on POD#2 due to gastric obstruction Mild to moderate nausea in all patients (2 severe). Resolved within two weeks. One GCP patient required laparoscopic cholecystectomy 11 months after procedure Brethauer SA et al. SOARD 2011 7:15-22

21. Laparoscopic Gastric Greater Curvature Plication: Results and Complications in a Series of 135 Patients Skrekas et al. Obes Surg. 2011 Nov;21(11):1657-63. April 2008 – December 2009 One or two-layer plication over 36 Fr Bougie Mean OR time 40-50 minutes Mean LOS 1.9 days (1-6) Mean F/U 22 mos (8-31)

22. Skrekas et al. Obes Surg. 2011

23. Multicenter Trial Underway 3 centers 45 patients 3 year follow-up All sutured Greater Curve Plication Standardized technique Enrollment complete

24. Plication with Gastric Banding

25. Laparoscopic Gastric Plication Summary Anterior Plication safe, but not effective Greater Curve Plication – Technically feasible, reproducible – Good short-term weight loss – Low major complication rate – Remains investigational (ASMBS Position Statement)

26. MISS 2013: Las Vegas FEBRUARY 21-23, 2013 YearVenue 2001Snowbird, UT 2002Beaver Run, Breckenridge, CO 2003Squaw Creek, Lake Tahoe, Calif 2004Whistler, British Columbia 2005Squaw Creek, Lake Tahoe, Calif 2006Vail Cascade, CO 2007Snowbird, UT 2008Steamboat, CO 2009Harrah’s, Lake Tahoe, NE 2010Marriott Marina, San Diego, Calif 2011Grand America Hotel, Salt Lake City 2012Grand America Hotel, Salt Lake City 2013 www.miss-cme.org

27. Thank You