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

Abstract

Background: 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.

Aim: To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB.

Methods: 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.

Results: 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%).

Conclusion: 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.

Keywords: Endoscopic revision; Gastrojejunal anastomosis; Obesity; Purse-string; Roux-en-Y gastric bypass; Transoral outlet reduction; Weight recurrence.

Figure 1

Steps of transoral outlet reduction. A: Examination of the pouch, outlet, and jejunal limbs. Gastrojejunal anastomosis (GJA) appears dilated; B: Circumferential mucosal ablation with argon plasma coagulation of the gastric tissue of GJA; C: Purse-string suturing of the outlet using the Overstitch endoscopic suturing system; D: Cinching of the suture over a through-the-scope fluid-filled balloon positioned through the outlet into the efferent jejunal limb; E: Final view of GJA after transoral outlet reduction; F: Healed appearance of GJA 12 wk after transoral outlet reduction.

Figure 2

Total body weight loss after transoral outlet reduction. Weight loss from time of transoral outlet reduction (TORe) is represented over the following year. Total body weight loss represents response to TORe and does not include initial weight loss to gastric bypass. TORe: transoral outlet reduction.

Figure 3

Clinical response rates at 12 mo from transoral outlet reduction. The percentage of the cohort achieving a total body weight loss response category at 12 mo is shown. Total body weight loss represents response to transoral outlet reduction and does not include initial weight loss to gastric bypass. TBWL: Total body weight loss.

Figure 4

Weight trajectory of cohort. The mean and standard errors for weight at Roux-en-Y gastric bypass (RYGB), post-RYGB weight nadir, transoral outlet reduction (TORe), and the year after TORe are depicted for the cohort. Time for post-RYGB weight nadir is not known or specified. This figure illustrates the importance of TORe to interrupt and reverse the post-RYGB weight recurrence trajectory. RYGB: Roux-en-Y gastric bypass; TORe: Transoral outlet reduction.