Outlet Reduction Research Articles

Impact of Leptin-Melanocortin Pathway Genetic Variants on Weight Loss Outcomes After Endoscopic Transoral Outlet Reduction.

Variants in the leptin-melanocortin pathway (LMP) are associated with severe obesity. We evaluated weight loss of patients with or without heterozygous LMP variants, with weight recurrence after Roux-en-Y gastric bypass, who underwent endoscopic transoral outlet reduction (TORe). We retrospectively reviewed patients genotyped for an LMP who had undergone TORe, classified as "carriers" or "non-carriers" of genetic variants. We included 54 patients (22 carriers, 32 non-carriers). We identified 34 genetic variants in 21 different genes in 22 patients. Total body weight loss (%TBWL) after TORe was significantly different at 9 and 12months (12months: 0.68 ± 7.5% vs. 9.6 ± 8.2%, p < 0.01). This difference in weight loss was present even when analyzed in subgroups of patients who had undergone tubular TORe technique, and TORe plus APC. At 3, 6, and 12months, the percentage of carriers achieving ≥ 5% and ≥ 10% TBWL was lower than non-carriers. Patients with LMP variant who underwent RYGB had decreased weight loss 1year after undergoing TORe.

S2122 Longitudinal Weight Loss Outcomes Following Transoral Outlet Reduction (TORe) in a Minority Patient Population at an Urban Safety Net Hospital

S2122 Longitudinal Weight Loss Outcomes Following Transoral Outlet Reduction (TORe) in a Minority Patient Population at an Urban Safety Net Hospital

S1555 Predicting Factors of Higher Weight Loss After Endoscopic Transoral Outlet Reduction (TORe) in a Large Cohort of Bariatric Patients

S1555 Predicting Factors of Higher Weight Loss After Endoscopic Transoral Outlet Reduction (TORe) in a Large Cohort of Bariatric Patients

S1618 Efficacy of Endoscopic Transoral Outlet Reduction (TORe) on Weight Loss Outcomes in Diabetic vs Non-Diabetic Patients Following Roux-en-Y Gastric Bypass

S1618 Efficacy of Endoscopic Transoral Outlet Reduction (TORe) on Weight Loss Outcomes in Diabetic vs Non-Diabetic Patients Following Roux-en-Y Gastric Bypass

S1598 Efficacy of Transoral Outlet Reduction for Weight Regain Following Roux-en Y Gastric Bypass: A Comparison of Pre and Post COVID-19 Pandemic

S1598 Efficacy of Transoral Outlet Reduction for Weight Regain Following Roux-en Y Gastric Bypass: A Comparison of Pre and Post COVID-19 Pandemic

S1515 The Role of Endoscopic Submucosal Dissection, Pursestring Suturing, and Anti-Obesity Medications in Enhancing Weight Loss After Transoral Outlet Reduction in Roux-en-Y Gastric Bypass Patients With Weight Regain

S1515 The Role of Endoscopic Submucosal Dissection, Pursestring Suturing, and Anti-Obesity Medications in Enhancing Weight Loss After Transoral Outlet Reduction in Roux-en-Y Gastric Bypass Patients With Weight Regain

Long-term results after transoral outlet reduction (TORe) of the gastrojejunal anastomosis for secondary weight regain and dumping syndrome after Roux-en-Y gastric bypass.

Bariatric surgery has been proven to be the most effective therapy for obesity and Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedure. However, weight regain and dumping syndrome occur over time. The transoral outlet reduction (TORe) procedure using an endoscopic suturing device may be an option to treat these conditions. We aimed to analyze outcome parameters and long-term results for this endoscopic technique. A retrospective data analysis of patients who underwent TORe using an endoscopic suturing system at our institution from January 2015 to December 2020 was performed. A total of 71 subjects were included. Forty-five patients received the intervention for weight regain, 9 for dumping syndrome and 17 for both. The primary endpoint was weight stabilization or weight loss for subjects with weight regain, and resolution of symptoms for those with dumping syndrome. Secondary endpoints were intraoperative complications, procedure time, length of hospital stay and diameter of gastrojejunal anastomosis 1year post-intervention. The median size of the gastrojejunal anastomosis was estimated at 30mm before intervention, and after performing a median of 3 endoscopic sutures, the median estimated gastrojejunal anastomosis width was reduced to 9.5mm. Eight perioperative complications occurred. Overall mean follow-up was 26.5months. All interventions achieved weight stabilization or weight loss or resolution of dumping symptoms within the first 3months, 98.2% at 12months, 91.4% at 24months and 75.0% at 48months. In 22/26 subjects a persisting improvement of dumping syndrome was achieved. TORe is a safe and effective procedure in the treatment of patients with dumping syndrome after laparoscopic RYGB, the effect on weight stabilization is less significant. A prospective randomized trial should be conducted to compare the effects of TORe with other surgical methods like banding the gastrojejunal anastomosis.

Endoscopic therapies for bariatric surgery complications.

The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications. The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB. Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required.

Endoscopic transoral outlet reduction induces enterohormonal changes in patients with weight regain after Roux-en-Y Gastric Bypass.

Background and aims: Transoral outlet reduction (TORe) has long been employed in treating weight regain after Roux-en-Y gastric bypass. However, its impact on gut hormones and their relationship with weight loss remains unknown. Patients and Methods: This is a substudy of a previous randomized clinical trial. Adults with significant weight regain and dilated gastrojejunostomy underwent TORe with Argon Plasma Coagulation (APC) alone or APC plus endoscopic suturing (APC-Suture). Serum levels of ghrelin, GLP-1, and PYY were assessed at fasting, 30, 60, 90, and 120 minutes after a standardized liquid meal. Results were compared according to allocation group, clinical success, and history of cholecystectomy. Results: Thirty-six patients (19 APC vs. 17 APC-Suture) were enrolled. There were no significant baseline differences between groups. In all analyses, the typical postprandial decrease in ghrelin levels was delayed by 30 minutes, but no other changes were noted. GLP-1 levels significantly decreased at 12 months in both allocation groups. Similar findings were noted after dividing groups according to the history of cholecystectomy and clinical success. The APC cohort presented an increase in PYY levels at 90 minutes, while APC-Suture did not. Naïve patients had significantly lower PYY levels at baseline (p=0.01) compared to cholecystectomized individuals. This latter group experienced a significant increase in the AUC for PYY levels, while naïve patients did not, leading to a higher AUC at 12 months (p=0.0001). Conclusions: TORe interferes with the dynamics of gut hormones. APC triggers a more pronounced enteroendocrine response than APC-Suture, especially in cholecystectomized patients.

Transoral Outlet Reduction: Expert Tips, Tricks, and Troubleshooting.

Transoral outlet reduction (TORe) is an incisionless, endoscopic procedure to address weight recurrence after Roux-en-Y gastric bypass. Given the chronic, progressive nature of obesity and the minimally invasive, anatomy preserving technique of TORe, the procedure is expected to be met with high patient acceptance and widening clinical adoption. Nevertheless, the approach to TORe has been heterogeneous. As endoscopic bariatric therapies are increasingly incorporated into the multidisciplinary management of obesity, it is crucial to have a standardized, evidence-based framework for their implementation. In this review, based on the available literature and the authors' combined experience of over 1,000 TORe procedures, we present our approach to patient selection, procedural technique, troubleshooting, and patient aftercare unique to TORe.

“How I Do It: Endoscopic Management of Weight Regain After Roux-en-Y Gastric Bypass (With Video)”

Transoral outlet reduction (TORe) is an endoscopic intervention for patients who have weight recurrence, dumping syndrome, or post-prandial hypoglycemia following Roux-en-Y gastric bypass (RYGB). TORe offers a minimally invasive alternative to surgical revision, which is often associated with high morbidity rates. This paper will detail the approach to TORe in regard to patient selection, endoscopic technique, and post-TORe outcomes.

Transoral outlet reduction: Outcomes of endoscopic Roux-en-Y gastric bypass revision in 284 patients at a community practice.

Transoral outlet reduction (TORe) is a minimally invasive endoscopic revision of Roux-en-Y gastric bypass (RYGB) for weight recurrence; however, little has been published on its clinical implementation in the community setting. To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB. This is a retrospective cohort study of argon plasma coagulation and purse-string suturing for gastric outlet reduction in consecutive adults with weight recurrence after RYGB at a single community center from September 2020 to September 2022. Patients were provided longitudinal nutritional support via virtual visits. The primary outcome was total body weight loss (TBWL) at twelve months from TORe. Secondary outcomes included TBWL at three months and six months; excess weight loss (EWL) at three, six, and twelve months; twelve-month TBWL by obesity class; predictors of twelve-month TBWL; rates of post-TORe stenosis; and serious adverse events (SAE). Outcomes were reported with descriptive statistics. Two hundred eighty-four adults (91.9% female, age 51.3 years, body mass index 39.3 kg/m2) underwent TORe an average of 13.3 years after RYGB. Median pre- and post-TORe outlet diameter was 35 mm and 8 mm, respectively. TBWL was 11.7% ± 4.6% at three months, 14.3% ± 6.3% at six months, and 17.3% ± 7.9% at twelve months. EWL was 38.4% ± 28.2% at three months, 46.5% ± 35.4% at six months, and 53.5% ± 39.2% at twelve months. The number of follow-up visits attended was the strongest predictor of TBWL at twelve months (R2 = 0.0139, P = 0.0005). Outlet stenosis occurred in 11 patients (3.9%) and was successfully managed with endoscopic dilation. There was one instance of post-procedural nausea requiring overnight observation (SAE rate 0.4%). When performed by an experienced endoscopist and combined with longitudinal nutritional support, purse-string TORe is safe and effective in the community setting for adults with weight recurrence after RYGB.

S1219 Total Intravenous Anesthesia vs Inhalation Anesthesia for Transoral Outlet Reduction

S1219 Total Intravenous Anesthesia vs Inhalation Anesthesia for Transoral Outlet Reduction

S1253 Efficacy and Safety of Transoral Outlet Reduction for Dumping Syndrome After Roux-En-Y Gastric Bypass: A Systematic Review and Meta-Analysis

S1253 Efficacy and Safety of Transoral Outlet Reduction for Dumping Syndrome After Roux-En-Y Gastric Bypass: A Systematic Review and Meta-Analysis

Transoral gastric outlet reduction for post-prandial hypoglycemia after Roux-en-Y gastric bypass.

Post-prandial hypoglycemia is an uncommon but disabling late complication of Roux-en-Y gastric bypass (RYGB). Most patients can be treated with dietary interventions and medications; however, some patients develop refractory hypoglycemia that may lead to multiple daily episodes and seizures. While RYGB reversal surgery is an effective treatment, complication rates are high, and patients inevitably experience weight regain. Transoral gastric outlet reduction (TORe) is a minimally invasive treatment that is effective for early and late dumping syndrome. However, prior studies have not distinguished the effectiveness of TORe specifically for patients with post-prandial hypoglycemia. This study aims to describe a single institution's experience of TORe for treating post-prandial hypoglycemia. This is a case series of patients with prior RYGB complicated by post-prandial hypoglycemia who underwent TORe from February 2020 to September 2021. Pre-procedural characteristics and post-procedural outcomes were obtained. Outcomes assessed included post-prandial hypoglycemia episodes, dumping syndrome symptoms, and weight change. A total of 11 patients underwent TORe from 2020 to 2021 for post-prandial hypoglycemia. Three (27%) patients had a history of seizures due to hypoglycemia. All had been advised on dietary changes, and ten patients (91%) were on medications for dumping. All patients reported a reduction in post-prandial hypoglycemic events as well as the majority of dumping syndrome symptoms during an average follow-up time of 409 ± 125days. Ten patients (91%) had experienced weight regain from their post-RYGB nadir weight. For these patients, the average total body weight loss 12months post-TORe was 12.4 ± 12%. There were no complications requiring hospitalization. One patient experienced post-TORe nausea and vomiting requiring dilation of the gastrojejunal anastomosis with resolution in symptoms. TORe is a safe and effective treatment for post-prandial hypoglycemia and weight regain after RYGB in patients with symptoms refractory to medications and dietary changes.

Tubularization of the gastric pouch helps sustain weight loss after transoral outlet reduction for post-Roux-en-Y gastric bypass weight recurrence.

Background and study aims Traditional transoral outlet reduction (TORe) is a minimally invasive endoscopic approach focused on reducing the aperture of the gastrojejunal (GJ) anastomosis, while the tubular transoral outlet reduction (tTORe) consists of tabularization of the distal pouch utilizing an O-shape gastroplasty suturing pattern. The primary aim of this study was to compare short-term weight loss between TORe and tTORe. Patients and methods Retrospective analysis of a prospectively maintained database was conducted at a tertiary care bariatric center of excellence. The study included patients with history of Roux-en-Y gastric bypass (RYGB) who had an endoscopic revision by TORe or tTORe and had follow-up data in their electronic medical record. The primary outcome was percent total body weight loss (%TBWL). Results A total of 128 patients were included (tTORe=85, TORe=43). At 3 and 6 months, the tTORe and TORe cohorts presented similar %TBWL (3 months: 8.5±4.9 vs. 7.3±6.0, P = 0.27 and 6 months: 8.1±7.4 vs. 6.8±5.6, P = 0.44). At 9 months, there was a trend toward greater weight loss in the tTORe cohort (9.7±8.6% vs. 5.1±6.8%, P = 0.053). At 12 months, the %TBWL was significantly higher in the tubularization group compared to the standard group (8.2±10.8 vs. 2.3±7.3%, P = 0.01). Procedure time was significantly different between both groups (60.5 vs. 53.4 minutes, P = 0.03). The adverse events rate was similar between groups (8.2% vs. 7.0% for tTORe and TORe, respectively, P = 0.61). Conclusions The tTORe enhances efficacy and durability of the standard procedure without adding significant procedure-related risks.

Development of a novel endoscopic suturing simulator: validation and impact on clinical learning curve (with video)

Background and AimsEndoscopic suturing is a complex skill with broad applications. This study aims to develop and validate a novel endoscopic suturing simulator and scoring system for the pursestring suture pattern. MethodsThis was a prospective study of an endoscopic suturing simulator, which consists of a circular opening representing a dilated gastrojejunal anastomosis of Roux-en-Y gastric bypass with 12 small target holes around its circumference. Pursestring suturing is performed in a counterclockwise fashion. Time allotted is 5 minutes. Each successful bite is awarded 10 points. Participants were divided into the novice, intermediate and experienced groups. Validity evidence based on content, validity evidence based on other variables and validity evidence based on consequences of testing were assessed. Results17 subjects (3 novice, 7 intermediate and 7 experienced) participated in the study. Validity evidence based on content: The content validity index for realism, relevance and representativeness was 0.89, 1.00 and 1.00, respectively. Validity evidence based on other variables: The novice, intermediate and experienced groups scored 30.0±8.2, 57.1±28.1 and 131.2±51.7, respectively (p=0.001). Validity evidence based on consequences of testing: The simulator group required 5±5 transoral outlet reduction cases before being able to independently complete an entire pursestring, while the non-simulator group required 38±11 clinical cases (p<0.0001). ConclusionThis novel endoscopic suturing simulator appears realistic, relevant and representative of the clinical suturing experience. Additionally, it appears effective at objectively assessing suturing skills and shortening the clinical learning curve.

Efficacy and safety of revisional treatments for weight regain or insufficient weight loss after Roux-en-Y gastric bypass: A systematic review and meta-analysis.

Weight regain or inadequate weight loss following Roux-en-Y gastric bypass poses a significant clinical challenge. Our objective was to evaluate various revisional techniques for addressing weight regain and insufficient weight loss after Roux-en-Y gastric bypass through a systematic review and meta-analysis. We performed a literature search (in PubMed and Embase) on revisional interventions in collaboration with a medical information specialist. Measured outcomes included body mass index at intervention, total weight loss during follow-up, and complications. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals. Thirty-nine studies were included: four studies reported on argon plasma coagulation, four studies on transoral outlet reduction, nine studies on transoral outlet reduction + argon plasma coagulation, four studies on pouch/gastrojejunal anastomosis revision, five on laparoscopic gastric banding, two studies on laparoscopic gastric banding + pouch resizing, 10 on distalization-RYGB, and one on duodenal switch. All techniques resulted in short-term clinically relevant weight loss. Endoscopic procedures had a short follow-up and resulted in modest and temporary weight loss. Surgical revision techniques were successful for weight loss in longer term follow-up, at the expense of high complication rates.

Effect of Transoral Outlet Reduction on Hepatic Fibrosis in Roux-en-Y Gastric Bypass Patients with Weight Regain and Non-alcoholic Fatty Liver Disease.

Weight regain after Roux-en-Y gastric bypass (RYGB) is associated with worsening of liver outcomes. However, the effect of transoral outlet reduction (TORe) on liver fibrosis in RYGB patients with weight regain and possible advanced fibrosis remains unknown. This was a retrospective analysis of prospectively collected data of RYGB patients who underwent TORe for weight regain. Only patients with possible advanced fibrosis were included. TORe was performed using either an endoscopic suturing device (S-TORe) or plication device (P-TORe) to reduce the gastrojejunal anastomosis (GJA) and pouch sizes. Primary outcomes included changes in non-invasive tests (NITs) for fibrosis at 6-12months. Secondary outcomes included weight loss and changes in insulin resistance and lipid profile at 6-12months. Fifty RYGB patients were included. Baseline age and BMI were 55 ± 11years and 40.1 ± 7.3kg/m2. Baseline GJA and pouch sizes were 20 ± 7mm and 5 ± 2cm, respectively. Thirty patients (60%) underwent S-TORe and 20 patients (40%) underwent P-TORe. At 12months following TORe, there were statistically significant improvements in NITs for fibrosis, including ALT, AST and FIB-4. There was a trend towards significant improvement in liver stiffness measurement on transient elastography. Patients experienced 8.8 ± 11.2% total weight loss (TWL) (p < 0.0001), with 60% experiencing at least 10% TWL. Additionally, there was a significant improvement in HbA1c and a trend toward significant improvement in Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), suggestive of improved insulin sensitivity. TORe is associated with an improvement in hepatic fibrosis in patients with NAFLD and possible advanced fibrosis.

A140 Endoscopic Trans-Oral Outlet Reduction with Overstich as an Effective Alternative to Surgical Revision of Gastric Bypass

A140 Endoscopic Trans-Oral Outlet Reduction with Overstich as an Effective Alternative to Surgical Revision of Gastric Bypass