I'm going to move on to not primarily weight loss therapies, but discuss techniques to manage weight regain after bariatric surgery, particularly rheumatoid gastric bypass. And it's a pleasure to ask Dr. Sai Girapina to speak now on transoral gastrointestinal reduction, tips and tricks for maximizing weight loss. She is one of the most published people in the field of endobariatrics, and particularly the revisional therapies. She's the Director of Bariatric Endoscopy Fellowship and the Associate Director of Bariatric Endoscopy at Brigham and Women's Hospital in Boston. Sai, thanks so much for joining us. Take it away, please. Hi, everyone. I'd like to thank Dr. Kumbhari, Dr. Panella, and Dr. Pryor for the invitation. Today, I'm very honored and excited to talk about one of my favorite procedures, TOR, with a focus on tips and tricks for maximizing weight loss. Here are my disclosures. You may wonder, now that I know the steps of transoral outlet reduction, or TOR, how do I maximize the amount of weight loss following the procedure? The goal for this talk is to help you understand optimal technical aspects of TOR, and also identify any tips around the procedure to achieve greater weight loss. We're going to start with a brief overview of TOR, followed by any tips and tricks around the procedure. What is TOR, or transoral outlet reduction? This refers to an endoscopic procedure focusing on reducing the outlet size to treat weight regain after room-wide gastric bypass. As you can see in the video, with time, the outlet becomes larger in diameter and also more incompetent. On the right is a graph from a study conducted by Dr. Arbudaie and Chris Thompson, showing a positive correlation between the size of the outlet and the amount of weight regain. Moving on to TOR timeline. The procedure was first described by Chris Thompson in 2003. At that time, the endoscopic suturing device was used. This was followed shortly after with a patent being filed. In 2006, the restored trial looking at this procedure was started. The study was a randomized sham control trial. The study randomized 77 room-wide patients with weight regain or inadequate weight loss to a TOR or sham procedure. At six months, patient in the TOR group experienced greater weight loss, 3.5% total weight loss, compared to 0.4% total weight loss in the sham group. There were no serious adverse events. It's important to note that in this study, they used the endosynch partial thickness suturing device. Now we know that the currently available full thickness suturing device used greater weight loss. Nevertheless, this study was important because it established level one evidence for this procedure. Since then, several TOR procedures have been described in the literature. For today's talk, we're gonna be focusing on placation TOR or rows using the IOP system and suturing TOR using the overstitch device. Now we're gonna move on to pre-procedure tips and tricks. Here's our TOR workup. I wanna draw your attention to smoking history. You wanna make sure that your patient stops smoking cigarettes and marijuana for at least three months. We notice that when you sew patients who recently smoked, they tend to bleed more and to choose more friable. Additionally, you wanna order some blood work and replete any abnormalities before sewing. I highlight the labs that are usually abnormal in our patient population here. And last but not least, I usually order either an upper GI series or do an upper endoscopy, mainly to look for a gastro-gastric fistula. If you see a gastro-gastric fistula, the management of TOR in that setting is different, but it's beyond the scope of the talk today. Now that you complete the workup, you may wonder which TOR procedure should I offer to my patients? Currently at our institution, we offer three procedures. These are argon plasma coagulation, suturing TOR and placation TOR or ROS. The optimal procedure depends on the patient's anatomy. Specifically, if the pouch is shorter than five centimeters and the outlet is smaller than 18 millimeters, APC or suturing TOR results in similar weight loss and either one can be offered. If the outlet is greater than 18 millimeters, suturing TOR results in better weight loss. Now, if the pouch is long, longer than five centimeters and the outlet is smaller than 30 millimeters, placation TOR should be offered. However, if the outlet is really large, greater than 30 millimeter in diameter, suturing TOR is recommended. All right, so now we're gonna move to tips and tricks during the procedure. We're gonna start with suturing and then placation TOR. For suturing, we have seen the device described in the earlier talks. For the procedure itself, we start by doing APC around the outlet. After that, we start sewing using a purse ring suture pattern. Specifically, as shown here, we start at the five o'clock position, then move counterclockwise and place each stitch about five millimeters apart. Our goal is to get about at least 12 stitches around the outlet using one suture. We then drop the needle that becomes a T-tag, pass the cinching device, and then cinch the outlet over a CRE balloon. Here's the final appearance of the outlet after the TOR procedure. Now, we're gonna talk about tips and tricks. For this, I'm gonna break down the procedure into four major steps. First, mucosal devitalization, followed by outlet reduction, cinching, and finally, pouch reduction. For the first step, the options are you either perform an APC or ESD around the outlet. The three major benefits to mucosal devitalization. First, it promotes submucosal-to-submucosal or muscular-to-muscular layer tissue healing. Second, it minimizes risk of bleeding during the sewing step. And thirdly, it helps mark the suturing treatment area. You may be thinking, how do I choose between APC versus ESD? If you look at the picture on the left, you see that there's no clear gastric border and where the arrows are pointing, so ESD would be difficult and I would go for APC. In contrast, on the right, you see a very nice, obvious rim around the outlet, and the outlet itself is forward-facing, so for this case, ESD would be preferred. If you go for APC, what setting should you use? Here's a study from our group looking at APC alone for their treatment and weight regain. In this study, we compared two sets of settings. One is a low-dose APC, which refers to 45 to 55 watts, and the other setting is high-dose APC, which refers to 70 to 80 watts. What we found was that high-dose APC was associated with greater weight loss compared to low-dose APC. We therefore apply the same concept from this study and use the same setting for TOR, which is forced APC, 70 watts, and flow of 0.8 liters per minute. What about ESD TOR? Here's a video of how we do the procedure. First, an injection needle is used to inject a solution of hecto starch with methylene blue epinephrine into the submucosal layer. Mucosal incision is then performed around the outlet. The incision is usually made around one centimeter from the rim. One may then switch to an insulated tip knife after gaining access into the submucosal layer. Subsequently, the submucosal space is trimmed to widely expose the muscular layer around the outlet. After that, APC is performed at the inner and outer rim around the outlet. This ESD part is then completed and we proceed to the suturing step. In our study, we compared ESD TOR to APC TOR. Specifically, we match the two groups based on the initial outlet and pouch sizes. The study showed that at six months and also at one year, patients in the ESD TOR experienced greater weight loss, 12% total weight loss compared to about 8% total weight loss in the APC group. As a result, if resources are available and the anatomy is appropriate, ESD TOR is recommended as it yields greater weight loss compared to APC TOR. Moving on to the next step, which is outlet reduction. As mentioned earlier, our go-to technique for outlet reduction is using a purse-string suture pattern. In this study, we looked at 252 patients who underwent purse-string TOR, and we found that at one year, patients experienced 8.4% total weight loss with improvement in comorbidities. Subsequently, a formal comparison between the purse-string pattern to the older interrupted pattern was made. As shown here, the purse-string pattern was confirmed to be a superior pattern compared to interrupted pattern, 8.6% total weight loss compared to 6.4% total weight loss at one year. Some of you may have seen this study from the Brazil group in GIE last year. It's a randomized trial comparing APC alone to APC plus TOR. The study had 39 room-wide patients, about half in each group. And the study shows similar efficacy at one year. However, if you look at the TOR group, a modified figure of eight pattern was used, which is known to be less effective compared to a purse-string pattern. So now you're thinking of doing purse-string. What can go wrong? First is suture crossing. It's important to recognize when you're about to cross and prevent it. However, if the two ends of the suture do cross, this may create a knot. So it's also important to be able to untie a knot if one happens. Additionally, because you're working in a tight space, if there's too much suture slack, this may cause the suture to wrap around the tower. So to be able to do a successful purse-string, suture management is key. What about singeing? For this step, we singe over a six to eight millimeter CRE balloon. I prefer a seven millimeter size. However, if the outlet is off axis, I use six millimeters. So in the video here, you see that when you start pulling the suture, the outlet comes out very nicely around the balloon. However, if you pull the suture during the singeing step and the outlet doesn't shrink down in size, like this video, this can be due to a variety of reasons, including a cross suture during the sewing step, placing the singe tip too distal into the jejunal side of the outlet, or the singeing mechanism breaks. Now, moving on to the last step, which is pouch reduction. For this step, one to two interrupted sutures are placed in the distal pouch for reinforcement. However, if the pouch is long, you may consider performing an ESG pattern to shorten the pouch. Here's a recent patient of mine. You see that I use a two triangular pattern to further shorten the pouch. I start from the anterior, greater curvature, posterior, going back to anterior, greater curvature, and posterior, and then singe. Here's the final look after pouch reduction. At this year's DDW, Dr. Abudaiye's group reported an outcome on 131 ruined white patients. They compared routine TOR, using an interrupted pattern to reduce the outlet, to T-TOR, which is when they combined interrupted pattern around the outlet with the ESG pattern in the pouch. They found that at one year, T-TOR experienced greater weight loss, 7.7%, compared to 0.8% in the interrupted pattern only. So this show that reducing the pouch length may be beneficial, but also show that interrupted pattern appears to yield less weight loss compared to push ring pattern. Time for placation TOR, which is also known as ROS. For this procedure, the IOP system, which we saw in Dr. Thompson's talk, is utilized. The three major tricks for this procedure are, number one, for APC, you want to make it a thin rim because placations are placed outside the APC area. Number two, you start with the outlet first. And for this step, I usually go for the easiest spot where you can pull the most gastric tissue into the approximation device. Here you see, we pass a needle, drop the first tissue anchor, the second tissue anchor on the other side, and then cinch them together. The suture is then cut and released. Now we're moving to the other side of the outlet, and the same steps are repeated. And one thing to note is that the G-prox here is 16 millimeters, so it's a smaller size compared to the device that we use for our primary bariatric case. So after we're done with the outlet reduction, we then move up into the pouch. And the trick here is that you want to make sure you orient your G-prox so that it lies parallel to the force of the outlet. Otherwise, you might end up opening the outlet that uses reduced. Here's the final look of the pouch and also the outlet after placation tour. Our experience on 70 patients who underwent placation tour demonstrated a 9% total weight loss at one year. The GJA sonotic rate was about 9% with 80-watt APC. Since then, we have dialed down the APC setting to 70 watts, which was associated with about 3% sonotic rate. All cases were treated endoscopically. Is there anything else we can do after the procedure to ensure good weight loss? This is the previous patient who underwent placation tour. At a one-month follow-up, she was not able to tolerate anything PO. A diagnostic endoscopy showed GJA stenosis, which was treated with a CRE balloon up to 7 millimeters. A month later, her symptoms improved. However, she's still unable to tolerate solid diets. A luminoposine metal stamp was there for a place and dilated to 10 millimeters. Her symptoms resolved, and she's now happy at 18% total weight loss at one year. So another trick here is to avoid dilating GJA stenosis to greater than 15 millimeters to minimize weight gain. What do patients do at five years after the procedure? In this series, we show that patients maintain about 9% total weight loss at five years, and about 60% of them maintain at least 5% total weight loss. Here's a summary slide of the tour tips and tricks that we went over today. Thank you very much for your time and attention.

weight regain

bariatric surgery

roux-en-y gastric bypass

transoral gastrointestinal reduction

TOR procedures