What is Soft Tissue Approximation (TORe) and the WLS Connection & Weight RegainJuly 8, 2019
My office received a call in the spring of 2018 from a woman who was desperate for help. Tearfully, she relayed to my office that she had an open Roux-en-Y gastric bypass surgery 15 years ago with my father when he was in practice. She said she was calling my office as a last resort because she did not have anywhere else to turn to and she thought, because I, too, was a bariatric surgeon, that maybe I could help her.
Symptoms of Stomal Dilation
Now, for a little background. This patient is a very successful entrepreneur having built her own business in North Dakota. Initially, she had done well with weight loss following her bypass operation however soon following she began to experience diarrhea often within minutes following a meal. Her symptoms were manageable at first but continued to progress. She had sought help with numerous different gastroenterology and bariatric practices over the past decade, but every medical provider that she consulted with told her there was nothing wrong. There were no “physical” explanations for her symptoms.
After years of hearing the same conclusion, she started to believe this may be true. Was it all in her head? Her symptoms progressed. She started to experience swallowing problems and heartburn. She started to regain weight as she transitioned her diet to more easily digestible food choices.
Her business required her to network and practice build, entertaining clients often at lunches, dinners, and social events. When she first contacted my office, she shared that she’d recently lost two of her top clients due to her inability to maintain this level of client contact and service. She was mortified that she’d have a bout of diarrhea while at an event or during a lunch with clients. This led her to become less active, less social, and less engaged in her business development.
As I spoke with this patient, I let her know that I believed that I could help her – at least I would try. I felt certain that this patient was experiencing chronic dumping from stomal dilation (an enlarged stoma opening of the new Roux-en-Y gastric stomach).
With a dilated opening or stoma, food or liquids rapidly move through the small stomach following gastric bypass, entering into the small intestine in an undigested state. This is irritating to digestion and does not allow for the breakdown of the foods or liquids consumed. The result is rapid transit of food through the intestine causing immediate diarrhea (dumping), swallowing discomfort (dysphagia), and reflux of intestinal fluids (reflux). Weight gain often follows because, with this rapid transition of food into the small intestines, the patient never experiences fullness to a meal so they tend to overeat.
This patient drove to my clinic from North Dakota, with a complete assessment scheduled upon arrival. She was set up to undergo an Upper GI small bowel follow through (barium swallow) and a diagnostic upper endoscopy (EGD). Her UGISBFT demonstrated rapid transit of the barium from her swallowing through her intestine to her colon in less than 20 minutes (normal is 120 minutes). Her diagnostic EGD demonstrated a dilated stoma which measured greater than 4 centimeters in diameter. (By definition, stomal dilation is 2.5 centimeters in diameter or greater.)
The diagnostics confirmed her problem to be chronic dumping secondary to stomal dilation following RNY gastric bypass. Stomal dilation, while not common following gastric bypass, can happen. In this case, it is a bit unusual that it happened so quickly following her operation.
Soft Tissue Approximation (TORe)
So what can be done?
Recall, this patient had an open RNY gastric bypass 15 years ago. These early open gastric bypass operations are very difficult to revise surgically. Inherently, these operations carry a much higher degree of risk, complexity, and post-surgical complications. Because of this, surgical revision is, in most cases, prohibitive. With the desire to help these individuals, I began to pursue an alternative solution for stomal dilation with chronic dumping termed TORe, also known as an Endoscopic Soft Tissue Approximation.
TORe is a procedure done with a scope through the mouth with the patient asleep. The RNY gastric bypass anatomy gastric anatomy is accessed endoscopically during which the surgeon sutures close a portion of the dilated opening of the pouch to restrict down and correct the size of the stomal opening to less than 2.5 cm.
The procedure is done on an outpatient basis, versus inpatient (which is required for a formal revision). Because it is performed endoscopically, there are no cutting or abdominal incisions. Patients are back to feeling well, with a resolution of their symptoms within 24 hours. I performed this patient’s procedure and, the next day, she reported feeling great with a resolution of all of her digestive problems.
Results of the TORe Procedure: Back to Her Old Self
Today, she is back to her go-getter, confident - back to work without anxiety self. She shared that during her first business lunch following her procedure she had no digestive complaints and was able to sit through the entire lunch. She was so excited about the possibility of getting her business back on track.
As a result of the TORe procedure, my patient started to lose weight because she is finally able to appreciate fullness.
As cycles and trends in bariatric surgery occur, I continue to see an increase in the number of RNY gastric bypass patients suffering from stomal dilation. Being able to perform the soft tissue approximation has allowed me to help those patients with a safe and effective procedure.
If you are a patient that is suffering from symptoms such as chronic rapid dumping, reflux, swallowing discomfort, abdominal pain or lack of fullness, you should talk with your bariatric surgeon about the possibility that you might have stomal dilation. Could this be the cause of your symptoms? It is simple to diagnose and there are safe solutions available. If this is the case for you, there’s good news - there is help to getting you feeling better and back on track and into health. The results are life changing.
ABOUT THE AUTHORDr. Jeffrey Baker is a board-certified physician specializing in bariatric surgery. He has performed over 2,500 weight loss surgeries since specializing in bariatrics in 2003. He sits on the review boards of two international state-of-the-art medical device companies developing new technologies for bariatric innovations.
Read more articles by Dr. Baker!