Transoral Outlet Reduction (TORe)
Allison R. Schulman, MD, MPH
Roux-en-Y gastric bypass (RYGB) has traditionally been the most commonly performed bariatric surgical procedure. It involves stapling of the stomach to create a small gastric pouch and connecting it to a portion to the jejunum (known as the Roux limb) to create a gastrojejunal anastomosis (GJA). While diet and lifestyle factors play a role in weight regain after RYGB, studies have demonstrated that a dilated GJA aperture is an independent predictor of weight regain with a linear association.1 Endoscopic sutured transoral outlet reduction (TORe) is a safe and effective treatment for management of a dilated GJA.
1. Lack of informed consent
2. Cardiac instability, respiratory insufficiency, or other life-threatening cardiopulmonary conditions
3. Significant bleeding diathesis
4. Warfarin or heparin use
5. Marginal ulceration (i.e., ulceration at the site of the GJA)
6. Lack of patient cooperation
7. Portal hypertension
8. Active tobacco use
1. Obtain informed consent which includes a detailed discussion with the patient about indications for the procedure, alternative therapy, possible adverse events, and weight loss expectations.
2. An initial upper endoscopy should be performed to assess pouch length and size of the GJA to determine if the RYGB anatomy is amenable to endoscopic-sutured TORe. It is also important to confirm absence of structural abnormalities, marginal ulceration, or severe esophagitis before proceeding. Foreign surgical material such as sutures and staples can also be removed at the time of index endoscopy to prevent interference with eventual reconstruction.2,3,4,5,6
3. Bowel preparation: See Chapter 3 on bowel preparation. Bowel preparation is optional and can be considered the night before the procedure to prevent intraprocedure bowel movements and postprocedure abdominal pain, constipation, and/or straining.
4. Preprocedural fast: Liquid diet the day prior to the procedure, and nothing by mouth (NPO) for 12 hours prior to the procedure.
5. Medication: The procedure is performed under general anesthesia with endotracheal intubation, and with CO2 insufflation. Aggressive antinausea control is essential, including preprocedural administration of a scopolamine patch, dexamethasone, and liberalized use of other antiemetics.
1. Double-channel endoscope (GIF-2T160 or GIF-2T180; Olympus America, Center Valley, PA)
2. Apollo OverStitch Endoscopic Suturing System (Apollo Endosurgery, Austin, TX)
3. Polypropylene nonabsorbable surgical suture (2-0 DemeLENE, DemeTECH, Miami Lakes, FL)
4. An overtube (Guardus; US Endoscopy, Mentor, OH, or OverTube Endoscopic Access System, Apollo Endosurgery)
5. OverStitch Suture Cinch (Apollo Endosurgery)
6. OverStitch Tissue Helix (Apollo Endosurgery)
7. Argon plasma coagulation (APC)
8. Simethicone (60 mL)
9. Through-the-scope (TTS) balloon dilators of various diameters (8 to 12 mm in size)
10. Dilating gun or inflation device to maintain pressure
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