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Treatments Available for Obesity - Bariatric Surgery and Considerations for Treatment | Gastric Artery Embolization: Past, Present, and Future
Treatments Available for Obesity - Bariatric Surgery and Considerations for Treatment | Gastric Artery Embolization: Past, Present, and Future
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Gastric Sleeve Resection | Gastric Artery Embolization: Past, Present, and Future
Gastric Sleeve Resection | Gastric Artery Embolization: Past, Present, and Future
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Roux - En - Y Gastric Bypass | Gastric Artery Embolization: Past, Present, and Future
Roux - En - Y Gastric Bypass | Gastric Artery Embolization: Past, Present, and Future
absorbedanastomosisbowelcoloncomplicationsdiarrheafoodgastricinfectionsjejunaljejunumpathwaypouchpronesecretionsstomachstraightsurgerytypically
Other Options For Treatment - Vbloc Gastric Balloon and Aspire Assist | Gastric Artery Embolization: Past, Present, and Future
Other Options For Treatment - Vbloc Gastric Balloon and Aspire Assist | Gastric Artery Embolization: Past, Present, and Future
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Success of Bariatric Surgery and High Risk Population | Gastric Artery Embolization: Past, Present, and Future
Success of Bariatric Surgery and High Risk Population | Gastric Artery Embolization: Past, Present, and Future
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Alternatives and The Past | Gastric Artery Embolization: Past, Present, and Future
Alternatives and The Past | Gastric Artery Embolization: Past, Present, and Future
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Ghrelin: The Theory | Gastric Artery Embolization: Past, Present, and Future
Ghrelin: The Theory | Gastric Artery Embolization: Past, Present, and Future
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Vascular Anatomy | Gastric Artery Embolization: Past, Present, and Future
Vascular Anatomy | Gastric Artery Embolization: Past, Present, and Future
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Effects of Gastric Fundal Embolization in Swine and Endovascular Bariatrics on Humans | Gastric Artery Embolization: Past, Present, and Future
Effects of Gastric Fundal Embolization in Swine and Endovascular Bariatrics on Humans | Gastric Artery Embolization: Past, Present, and Future
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Active FDA Trials - Get LEAN BEAT Obesity and Albany Study | Gastric Artery Embolization: Past, Present, and Future
Active FDA Trials - Get LEAN BEAT Obesity and Albany Study | Gastric Artery Embolization: Past, Present, and Future
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Radial Access and BAE Aid in HgA1C Control | Gastric Artery Embolization: Past, Present, and Future
Radial Access and BAE Aid in HgA1C Control | Gastric Artery Embolization: Past, Present, and Future
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Barriers | Gastric Artery Embolization: Past, Present, and Future
Barriers | Gastric Artery Embolization: Past, Present, and Future
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Limiting Factors | Gastric Artery Embolization: Past, Present, and Future
Limiting Factors | Gastric Artery Embolization: Past, Present, and Future
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Take Homes - Conclusion and Questions | Gastric Artery Embolization: Past, Present, and Future
Transcript

dr. Schramm did his medical school at Cincinnati he also did his internal medicine internship there too he is currently working at the Medical College of wins concen he has the pleasure of delivering our last talk for us but it's another good one gastric artery

embolization the past the present in the future thank you very much all right hi everybody thanks for having me up here to talk to you guys about gastric embolization so I know this is a very last session so I try to keep this spot

as light is physically possible so we're going to talk about big drink all right so you guys recognize this character I don't know if any of you were fans of the off power series back in the early 2000s one of my favorite characters from

the series is FB and we're going to talk about how you get from this to this so this is after he went on the subway diet right so we're going to talk about kind of what options that are out there right now for weight control how big of a

problem is the obesity epidemic and where do we stand in gastric embolization which is one of the emerging therapies no financial disclosure is obviously mo celoso haven't been sponsored by anybody other

disclosures for the data on bariatric embolization is taken from multiple different sources many of these are unpublished and just have been presented in presentation format so these are things that get presented at jest at I

set and then here actually in the afternoon there's going to be a further update I think it one of the afternoon sessions today if you guys are interested cruise on up there I learn more about that because of the nature of

this topic procedures discussed here still considered experimental borrowed justice and graphics for education so that resulted in massive cock an infringement on some of these movies and stuff that I reference having that

time to keep up with pop culture and my fellowships and my jokes are pretty dated as you see so obesity how much of

an active epidemic is this so this is a heat map from the CDC kind of illustrating how the how BM eyes have

changed in the past 15 to 20 years and as you can see red is worse and we're going from light blue to red throughout the course of these and as you can see you know obesity you know greater than thirty percent over your body weight or

recommended body weight that's that's the majority of the country right now so you know this is going to be a continuing problem with the American diet with you know focused on fast food and all that sort of things it's only

increasing in 2008 data from the CDC there's a 1.5 billion overweight individuals in the United States a major factor in the development of diabetes heart attack stroke cancer and osteoarthritis fifth leading cause of

death globally by some estimates in 20-25 forty percent of Americans will be morbidly obese so how does that impact

us as physician so this is a relationship of weight and cardiovascular disease and as you can

see as your BMI gets over 30 which is considered obese you basically have this very very acute uptick in your risk of cardiovascular disease so to BMI of 35 which is considered morbidly obese and an indication for bariatric surgery your

relative risk of death from cardiovascular disease is about double so you can see that own kind of the far right of the screen so more the same see you in the spring toes that's kind of how I fell feel when I when I went to

Wisconsin from Colorado so treatments

available medications are out there so orlistat phentermine and I reduce I'd these have for average weight loss long term some of these drugs have been linked to other heart disease so you

guys probably remember defense been crazed of the 90s you know a lot of these patients went on to have really bad sequelae of taking medications to try to decrease their weight orlistat I actually sauced

there's some vendor upstairs for orlistat you know those patients have diarrhea from malabsorption and all these other things that are make that not a great option as well surgery the fastest growing subgroup as you guys

know bariatric surgery is a is increasing will kind of go through a little bit of data on that and what options are out there how they compare to each other this population by nature is at risk for bad wound complications

and sometimes these people are just too obese to safely performs to agree I mean you're making a big wooden you know a big incision on someone who has an obese abdomen there's a lot of tension on that wound and these patients you know

sometimes have other comorbid conditions that predispose them to loom wound issues so many overweight people are diabetic diabetics by nature are much more prone to infection than the average population some of these surgeries are

also prone to develop malabsorptive or dumping syndrome so I don't know if you've ever had known anybody does gastric bypass but one of my aunt's had it and she had uncontrolled diarrhea afterwards she just you know she would

eat her normal food and then she'd get stomach cramping and diarrhea you know within 20 minutes of eating and she was like I wish I'd never had the surgery the weight loss isn't even important to me anymore because this is ruining my

life and then lastly diet and exercise I don't know anybody who's ever had a new year's resolution know how difficult this is it's very easy to start but very hard to maintain right so this requires a lot of dedication to get your weight

down by exercise it's a huge time commitment going to the gym and eating well when you know you're you're out and about can be difficult as well so bariatric surgery numbers 2011 2015 as you can see kind of top bolded row the

numbers are vastly increasing you know through the years so more and more people are turning to bariatric surgery as they can help them with their weight control issues we'll talk about the different types of bariatric surgery

here in a second those are lifted all the way on screen if you look at those furthest or the fastest-growing surgery here gastric sleeve resection so we'll kind of talk about what that is and then the gastric

banding and how that has how that has evolved in the past couple of years so who do we consider for bariatric surgery BMI greater than 40 or BMI greater than 35 with comorbid condition so if you have if you have diabetes if you

obstructive sleep apnea if you have other things that are caused by your weight then you're you're considered for for surgery at that point so we'll go through the couple of common types of bariatric surgery so lap band surgery

ruined why and gastric sleeve resection

so laparoscopically placed adjustable gastric banding there are still some of these very few of these being done now but a lot of these are floating around still so basically the procedure what

they do if you guys have ever seen the chest port you actually get a little thing that looks like a chest fourth sits on your ribs over in the earth kind of the left side of your abdomen on the inside you have this donut that goes

around the top after your stomach and it basically constricts the top portion of your stomach so that all your food kind of goes up in this little pouch at the top and you have delayed emptying down into the bottom part of your stomach and

I'll limits the amount that you can eat comfortably so provides this physical constraint to superior pouch the only donut that won't make you fat complicated by band slippage obstruction and erosion of the band so we'll kind of

talk about that here in a second average cost about 15 grand a 33 grand that doesn't include follow-up visits which are about 3 to 13 months worth of follow-up currently under investigation due to recent patient death so in the

2000s when they were kind of promoting these things these were the signs that they ad out in California these 1-800 gets in signs and a lot of people got gastric bands as a result of just kind of this being as seen as a minimally

invasive alternative to the ruined y which is a major surgery so they started noticing that these patients were having an increased risk of complications as early as 2012 so the you know government essentially decided to investigate this

a little bit further in see you know what's going on with these patients so now those signs have been replaced by these which are signs for lawyers so 1 800 bad plan so a lot of the surgeons who perform the gastric

bands without any you know a whole lot of data to to justify what they're you know complication rates were are now getting sued as a result so reminds me of this you know better call Saul and then for you guys who are from Wisconsin

Gruber losses so this guy is his his moniker is one call that's all and this is a this is on our you know you know on our TV every every second that you're on there so we'll move on to the fastest

growing subgroup of surgery the gastric

sleeve resection so basically what surgeon does is he goes in with a laparoscope so a couple of small incisions he will take a stapler and staples a greater curvature of the stomach off so as you can see here where

those two little suture lines are it kind of excludes a large portion of the stomach results in a hospitalization of about three to five days so the stomach actually reduced about fifteen percent of the size of the native stomach by

removing the greater curvature ends up being about 150 cc's complicated by slieve league damage to the vagus nerve and reflux so overall it's a pretty safe procedure can reduce excess weight by sixty percent in three years and it's

much quicker and has a lower complication rates and grew and why gastric bypass cost is pretty similar across all these different surgeries about nineteen thousand dollars on average 12 250 grand range for that so

lastly we'll talk about the ruined why gastric bypass so what they do in the Rue and why it's an open procedure typically they swing a portion of the small bowel up and they stow it to the top part of the stomach they cut the

stomach at this kind of superior pass here and then your stomach contents drain via your natural pathway and your the food that you get actually goes straight into your your jejunum typically which is one of the lower

portions of your small bowel now the risk of this is that you're getting you know all of this stuff you know all these nutrients all the fat all the stuff that goes straight into your jejunal so your body obviously

wasn't designed that way so this is these patients are the ones that are prone to dumping syndrome where they get really bad stomach cramps to get malabsorption and they get diarrhea because this stuff kind of funnels

straight into their colon and your your colon is used to handling you know food products that have already had all the nutrients and sugars absorbed from them when you get it into the colon and those haven't been absorbed it's an osmotic

you know ages so it kind of pulls water into the colon and then you you have diarrhea so this is kind of a graphic as to how like the two tubing's work because this was kind of confusing to me when I was in medical school so food

kind of comes up from the top dumped straight down into the small bowel through this artificially created pouch and then your normal gastric secretions and pancreatic secretions come down through their natural pathway and

there's a little anastomosis or connection down in the small part of the of the bow on the bottom screen so this creates about a third 15 to 30 cc pouch isolated from the distal stomach complications include minor leaks

intra-abdominal abscess is wound infections and respiratory infections so these are a little bit bigger surgery than the other procedures and these are a little bit more prone to developing some of the infectious complications

cost of surgery is between 15 and 30 grand so very similar across the

different options so other options that are out there for minimally invasive control so the bottom left is the Vblock procedure so this is basically a little

nerve stimulator so your gastric emptying is controlled by your vagus nerve so this thing actually just kind of works to slow your gastric emptying keep you fuller longer so that you don't get hungry there's a gasket balloon

which is the top left where you actually gastroenterologist gives you a balloon that inflates in your stomach so that it kind of sits there and occupies space and then the Aspire assist which this just got recently fda approved this is

kind of I think one of the most absurd you know devices I've ever seen it's a it's a g-tube essentially you got some all places in your practices and it's a g-tube that you use to vent your stomach after you

eat so it's essentially medical bulimia which is I think I'm surprised i actually made it through but it did back in as you see up there June 14.6 teen to this past summer the school's FDA approved for for insertion so pretty

pretty ridiculous I don't know if you asked me that that we're actually you know encouraging this type of behavior

surgery do really well actually so average sustained weight loss across all

bariatric surgeries about 88 pounds so that's really really good if you're you know if you're taking that these patients with a BMI of 35 to 40 are going to be you know in the 300 pound range you're knocking off you know a

third of their weight that's pretty good decrease in other comorbid conditions is pretty good seventy percent have resolution of diabetes sixty-two percent resolution hypertension eighty-six percent resolution sleep apnea and

eighty-seven percent have improvement in their hypercholesterolemia so while the risks are great of these bariatric surgeries the benefits are really good too i mean this is going to decrease your your underlying comorbid condition

so pretty pretty good however if you go under go bariatric surgery you're at a really high risk of having a complication mortality as reported as one to two percent so think about that i mean you're taking what is essentially

an elective procedure and saying there's a two percent chance that you're not going to make it through because you're going to have a complication wound complications is high seven percent post-operative hernias from the

incisions in as high as nine percent and this is you know these numbers don't include those patients that they say hey you're basically too big for us to

us to bariatric embolization kind of a

purpose of a talk so this is you know gaining a little bit of traction in the in the media as you can see here got something from the nightly news talking about this procedure so where did this idea come from right so actually this is

the data or the reasoning behind behind this in an experimental fashion came from anecdotal ir reports so back in the 70s for ulcers before they had you know all of the endoscope technology that we had now sometimes IRS would do left

gastric embolization prophylactically to control life-threatening bleeding from ulcers so the ir docs noticed that these patients who underwent embolization for their life-threatening bleeding actually lost weight further on down the line so

they decided to take a look at some of the charts and actually try to figure out how much weight these patients were losing so Mass General came out with the first study in 14 patients who had underwent left gastric embolization for

hemorrhage and they looked at a teenage mashed matched patients who underwent embolisation of a different upper gastric artery and they notice that the left gastric artery embo you know the patients who underwent gdam elevation or

other gastric embolization only had a 1.2 percent weight loss so they thought a man there's something about this artery that really you know there's something more to this why are these patients losing weight and our other

patients aren't so this is the theory

behind it ghrelin this is a hormone that controls hunger so this is what this thing looks like this is a very complex you know there's a very complex feedback mechanism in the body about controlling

you know depending how much you eat your grill and release and then how that stimulates appetite these things are a little complicated for me to understand so this is how I understand it the more grill and you have the hungrier you are

so where does it live the G ourselves up here that ghrelin releasing cells are up in the gastric fundus all the other cells in the body that control other proportions of hunger so parietal cells which control acid secretion some of

these other cells that control other functions of the stomach are in different different areas so the left gastric artery supplies blood to the fundus and animal studies have actually shown that embolization of the left

gastric artery decreases blood levels of ghrelin these animals actually also show weight loss so there's a couple of studies that you know anecdotally before the these left gastric emilie's issues were

performed that suggested does this you know these might be more strongly connected than we first thought so they measured ghrelin and rats and rats who have higher level levels of ghrelin are more prone to be obese and more prone to

eat more so changes in ghrelin after ruined my gastric bypass so as you alter that Anatomy as your you're sniffing things around up there you're almost feel decreasing the amount of ghrelin from your excluded portions of your

stomach and that's actually predictive of weight loss and ruin my gastric bypass so again going back to this you can imagine that you know if we can embolize the cells that produce this hunger producing hormone maybe we could

decrease weight gain or actually result

in weight loss so this to review vascular Anatomy you guys see this all the time you know when you guys are doing liver directed therapy but you know one of the main arteries to the top

half of the day the gut and some of the superior organs in the abdomen is the celiac first branch off of the celiac going straight north is the left gastric artery this is what it looks like to us under angiography so cannulation of the

celiacs pretty quick after access it's you know pretty easy to get into and getting into the left gastric is it's the first branch off of there so fairly easy to get to this is what the left gastric looks like when you actually

inject it would die and as you can see these little kind of curly q arteries going out to the stomach are are all just all the arteries that would would basically go to where you're ghrelin producing cells are so those kind of

superiorly directed arteries up there on

2012 the first animal studies so they studied effects of gastric funnel embolization in pigs they noticed that pigs do I'd left gastric embolization

had slower weight gain than the non embolized pigs repeated these results a little bit later with a control procedure where they would go up into the left gastric artery but not actually embolized and the results were similar

so they had slower weight gain in pigs I guess figs being pigs they still ate a lot so they still were gaining weight but just at a slower yeah the other one so this is the first published human study for love gastric

embolisation so this is in 2015 so this is all fairly new and this was at eclipse with AZ out of out of the New England area first published in 2015 so he thought you know let's get crazy and try this on people see what happened so

he enrolled five patients all these patients were obese is the average BMI of 40 to embolize the left gastric artery with 300 500 micrometer beads and then later using endoscope to examine the stomach and esophagus to kind of

figure out what were we doing actually to the mucosa is this causing you bad effects so you actually noticed pretty good weight loss so at one month at 29.2 pound average weight loss three months 37 pound Everidge weight loss in at six

months 45-pound weight loss so it's pretty dramatic for a procedure that can take 40 to 45 minutes of the posts of major surgery baseline ghrelin levels dropped you know that kind of correlates to what we what we think is causing this

which is a decrease in grown and vm i went from 42.3 to 35.3 and if you guys can think back to that second or third slide I showed you about the risk of cardiovascular death in these patients at 42 your relative risk of

cardiovascular death is like you know is about three times your average your average person at 35 it's closer to 1.2 so you're decreasing you know you potentially be decreasing the relative risk of cardiovascular death from other

causes through this so there's three

currently active FDA trials a couple of them have kind of neat names so there's a get lean trial the gastric artery embolization trial for the lessening of appetite non-surgically out of date in

Ohio they're using three to five hundred bead block beads the beat obesity trial or the bariatric embolisation for arteries and treatment of obesity three to five hundred embo spheres they're using and then Albany study their use in

five to seven hundred TVA so who are they looking at they're looking at patients with morbid obesity BMI over 40 age / 22 waits got to be less than 400 pounds and that's basically due to some of these these institutions angiography

cable limit they have to have failed previous attempts at weight loss through diet exercise and behavior modification who's being excluded these are all kind of you know typical people that be excluded from any study recent surgery

prior radiation or embolisation procedures in the abdomen and all these other comorbid conditions the biggest one I think to highlight is the psych disorders one as you guys know if you are morbidly obese your risk of having a

psychologic disorder is very very hot actually either depression or there may be something underlying that got you to that point where you turn to food as a as a crutch so this will kind of talk about some of the limitations of the

study so how do we do this femoral radio access saying that's for conventional angio we get into the celiac with a c2 or soft sami select and left gastric artery with the microcatheter and you select passkey esophageal branches

particle embolisation depends on your protocol and point five beats of stasis use a closure device to get out once you're done and as you guys know this is kind of how these things go up so you basically you know sprinkle some

particles in there and then wait till they include the arteries based on your follow-up angiography so the get lean trial how their house their data been pretty good as well so at six months there you know finding that their

patients are losing about 20 pounds the beat obesity trial at six months they're finding their patients lost about 20 pounds so losing about 13 4.4% of their excess weight loss so preliminary

results there's actually studies been

being done in other countries right now and they pulled all of that data and this was most recently presented at I set 2017 about a month ago so this is some borrow data from them I know this they're probably too small to read so I

blew up the total so the total number of patients that have been treated with this 58 they've been followed between 2 to 24 months and their weight loss mean has had been about nine percent so if you take someone who is 300 pounds

and you have a nine percent weight loss these patients are losing about 30 pounds at two years so that's pretty good that's pretty good risk of minor adverse events is 32 point five percent but many of these are they get benign

gastric ulcers that the patient doesn't notice they're noticed on endoscopy and they keel spontaneously so what kind of adverse events have they been talking about so superficial officers in the me in the stomach mucosa all of these have

been filled you know thus far and then one of the patients the beat obesity trial got pancreatitis which they're not sure whether this was related to the procedure or not but they included it so is this the next big thing amazon you

know netflix apple maybe maybe not it has a little bit of promise you know this is an outpatient procedure can be done skin to skin in 45 minutes and i think the role for this is going to be in bridging a patient to the more

permanent fix ie surgery if they're too

obese to safely perform gastric bypass so you know via radial access you can get down into the celiac you're avoiding any growing complications you know as you as you guys know if you have an

obese patient trying to get into the femoral artery and do it safely can be challenging right i mean there's a you know you have to tape them you do all these other sort of sorts of adjectives maneuvers but if you can go through the

radial access you know you put that TR band then we saw on earlier and you avoid any any wound complications in the groin and if these patients can lose 30 pounds gets them to a surgery where it might be safer for them you know so

they're going to through that 30-pound weight loss it's going to be you know or reduction in diabetes and those sort of things you may be less prone to having wound complications may be less prone to having you know a complication of your

surgery if your weight less when you undergo gastric bypass so there's actually that is to support that too so bariatric emilie's ation aids and hemoglobin a1c control so hemoglobin a1c is what they measure in diabetics to

determine long-term glucose control so how much are you fluctuating you know are your sugars three hundred than 100 and 300 + 100 are or are you staying steady at 120 or so so this actually improves

Lukos control so hemoglobin a1c is directly translatable to risk of cloth surgical infection so if you can have better hemoglobin a1c control you're going to decrease the risk of infection when you eventually get this person

gastric generalization so they have to have an ability to sustain diet and exercise post-op so if you if you're trying to enroll patients who are limited in mobility because of their

weight osteoarthritis all these other things then they might not be the ideal patient so big people are sick people so they're comorbid conditions preclude Universal application we saw that big list of people that they're excluding

you know if you if you have any of those comorbid conditions you're excluded right now from from being studied the BMI cut off you're not eligible currently if you're under BMI of 40 and as we saw there are some people who fit

that BMI of 35 to 40 that are still going to have the bad adverse effects because of their weight but they're currently not a non eligible eligible for treatment and then depressed patients or those on antidepressants are

excluded so going back to our guy from

Austin Powers I eat because I'm unhappy I'm unhappy because I eat so there's a direct correlation between between you know kind of depression mental disorders and obesity so that may be something

that complicates patient selection in the future additionally this may potentially limit future gastric surgery we don't really know how emboli zhing you know a quarter of the stomach is going to you know how these patients are

going to do surgically afterwards you know by you know decreasing the blood flow to these smaller arteries are we going to make them more prone to have a leak or a wound instance or something like that out there and ask the mostest

once they get them to the surgery and right now we don't really know what the side effects of decreasing your ghrelin are so we know that you might lose weight but is there other other other things on down the line that might

happen the result of growing petitions so to speak so I think one of the biggest limiting factors is the American diet right so you know nobody likes to be healthy you know and i think you know bariatric embolization may be seen as a

and surgery is kind of seen as a crutch saying oh well you know I might not have to develop these healthy habits eating regular you know eating well and exercising regularly if you know a surgery can fix it or this embolization

procedure can fix it so my take home is

kind of from the stock it's a promising procedure for the future and there's potential for major weight loss and at least safe and effective in the short term may actually make gastric surgery

safer in the future however i think the real thick homes are you have to be comfortable in your own skin get outside be active and eat well and cheat occasionally so really a healthy healthy diet and exercise are really the the

main things that you can do to you know to kind of make yourself healthier in the long term and avoid any of these these things in general so these are pictures of me from my time when I was on residency in Colorado myself in my

fiance doing a couple of different hikes the maroon bells which are like the most photographed mountains in America down there on the bottom and then us doing a little bit of rafting some of me and my co residents out there in the indoor

canyon so thank you guys for opportunity to talk to you guys and hope you enjoyed the time [Applause] they do they do yeah so that's one of the things i think the surgeons right

now are a little bit apprehensive to undergo this procedure because we don't really know how this can affect their future surgeries but in those in those institutions those patients are seeing a nutritionist they're seeing you know all

the other support staff and they're also seeing a surgeon to evaluate their further options on down the road so those are part of the the three trial placed in Albany in baton yeah I'm not not certain I didn't really look into

that when I was doing that doing the research but you know certainly that's that's one of the things you know we we know that this you know procedure decreases ghrelin levels which decreases hunger which decreases weight but you're

emboli zhing a lot of things that aren't specifically your ghrelin producing cells so what's the downstream effects of those might be or not I don't think there's there's really a lot of data on that quite yet yeah so those are their

ex their one of the inclusion criteria is that they've had to have done diet and exercise and have that fail in weight loss so that was one of the inclusion criteria for for these studies but they continued that diet and

exercise regimen you know after yeah and I think as you know kind of highlighted I think use of this is a potential bridging therapy where you know someone sees initial weight loss in a they're encouraged by that or makes

them you know it makes walking easier so they get out and go for a walk and the folks are you know sitting around the house or whatever because they've lost a little bit of weight because of this this is you know I think use of this to

kind of spur the initial weight loss is going to be where the value is and whether that bridges them to surgery or like you said it you know the first part of weight loss kind of motivates them or makes it easier for them to get out and

exercise or you don't have a cleaner diet I think I think that's where the promises thank you [Applause]

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