TORe is safe and effective treatment for patients with medically refractory dumping syndrome

Transoral outlet reduction (TORe), a minimally invasive endoscopic procedure that reduces the size of the gastrojejunal anastomosis (GJA) through ablation and/or endoscopic suturing, is a safe and effective minimally invasive treatment for patients with medically refractory dumping syndrome, according to a study led by researchers from Indiana University School of Medicine, Indianapolis, IN.

Transoral outlet reduction (TORe) (Credit: Boston Scientific)

The researchers explained that dumping syndrome, a frequent but underdiagnosed complication of RYGB, affects up to 25–50% of patients and can significantly reduce health-related quality of life. Dumping syndrome is classified into two types: early dumping syndrome, which typically occurs within one hour after eating and is believed to result from rapid fluid shifts, and late dumping syndrome, which manifests one to three hours post-meal and is thought to stem from an incretin-driven hyperinsulinemia after carbohydrate ingestion. The researchers meta-anaylsis sought to evaluate the efficacy and safety of TORe for dumping syndrome.

They conducted a comprehensive literature search of for published studies that assessed the efficacy and safety of TORe for management of dumping syndrome. Of the 101 studies initially screened, ten met the inclusion criteria for this systematic review. However, four of these were excluded. Therefore, six were included in the final meta-analysis. A total of 333 post-RYGB patients with dumping syndrome who underwent TORe were included in the six included studies.

In total, 87% of patients were female, with a mean age of 47.5 ± 11.2 years and a mean BMI of 42.2 ± 10.3 kg/m2. Among the four studies reporting these data, the baseline mean diameter of the GJA was 34.2±9.8mm, and the mean baseline Sigstad score (diagnostic score system is used to determine dumping syndrome versus non-dumping syndrome) was 16.2±7.4. All TORe procedures used the OverStitch (Apollo, Boston Scientific) device for endoscopic suturing. The mean procedure duration, reported across five studies, was 45.3± 7.4 min. In the small subset of patients with available data (n=62), the mean post-procedural GJA diameter was reduced to 6.6±4.01 mm. Follow-up durations across the studies ranged from 3 months to 3.4 years.

All studies (n=312 patients, 21 patients lost to follow up) reported clinical success. The overall pooled clinical success was 83%. Four studies (n=211 patients) reported pre-TORe and post-TORe Sigstad’s score. TORe resulted in a significant improvement in Sigstad’s score (p<0.001).

Four studies (n=177 patients) reported the rate of surgery post-TORe. The pooled rate of surgery post-TORe was 5.8%. All studies (n=235 patients) reported the rate of repeat TORe. The pooled rate of repeat TORe was 6.9%. All studies (n=333) reported the rate of serious adverse events. The pooled overall rate of serious adverse events was 3%.

The risk of bias was assessed, of the six included studies, four were of low risk of bias while two were of high risk of bias in the assessment of outcomes. They found no evidence of publication bias for clinical success (p=0.59).

“TORe should be considered before proceeding to surgical revision, which carries higher morbidity and technical complexity,” the study authors concluded. “Further prospective studies, particularly randomised trials with longer follow-up durations, are warranted to validate these findings.”

The findings were reported in the paper, ‘Transoral Outlet Reduction for Dumping Syndrome After Roux-En-Y Gastric Bypass: a Comprehensive Systematic Review and Meta-Analysis’, published in Obesity Surgery. To access this paper, please click here