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)

Abstract

Background: Enlargement of the remnant gastric pouch and gastro-jejunal (GJ) stoma are associated with weight regain after RYGB surgery. Current evidence suggests an excess weight loss (%EWL) of 12-25% with GJ outlet reduction (TORe) alone. However, the efficacy of a combined approach 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) is unknown. ii Methods: Patients who experienced inadequate weight loss (<50% EWL) or weight regain (>25% EWL from nadir) post-RYGB along with evidence of dilated GJ stoma and gastric pouch underwent a combined GJ stoma reduction and gastroplasty. The procedure involved ablation of the peristomal mucosa and gastric pouch using APC and placement of interrupted and running full-thickness plications (Overstitch, Apollo Endosurgery, Austin Tx) for a targeted GJ diameter of ~5-8 mm and significant reduction of gastric pouch volume. Results: 40 patients (78% females) with age 53±10 years, BMI 41±9 kg/m 2 , and time since RYGB 10±4 years were prospectively studied. Significant weight loss (>5% TBWL) was seen in 90% patients. Post Tore-G, mean (95% CI) %TBWL observed at 1, 3, 6, 9 and 12 months follow up

Efficacy of transoral outlet reduction in Roux-en-Y gastric bypass patients to promote weight loss: a systematic review and meta-analysis

“…At the 12-month mark there was evidence of weight recidivism from 11.34 % TWL at 6 months to 8.55 %. Two studies [24,36] showed persistent weight loss and the rest of the studies demonstrated weight recidivism at 12 months. It is hypothesized that the weight loss post TORe was secondary to reduction in GJA size, improved eating habits, quicker gastric emptying times, and induction of satiety by stimulating gastric stretch receptors [11,24,27,28].…”

“…Two studies 24 36 showed persistent weight loss and the rest of the studies demonstrated weight recidivism at 12 months. It is hypothesized that the weight loss post TORe was secondary to reduction in GJA size, improved eating habits, quicker gastric emptying times, and induction of satiety by stimulating gastric stretch receptors 11 24 27 28 . Weight recidivism was reported to be due to genetic factors, lack of dietary compliance, or due to suture breakage/migration leading to dilation of the GJA after TORe 26 27 28 36 .…”

“…However, according to Jirapinyo et al, there was an increased incidence of nausea and vomiting with GJA < 4 mm 37 . The majority of the studies aimed for a GJA size < 10–12 mm 12 23 24 25 26 27 29 36 .…”

“…Technical success of TORe procedure with full-thickness suturing device was defined in 7 studies. Four studies 12 23 24 25 considered post procedure GJA size < 10 mm and four studies 26 27 28 29 considered post-procedure GJA size < 12 mm to be technically successful.…”