Trans Oral Outlet Reduction 3

Weight Regain After WLS and the Trans Oral Outlet Reduction (TORe)

August 7, 2019

Endoscopic Non-Surgical Treatment for Weight Regain

Weight loss after bariatric surgery is life-altering, and in most cases, it not only gives patients health benefits but the freedom to do things they couldn’t do before. Many patients experience a small amount of weight regain after they hit their initial low weight.  However, some patients (30% or more) gain a significant amount of weight 5-10 years after surgery.

With this weight regain, patients may experience a return of past medical problems that went away with weight loss. In addition, some patients lose the ability to do some of the things they could when they lost weight. This can be a devastating blow.

Why Do Patients Regain Weight After Bariatric Surgery?

It’s not completely clear why people lose weight with bariatric surgery, in particular, gastric bypass and it’s also not completely clear why people regain weight. There are probably multiple factors that contribute to weight regain after bariatric surgery including behavior factors like frequent snacking, grazing and drinking high calories liquids but stretching of the connection between the gastric pouch and small intestines or “gastrojejunostomy” has been shown in multiple studies to correlate with weight gain.

Does this mean that the patient caused the gastrojejunostomy to stretch out because of eating too much? Probably not.  Although we don’t have a lot of data on this, there is evidence that even in the first year after bariatric surgery when patients are still losing weight, there is an increase in the volume of food that can be eaten in a meal.

This suggests that the gastric pouch and gastrojejunostomy are remodeling over time to adapt to the new post-surgical environment.  The ability of the GI tract to adapt like this is great for patients who have lost some of their stomach and intestines due to disease or injury, but it’s not great for patients trying to maintain a weight loss after bariatric surgery.

In my practice, I find that patients usually have a change in their hunger or fullness sensation, which causes them to eat more leading to weight regain.  This means the dilation of the gastrojejunostomy is happening first and leading to patients being able to eat more and feel hungrier.

Trans Oral Outlet Reduction (TORe Procedure)

Patients who have regained weight after bariatric surgery have previously had options for lifestyle therapy, medications or a repeat surgery to help with weight loss. Although revisional surgery does cause more weight loss, it also has higher rates of complications compared with the primary surgery.

There is a non-surgical option to reduce the size of the gastrojejunostomy available both in the US and abroad.  The procedure is called Trans Oral Outlet Reduction (TORe) and is performed endoscopically or through the mouth with no external incisions.

To perform the procedure, physicians currently use a suturing device that fits on the end of an upper endoscope, although other devices have been studied and may be used in the future.

There are several steps to this procedure and much like surgical techniques, the TORe procedure techniques vary slightly from physician to physician. The procedure is usually performed with general anesthesia and patients are typically given antibiotics during the procedure to prevent infection.

The first step in the procedure is to perform a diagnostic upper endoscopy to evaluate the gastric pouch, measure the gastrojejunostomy, look for and remove visible sutures or staples if they are present and would inhibit performing the procedure, evaluate for gastrogastric fistula, and evaluate for ulcers.

Once that is complete, the area around the anastomosis on the gastric pouch side is burned with argon plasma coagulation.  This is done to reduce bleeding and to help the gastrojejunostomy develop some scar to reinforce the final sutured diameter of the gastrojejunostomy. The endoscope is then removed, the suturing device is attached to the scope and the sutures are then placed around the gastrojejunostomy.  The goal is to tighten the sutures so that the size of the gastrojejunostomy is reduced to <10 mm.

After the procedure, the most common adverse events are due to nausea. Patients are given multiple medications to help with nausea. The diet is also modified for an extended period of time. This also varies from practice to practice, but in general, is similar to the diet after the original surgery with clear liquids for a few days, full liquids for a few weeks, pureed food for a few weeks then finally on to soft food.

Other serious complications which could occur include bleeding, infection, and perforation or putting a hole where there shouldn’t be one in the GI tract or outside of the GI tract. These serious complications are rare, a recent meta-analysis that included 330 patients found only one serious complication (perforation in the esophagus).

Weight loss with TORe is not as high as the weight loss with the original surgery and is reported as 11-25% excess weight loss at 12 months after the procedure and in a recent analysis of the procedure described above (suturing with a device that is “full-thickness” and using argon plasma coagulation) showed 10% total body weight loss at 12 months.

When Should You Seek TORe for Weight Regain?

The studies show that almost all patients stop gaining weight after TORe procedure, but weight loss is around 10% of their total body weight. For the best overall outcome, patients should consider seeking help if they regain more than 20% of the weight they lost.

Seeking help early on before a significant amount of weight will make it easier to get as close as possible to the lowest weight after surgery. And remember, dilation of the gastrojejunostomy is not the fault of the patient – don’t feel bad about it, just treat it!

Shelby Sullivan MD


Dr. Shelby Sullivan is an Associate Professor of Medicine at the University Of Colorado School Of Medicine and is the director of the Gastroenterology Metabolic and Bariatric Program. Dr. Sullivan developed the first endoscopic bariatric therapy program at Washington University School of Medicine and was recruited to The University of Colorado school of Medicine to establish the Gastroenterology Metabolic and Bariatric Program. She serves on the board for the Association for Bariatric Endoscopy and is the recent past chair of the Bariatric Surgery Section of The Obesity Society.