Roux-en-Y gastric bypass (RYGB) is a versatile bariatric surgery that produces long-term weight loss success for morbidly obese individuals. About one-fourth of RNY patients cannot reach ideal weight and request a second surgery. Revising a failed RNY gastric bypass is mechanically complex, has a high incidence of morbidity, and often leads to unsatisfying results.
Traditionally a gastric bypass correction is performed laparoscopically by either trimming down the size of the stomach pouch (stoma), bypassing more of the intestines, or a combination of both. The laparoscopic era revisional techniques generally have low success rates with high rates of complications.
Transoral Outlet Reduction (TORe) is an incision-less approach to resize the pouch without the need for demanding technical surgical challenges. TORe offers a safe and efficient way to treat patients with weight regain after Roux-en-Y gastric bypass.
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What is TORe?
If the bypass patient no longer feels any restriction when eating food, the gastric outlet (or GastroJejunal Anastomosis) may be enlarged and TORe may be the best option.
Studies have shown that an enlarged GastroJejunal Anastomosis (GJA) can directly lower the patient’s sense of satiety and escalate the likelihood of dumping syndrome. Resizing the GJA will help manage hunger hormones and food intake.
Transoral Gastric Outlet Reduction (TORe) is a non-surgical procedure in which the outlet between the stomach pouch and the intestine is narrowed to restore the effectiveness of the original operation. This therapy does not require any external cuts in the abdomen as it is carried out orally via a suturing endoscopic device. TORe is a well-tolerated procedure to lose substantial weight after the first gastric bypass.
Do I Qualify for Transoral Outlet Reduction?
Eligible individuals must be 18 years or older and have a body mass index (BMI) of at least 30. Gastrointestinal disease or any abnormalities in the larynx or esophagus may make the patient ineligible for surgery. Patients may not be pregnant within 6 months before or after surgery.
- 18 years or older
- 30+ BMI
- The diameter of the gastric outlet must be larger than 1.5 cm
The size of the gastric outlet can also influence the bariatric procedure. If the diameter of the gastric outlet is less than 1.5 cm, the surgeon will opt for another revision option.
* Patients with heart or lung issues, stroke, drug/alcohol abuse, cirrhosis, or individuals on blood-thinning medication would not be good candidates for this procedure.
How Transoral Outlet Reduction is Performed
Performed endoscopically through the mouth, the TORe procedure is the safest gastric bypass re-operative option as no cutting is needed. Similar to Endoscopic Sleeve Gastroplasty (ESG), the endo surgeon inserts a full-thickness stitching device called the Apollo Overstitch through the patient’s esophagus. Non-dissolvable polypropylene sutures reduce the gastric outlet connection to 10-12 millimeters in diameter.
The three common suturing patterns currently used,
- Interrupted suture pattern
- Purse-string suture pattern
- Running suture pattern
As a result, food will take longer to pass through the gastric outlet, causing the patient to stay full for longer periods between meals.
Preparation for TORe
A one-day liquid diet (no solid food allowed) is required before undergoing the endoluminal procedure. No eating or drinking after midnight on the night prior to the surgery.
Post-operative patients will have to follow a 4-week post-op diet as the stomach tissue heals. Patients will gradually transition from liquids back to solid foods as they recover. Diet compliance and staying active are crucial in long-term weight loss success.
Pros and Cons
Transoral Outlet Reduction can be an effective tool for gastric bypass patients after a lengthy weight loss stall or plateau. The new plicated pouch reestablishes the patient’s sense of fullness and prevents the gastric outlet from expanding, resulting in longer-lasting outcomes. While traditional reoperation can take 2-3 hours and involve several nights’ stay in the hospital, the TORe procedure lasts an hour and in most cases does not require any hospital stay.
Advantages of TORe
- Expedited hospital stay
- Shorter pre-op diet
- Incision-free procedure
- Quick recovery and gastric healing
- Longer periods of weight loss than laparoscopic revision procedures
- No additional scarring or adhesions
- Less difficult and lower risk
- Minimal complications
- Less pain
- Less time off is needed from work
- Return to normal activities sooner
- Can be performed at a surgery center instead of a full-service hospital
- Faster operation that can last up to an hour
- Least invasive revision option for gastric bypass patients.
General complication rates of the TORe surgery are 11.4%. In comparison, other RNY modification options have an adverse rate of over double that of the TORe procedure. The most common problem that can occur after a TORe revision is abdominal pain, nausea, and vomiting. Other issues such as bleeding and perforation in the stomach are rare.
Disadvantages of TORe
- New procedure
- Very little data on long-term results
- The gastric outlet may expand again
- Possibility of outlet damage
- The stomach pouch can increase in volume (stretch)
- Sutures may break over long-term
The greatest disadvantage with the TORe procedure is that the gastric outlet can eventually regrow. Without dietary changes and consistent exercise, the stomal restriction can disappear and the patient can get heavy again. If you do not find the underlying cause for your weight relapse, history may repeat itself.
Weight Loss Expectations
On average, 20% to 30% of gastric bypass patients end up with insufficient weight loss. Almost a third of them regain almost all of the weight they lost.
Doctors have found that the TORe surgery resulted in consistent weight loss over a 5 year period. At 3 months, patients lost (13.5 lbs) 6.69% of their total body weight (TWL). After 6 months, patients lost (22.5 lbs) 11.34% TWL and conserved (7.2 lbs) 8.55% TWL by the end of the year.
In a recent study, TORe patients achieved 3.5% TWL in 1 year, which was significantly higher than RNY patients who only maintained 0.4% TWL in that same year.
For RNY bypass patients who have regained weight, TORe is an innovative, non-invasive solution to avoid intra-abdominal surgery. While other reoperations are invasive with questionable efficacy, TORe patients are given a second chance on their original bypass procedure.
A small percentage of TORe patients may still require additional pharmacotherapy and/or limb distalization surgery if they still have inadequate weight loss.