Transoral outlet reduction: could additional sutures cause more harm?

Abstract

Background: The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastro-jejunal anastomosis (GJA). But there is a paucity of literature pertaining to post-TORe stenosis as an adverse event (AE). Our aim was to determine the rate of stenosis, its potential predictors, and other AEs of the DPSP TORe. Methods: We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019. Results: The adverse event rate (AER) of TORe was 17.1% (n=22), with a 13.2% (n=17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter (GJAD) pre-TORe, procedure duration, GJAD at end-of-TORe, and difference in GJAD between pre-TORe and end-of-TORe, were not predictive of stenosis. Of those that developed stenosis, 10 (58.8%) responded to endoscopic balloon dilation while 7 (41.2%) required stent placement. Conclusion: Due to its high AER, the DPSP technique should not be used as the procedure provides no benefit and increased procedure complexity.

Transoral Outlet Reduction: Expert Tips, Tricks, and Troubleshooting

“…The American Journal of GASTROENTEROLOGY stenosis rate (13.3%) (25). However, it may be useful for very dilated GJAs (i.e., diameter .50 mm) or if redoing the initial purse-string would worsen GJA tearing.…”

“…The most common risk factor of stenosis is history of stenosis after RYGB (10). While most stenoses will resolve in 1-2 dilations, in instances of significant stenosis with a "pinhole" outlet or for stenosis refractory to balloon dilation, endoluminal stenting may be necessary (25,28).…”

“…In this case, there are 2 options: (i) cut and remove the suture and repeat the purse-string or (ii) perform a second overlying purse-string. Option 2 should be used only in rare circumstances due to elevated stenosis rate (13.3%) (25). However, it may be useful for very dilated GJAs (i.e., diameter >50 mm) or if redoing the initial purse-string would worsen GJA tearing.…”