2010 NOTES ® Summit Working Group Report Endolumenal July 8-10, 2010 Chicago, IL

Endolumenal Working Group Procedures Obesity – most impact, most difficult to solve GERD – 2 nd most impact, 2 nd easiest to solve Full thickness resection – 3 rd most impact, easiest to solve Myotomy Drainage Perforations/Leaks

Endolumenal Working Group Obesity Gastric reduction Malabsorption Combined Implant Revision Applications > 35 BMI + co-morbid, > 40 BMI Bridge to surgery Metabolic Cosmetic

Endolumenal Working Group Obesity - Barriers Durability Need for restriction and malabsorption Reversibility – necessary for cosmetic market Environment to practice morbid obese – certified bariatric center cosmetic – need for comprehensive approach – diet, exercise, follow-up Reimbursement Enabling technologies – suturing, stapling

Endolumenal Working Group GERD Mimic surgery – Nissen New approach stem cell augmentation of LES remote electrical stimulation of LES

Endolumenal Working Group GERD - Barriers Reimbursement Durability Safety Efficacy – decrease acid exposure GERD - Solution Target population with unmet need inadequate response to PPI non acid reflux Nissen failures Non surgical candidates

Endolumenal Working Group Myotomy Crossing the GE junction Compare with laparoscopic approach Technical difficulty? Not a large patient population Comparison with balloon dilation

Endolumenal Working Group Full thickness resection Limited applicability (not for cancer because of need for LN harvesting) Closure Stapling seems most straight-forward approach vs pre- placed purse-string suture Identificaton and control of serosal vessels Not a large patient population Large right colon polyps but engineering staple system in right colon Specimen retrieval