Transoral Outlet Reduction Research Articles

Transoral outlet reduction: a comparison of purse-string with interrupted stitch technique

Weight regain after Roux-en-Y gastric bypass (RYGB) correlates with dilated gastrojejunal anastomosis (GJA). Endoscopic sutured transoral outlet reduction (TORe) is a safe and effective management and has predominantly been performed by either placing interrupted sutures at the GJA or the creation of a purse-string suture. The aim of the current study was to compare these techniques. All patients undergoing TORe for weight regain after RYGB were prospectively enrolled. Primary outcome was mean percent total weight loss (%TWL) at 3 and 12 months. Secondary outcomes included percent excess weight loss (%EWL), percent regained weight lost (%RWL), and total weight loss. Proportions were compared using the Fisher exact test and continuous variables using the Student t test. A P= .05 was significant. Multivariable regression analysis was performed. Two hundred forty-one patients were enrolled (purse string= 187, interrupted= 54). There was no statistical difference between the purse-string and interrupted groups at 3 months in %TWL (8.6 vs 8.0, P= .41), %EWL (20.5 vs 16.7, P= .39), % RWL (44.7 vs 33.3, P= .56), and total weight loss (9.5 vs 11.3, P= .32). At 12 months the purse-string group achieved statistically significant improvement in %TWL (8.6 vs 6.4, P= .02), %EWL (19.8 vs 11.7, P< .001), %RWL (40.2 vs 27.8, P= .02), and total weight loss (9.5 vs 7.8, P= .04). Multivariable regression showed that technique (P= .006) was an independent predictor of %TWL at 12 months. TORe is effective in treatment of weight regain after failed gastric bypass. The purse-string technique results in greater weight loss at 12 months than the traditional interrupted suture pattern.

Transoral Outlet Reduction for Therapy of Weight Regain After Gastric Bypass

Introduction: Enlargement of gastrojejunal anastomosis aperture is associated with weight regain in patients with Roux-en-Y gastric bypass (RYGB). Endoscopic transoral outlet reduction (TORe) has proven safe and effective for treatment of weight regain. The objective of this study was to evaluate the safety and the efficacy in weight loss of endoscopic outlet reduction in single Italian center.FigureMethods: The series included consecutive post-RYGB patients with weight regain and enlarged gastrojejunal anastomosis aperture (>15 mm). Endoscopic reduction was performed with Overstitch (Apollo Endosurgery) which is a full-thickness endoscopic suturing device. All the procedures were done at the Digestive Endoscopy Unit of the Catholic University of Rome. The procedure was done with the Overstitch and Olympus double channel operative endoscope. An Overtube was placed before the procedure in all patients. Before suturing the outlet rims were cauterized with pulsed pulsed Argon Plasma on 40 Watts. Results: Thirty-five patients who had weight regained after RYGB (BMI > 30) underwent TORe from January 2015 to February 2017. Baseline mean BMI was 37.9 (range 31-50) and weight was 106.8 kg (range 77-132). Mean procedure time was 34 minutes (range 15-60) and a mean number of 2.3 stitches per patient were placed (range 2-4) on the level of the gastric outlet. After suturing the patency of the new redone outlet was tested with standard gastroscope. There were three (9%) complications of which two were mild (1 intraoperative bleeding that arrested spontaneously and 1 patient with fever due to small retrogastric collection treated with antibiotics), while one patient (5.2%) had gastric perforation that required urgent surgery. Mean hospital stay was 2.4 days (range 1-10). Telephonic follow-up was done at 1, 3 and 6 months. Thirty-two patients completed at least 1 month follow up. Mean weight loss at 1 month follow-up was 9.3 kg, at 3 months was 12.7 kg while at 6 months was 15 kg. Only one patient regained weight compared to baseline during the 6 months follow up. Conclusion: In our experience TORe was a safe and effective procedure in patients with weight regain after RYGB. Longer follow-up and larger clinical trials are needed to establish the durability of these results and to better understand the role of TORe after RYGB and the methods for proper selection of the patients.

Botox Plus Transoral Outlet Reduction for the Treatment of Weight Regain After Bariatric Surgery: Matched Case Control Series in 10 Patients - Preliminary Results

Botox Plus Transoral Outlet Reduction for the Treatment of Weight Regain After Bariatric Surgery: Matched Case Control Series in 10 Patients - Preliminary Results

A5332 - The Addition Of Anti-Obesity Medications To Transoral Outlet Reduction For The Treatment Of Weight Regain After Bypass Surgery

A5332 - The Addition Of Anti-Obesity Medications To Transoral Outlet Reduction For The Treatment Of Weight Regain After Bypass Surgery

Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis.

Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature. Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used. 130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18months after TORe was 9.31±6.7kg (N=84), 7.75±8.4 kg (N=70), 8±8.8kg (N=46) (p<0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12months was 8.4kg (95% CI 6.5-10.3) with no significant heterogeneity across included studies (p=0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported. When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

641 Five Year Outcomes Following Transoral Outlet Reduction (Tore) Show Effective and Durable Treatment of Weight Regain After Roux-En-Y Gastric Bypass

641 Five Year Outcomes Following Transoral Outlet Reduction (Tore) Show Effective and Durable Treatment of Weight Regain After Roux-En-Y Gastric Bypass

Sa2017 Transoral Outlet Reduction Post Roux-En-Y Gastric Bypass: Evaluation of a Treatment Algorithm Using Two-Fold Running Sutures

Sa2017 Transoral Outlet Reduction Post Roux-En-Y Gastric Bypass: Evaluation of a Treatment Algorithm Using Two-Fold Running Sutures

548 Personalized Therapy for Weight Regain After Roux-En-Y Gastric Bypass: Transoral Outlet Reduction Versus Argon Plasma Coagulation

548 Personalized Therapy for Weight Regain After Roux-En-Y Gastric Bypass: Transoral Outlet Reduction Versus Argon Plasma Coagulation

641 - Five Year Outcomes following Transoral Outlet Reduction (TORe) Show Effective and Durable Treatment of Weight Regain after ROUX-EN-Y Gastric Bypass

641 - Five Year Outcomes following Transoral Outlet Reduction (TORe) Show Effective and Durable Treatment of Weight Regain after ROUX-EN-Y Gastric Bypass

Su2033 - Argon Plasma Coagulation is Effective in Roux-En-Y Gastric Bypass Patients that do not Achieve Weight Loss Goals after Sutured Transoral Outlet Reduction (TORe)

Su2033 - Argon Plasma Coagulation is Effective in Roux-En-Y Gastric Bypass Patients that do not Achieve Weight Loss Goals after Sutured Transoral Outlet Reduction (TORe)

613 - Transoral Outlet Reduction Utilizing a Pursestring Suture Pattern is Safe and Effective for the Treatment of Weight Regain after Roux-En-Y Gastric Bypass

613 - Transoral Outlet Reduction Utilizing a Pursestring Suture Pattern is Safe and Effective for the Treatment of Weight Regain after Roux-En-Y Gastric Bypass

Su1054 Transoral Outlet Reduction for Therapy of Weight Regain After Gastric Bypass

Su1054 Transoral Outlet Reduction for Therapy of Weight Regain After Gastric Bypass

Continuing Medical Education Exam: April 2016

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Yang D, Amin S, Gonzalez S, et al. Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study. Gastrointest Endosc 2016;83:720-9. Costamagna G, Iacopini F, Bizzotto A, et al. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker’s diverticulum. Gastrointest Endosc 2016;83:765-73. Kumar N, Thompson C. Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc 2016;83:776-9. Naravadi V, Gupta N, Early D, et al. Prevalence of advanced histological features and synchronous neoplasia in patients with flat adenomas. Gastrointest Endosc 2016;83:795-9. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

Endoluminal closure of gastrogastric fistula

Gastrogastric fistulas have a reported incidence of 1.3%–12% after gastric bypass for treatment of morbid obesity. The fistula can occur as a result of incomplete division of the stomach or staple line dehiscence, in the setting of a chronic or perforated marginal ulcer, or as a sequela of staple line leak. In the acute setting, patients can present with tachycardia, fevers, and abdominal pain. However, the development of a gastrogastric fistula in a chronic setting is more subtle: Patients may experience weight regain, postprandial abdominal pain with associated marginal ulcers, and esophageal reflux. Management traditionally consists of surgical revision with associated morbidity [ [1] Corcelles R. Jamal M.H. Daigle C.R. Rogula T. Brethauer S.A. Schauer P.R. Surgical management of gastrogastric fistula. Surg Obes Relat Dis. 2015; 11: 1227-1232 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar ]. Here we report on a treatment option that consists of endoscopic intervention with complete closure of the fistula with added benefits of same-day surgery, decreased operative time, no incisions, and minimal morbidity [ 2 Kantsevoy S.V. Thuluvath P.J. Successful closure of a chronic refractory gastrocutaneous fistula with a new endoscopic suturing device (with video). Gastrointest Endosc. 2012; 75: 688-690 Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar , 3 Kumar N. Thompson C.C. Transoral outlet reduction for therapy of weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc. Epub 2015 sep 5; Google Scholar ].

FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY.

ABSTRACTBackground: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled.Objective: The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice.Methods: Institutional experience and systematic review from the literature on revisional bariatric surgery.Results: Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained.Conclusion: Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

Peroral endoscopic reduction of dilated gastrojejunal anastomosis after bariatric surgery: Techniques and efficacy.

To investigate the techniques and efficacy of peroral endoscopic reduction of dilated gastrojejunal anastomosis after bariatric surgery. An extensive English language literature search was conducted using PubMed, MEDLINE, Medscape and Google to identify peer-reviewed original and review articles using the keywords "bariatric endoscopic suturing", "overstitch bariatric surgery", "endoscopic anastomotic reduction", "bariatric surgery", "gastric bypass", "obesity", "weight loss". We identified articles describing technical feasibility, safety, efficacy, and adverse outcomes of overstitch endoscopic suturing system for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass (RYGB). All studies that contained material applicable to the topic were considered. Retrieved peer-reviewed original and review articles were reviewed by the authors and the data extracted using a standardized collection tool. Data were analyzed using statistical analysis as percentages of the event. Four original published articles which met our search criteria were pooled. The total number cases were fifty-nine with a mean age of 46.75 years (34-63 years). Eight of the patients included in those studies were males (13.6%) and fifty-one were females (86.4%). The mean time elapsed since the primary bypass surgery was 5.75 years. The average pre-endoscopic procedure body mass index (BMI) was 38.68 (27.5-48.5). Mean body weight regained post-RYGB surgery was 13.4 kg from their post-RYGB nadir. The average pouch length at the initial upper endoscopy was 5.75 cm (2-14 cm). The pre-intervention anastomotic diameter was averaged at 24.85 mm (8-40 mm). Average procedure time was 74 min (50-164 min). Mean post endoscopic intervention anastomotic diameter was 8 mm (3-15 mm). Weight reduction at 3 to 4 mo post revision noted to be an average of 10.1 kg. Average overall post revision BMI was recorded at 37.7. The combined technical and clinical success rate was 94.9% (56/59) among studied participants. Endoscopic suturing can be technically feasible, effective and safe for transoral outlet reduction in patients with weight regain following RYGB.

Weight loss endoscopy: Development, applications, and current status.

Obesity and its comorbidities - including diabetes and obstructive sleep apnea - have taken a large and increasing toll on the United States and the rest of the world. The availability of commercial, clinical, and operative therapies for weight management have not been effective at a societal level. Endoscopic bariatric therapy is gaining acceptance as more effective than diet and lifestyle measures, and less invasive than bariatric surgery. Various endoscopic therapies are analogues of the restrictive or bypass components of bariatric surgery, utilizing gastric remodeling or intestinal anastomosis to achieve proven weight loss and metabolic benefits. Others, such as aspiration therapy, employ novel mechanisms of action. Intragastric balloons have recently been approved by the United States Food and Drug Administration, and a number of other technologies have completed large multicenter trials (such as AspireAssist aspiration therapy and Primary Obesity Surgery Endolumenal). Endoscopic sleeve gastroplasty and transoral outlet reduction for endoscopic revision of gastric bypass have proven safe and effective in a number of studies. As devices are approved for use, data will continue to accumulate for safety, effectiveness, and cost effectiveness. Bariatric endoscopists should be prepared to appropriately target and apply various endoscopic bariatric therapies in the context of a comprehensive long-term weight management program.

Endoscopic Trans-Oral Outlet Reduction in Combination with Gastroplasty (TORe-G) Is a Novel Technique That Is Highly Efficacious and Safe for Weight Loss in Patients With Failed Roux-en-Y Gastric Bypass (RYGB)

Introduction: Enlargement of the remnant gastric pouch or gastro-jejunal (GJ) stoma is associated with weight regain after Roux-en-Y Gastric Bypass (RYGB) surgery. Although evidence exists regarding outcomes of GJ outlet reduction in terms of weight loss, the efficacy of gastric pouch revision is still unclear. There are no published results using endoscopic trans-oral outlet reduction (TORe) in combination with gastroplasty of the entire gastric pouch from the gastro-esophageal (GE) junction to the GJ stoma (TORe-G) utilizing an endoscopic full thickness suturing device (Overstitch, Apollo Endosurgery, Austin Tx). We thus report the first description of using (TORe-G) to treat patients with failed RYGB. Methods: Patients who underwent a combined GJ stoma reduction and gastroplasty for inadequate weight loss [5% EWL from nadir) post-RYGB along with evidence of GJ diameter of ≥ 2 cm and dilation of gastric pouch were included. The procedure involved ablation of the peristomal mucosa and gastric pouch using argon plasma coagulation (APC) and placement of interrupted plications using 2-0 prolene sutures for a targeted GJ diameter of ˜5-8 mm and reducing gastric pouch volume to ˜30 mL. Results: A total of 20 subjects (90% females) with median age of 55 years (IQR 42.2-61) and median duration since RYGB of 10 years (IQR 6.2-12) were evaluated. Median follow up was 4.5 months (range 1-9 months). Median (IQR) baseline weight was 225 (198.2-287.2) lbs and BMI was 37.9 (32.7-44.8) kg/m2. Significant weight loss was seen in 100% of study patients post-revision (p < 0.001) (Figure 1). Median (IQR) %EWL seen at 1, 3, and 6 and 9 months was 21.3% (11.3-30), 39.35% (14.9-53.6), 52.8% (14.3-70.9), and 62.8% (57.2-68.3), respectively. Total weight loss [median (IQR)] was 10 lbs (7.5-25), 19 lbs (15-28), 17 lbs (10-37), and 24.5 lbs (15.5-48.5), respectively. Total percent weight loss [median (IQR)] was 5.1% (3.7-9.1), 8.6% (7.05-10.8), 8.5% (5.7-15.5) and 13% (10.6-17), respectively. None of the covariates including age, interval time since RYGB, and percent weight regained since RYGB predicted weight loss post revision. No major adverse events were observed.Figure 1Conclusion: We demonstrate for the first time the efficacy and safety of TORe-G to re-establish weight loss in patients with failed RYGB using a full thickness endoscopic suturing device. TORe-G resulted in robust weight loss, and may lead to superior restriction compared with TORe alone. Further comparative studies are needed.

Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up

Dilated gastrojejunal anastomosis aperture is associated with weight regain after Roux-en-Y gastric bypass (RYGB). Transoral outlet reduction (TORe) has proved safe and effective for the treatment of weight regain. The objective of this study was to determine the long-term weight trend and number needed to treat for TORe. This prospective series included consecutive post-RYGB patients with weight regain and a gastrojejunal anastomosis aperture greater than 15 mm. TORe was performed with a full-thickness endoscopic suturing device. A total of 150 patients who had regained 49.9% ± 3.6% of the weight lost after gastric bypass (4.1 ± 0.3 kg/y after nadir) before TORe. At TORe, body mass index was 40.2 ± 0.8 kg/m(2) and weight was 110.7 ± 2.2 kg. At 1 year, weight loss was 10.5 ± 1.2 kg or 24.9 ± 2.6% excess weight loss (EWL); at 2 years, weight loss was 9.0 ± 1.7 kg or 20.0% ± 6.4% EWL; at 3 years, weight loss was 9.5 ± 2.1 kg or 19.2% ± 4.6% EWL. The number needed to treat for arrest of weight regain was 1.0 at 6 months, 1.1 at 1 year, and 1.2 at 2 and 3 years. The number needed to treat to maintain weight loss of ≥5 kg from TORe was 1.2 at 6 months, 1.5 at 1 year, 1.9 at 2 years, and 2.0 at 3 years. TORe safely and effectively arrested weight regain and provided durable weight loss with a low number needed to treat. Patients with weight regain after RYGB should be evaluated for dilation of the gastrojejunal anastomosis, as TORe can be part of a multidisciplinary strategy to address post-RYGB weight regain.

The pursestring technique for endoscopic revision of gastric bypass

A significant proportion of patients regain weight after Roux-en-Y gastric bypass. Endoscopic revision of dilated gastrojejunal anastomosis, called transoral outlet reduction (TORe), has proven effective and allows patients to avoid reoperation. Traditionally, TORe has been performed with an interrupted stitching technique with placement of stitches across the anastomosis. In this video, we demonstrate the pursestring and double pursestring techniques for TORe.