Establishing standards of practice for transoral outlet reduction: an expert consensus using a modified Delphi method.

Weight regain after Roux-en-Y gastric bypass (RYGB) is associated with worsening of liver outcomes. However, the effect of transoral outlet reduction (TORe) on liver fibrosis in RYGB patients with weight regain and possible advanced fibrosis remains unknown. This was a retrospective analysis of prospectively collected data of RYGB patients who underwent TORe for weight regain. Only patients with possible advanced fibrosis were included. TORe was performed using either an endoscopic suturing device (S-TORe) or plication device (P-TORe) to reduce the gastrojejunal anastomosis (GJA) and pouch sizes. Primary outcomes included changes in non-invasive tests (NITs) for fibrosis at 6-12months. Secondary outcomes included weight loss and changes in insulin resistance and lipid profile at 6-12months. Fifty RYGB patients were included. Baseline age and BMI were 55 ± 11years and 40.1 ± 7.3kg/m2. Baseline GJA and pouch sizes were 20 ± 7mm and 5 ± 2cm, respectively. Thirty patients (60%) underwent S-TORe and 20 patients (40%) underwent P-TORe. At 12months following TORe, there were statistically significant improvements in NITs for fibrosis, including ALT, AST and FIB-4. There was a trend towards significant improvement in liver stiffness measurement on transient elastography. Patients experienced 8.8 ± 11.2% total weight loss (TWL) (p < 0.0001), with 60% experiencing at least 10% TWL. Additionally, there was a significant improvement in HbA1c and a trend toward significant improvement in Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), suggestive of improved insulin sensitivity. TORe is associated with an improvement in hepatic fibrosis in patients with NAFLD and possible advanced fibrosis.

many patients that undergo bariatric surgery (Roux-en-Y gastric bypass [RYGB]) may regain some of their weight lost over time. A transoral outlet reduction (TORe) with endoscopic suture could be a valid alternative in these patients. this was a retrospective initial series of 13 consecutive patients with weight regain after RYGB and a dilated gastro-jejunal anastomosis (> 15 mm). TORe was performed using an endoscopic transmural suture device (OverStitch-Apollo®), which was used to reduce the anastomosis aperture and also to treat the gastric pouch. The initial data of feasibility, safety and weight loss are described with a limited follow-up of six months. there was a mean maximum weight loss of 37.69 kg after RYGB and a subsequent average regain of 21.62 kg. The mean anastomosis diameter was 36 mm (range 20-45) which was reduced to 9 mm (range 5-12) (75% reduction), with an average of 2.5 sutures. The mean pouch size was 7.2 cm (range 2-10), which decreased to 4.7 cm (range 4-5) (34.72% reduction), with an average of 2.7 sutures. The mean weight loss six months after TORe was 12.29 kg, a weight loss of 56.85% of the weight regained after RYGB. No complications related to the procedure were recorded. endoscopic suture reduction of the dilated gastro-jejunal anastomosis and the gastric pouch seems a feasible and safe option in our limited initial experience. With a multidisciplinary approach and a short term follow-up, this seems to be a minimally invasive and effective option to control weight regain after RYGB.

Transoral outlet reduction (TORe) is a minimally invasive endoscopic revision of Roux-en-Y gastric bypass (RYGB) for weight recurrence; however, little has been published on its clinical implementation in the community setting. To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB. This is a retrospective cohort study of argon plasma coagulation and purse-string suturing for gastric outlet reduction in consecutive adults with weight recurrence after RYGB at a single community center from September 2020 to September 2022. Patients were provided longitudinal nutritional support via virtual visits. The primary outcome was total body weight loss (TBWL) at twelve months from TORe. Secondary outcomes included TBWL at three months and six months; excess weight loss (EWL) at three, six, and twelve months; twelve-month TBWL by obesity class; predictors of twelve-month TBWL; rates of post-TORe stenosis; and serious adverse events (SAE). Outcomes were reported with descriptive statistics. Two hundred eighty-four adults (91.9% female, age 51.3 years, body mass index 39.3 kg/m2) underwent TORe an average of 13.3 years after RYGB. Median pre- and post-TORe outlet diameter was 35 mm and 8 mm, respectively. TBWL was 11.7% ± 4.6% at three months, 14.3% ± 6.3% at six months, and 17.3% ± 7.9% at twelve months. EWL was 38.4% ± 28.2% at three months, 46.5% ± 35.4% at six months, and 53.5% ± 39.2% at twelve months. The number of follow-up visits attended was the strongest predictor of TBWL at twelve months (R2 = 0.0139, P = 0.0005). Outlet stenosis occurred in 11 patients (3.9%) and was successfully managed with endoscopic dilation. There was one instance of post-procedural nausea requiring overnight observation (SAE rate 0.4%). When performed by an experienced endoscopist and combined with longitudinal nutritional support, purse-string TORe is safe and effective in the community setting for adults with weight recurrence after RYGB.

Variants in the leptin-melanocortin pathway (LMP) are associated with severe obesity. We evaluated weight loss of patients with or without heterozygous LMP variants, with weight recurrence after Roux-en-Y gastric bypass, who underwent endoscopic transoral outlet reduction (TORe). We retrospectively reviewed patients genotyped for an LMP who had undergone TORe, classified as "carriers" or "non-carriers" of genetic variants. We included 54 patients (22 carriers, 32 non-carriers). We identified 34 genetic variants in 21 different genes in 22 patients. Total body weight loss (%TBWL) after TORe was significantly different at 9 and 12months (12months: 0.68 ± 7.5% vs. 9.6 ± 8.2%, p < 0.01). This difference in weight loss was present even when analyzed in subgroups of patients who had undergone tubular TORe technique, and TORe plus APC. At 3, 6, and 12months, the percentage of carriers achieving ≥ 5% and ≥ 10% TBWL was lower than non-carriers. Patients with LMP variant who underwent RYGB had decreased weight loss 1year after undergoing TORe.

Obesity remains a global health challenge. One-anastomosis gastric bypass (OAGB) has gained popularity for its advantages, including significant weight loss. However, concerns have arisen regarding weight regain and other complications. This study aims to assess the effectiveness and safety of endoscopic transoral outlet reduction (TORe) as a treatment for weight regain after OAGB. In this retrospective study, consecutive patients from two bariatric centers with weight regain following OAGB were evaluated. Eligible patients were those with an increase in weight of 10% or a BMI = > 30. Diagnostic gastroscopy determined anastomosis diameter and rule out contraindications for TORe. The procedure involved full thickness suturing over the anastomosis, following circumferential argon plasma coagulation. Patients data were collected, outcomes assessed in accordance with ethical standards. 64 patients were treated over a period of 4 years and were followed up for a minimum of 1 year. Mean age was 45.2 ± 1.4. Percentages of females were 47%. Mean pre-treatment BMI was 35.5 ± 0.5. Average weight regain from post OAGB nadir was19.4% (112.5Kg from 90.7Kg). Average weight loss following TORe was 7% of total body weight (TBW) after 6 months and 8% after 12 months (p = 0.03). Additional treatments were needed in 11 (17%) patients. Two patients suffered a perforation, one of which required surgical intervention. TORe appears moderately effective for the treatment of weight regain post OAGB, with a 97% safety rate. Sustained weight loss was seen during 1 year of follow up. Further investigation is needed to assess long term durability.

641 - Five Year Outcomes following Transoral Outlet Reduction (TORe) Show Effective and Durable Treatment of Weight Regain after ROUX-EN-Y Gastric Bypass

TRANSORAL OUTLET REDUCTION (TORE) WITH ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) VERSUS ARGON PLASMA COAGULATION (APC): IMPACT OF TISSUE PREPARATION ON WEIGHT LOSS IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS

INTRODUCTION: Endoscopic transoral outlet reduction (TORe) utilizing a full thickness endoscopic suturing device is a minimally invasive therapeutic option in bariatric surgery patients who have experienced weight gain. This procedure can be therapeutic not only for weight gain after Roux-en-Y Gastric Bypass (RYGB), but also can be used in patients who underwent Billroth II procedure with biliary reflux symptoms. CASE DESCRIPTION/METHODS: A 68-year-old female patient with a past medical history of hypertension, dyslipidemia and prior Billroth II procedure for management of peptic ulcer disease presented with severe epigastric pain and bloating after meals refractory to PPI use. She underwent an EGD and was diagnosed with severe biliary gastritis. Transoral endoscopic gastric outlet reduction was recommended for this patient. A diagnostic flexible endoscope was advanced to the site of gastroduodenal anastomosis. Then, the gastric mucosa on the side of the anastomosis was aggressively ablated using argon plasma coagulation (APC). An endoscopic scissor was then used for trimming the previous suture remnants. A double channel scope was then inserted with the OverStitch device. A 2-0 Prolene suture was placed at the 3 O'clock position using full thickness running suture technique. A total of 4 bites were used. The suture was subsequently tightened with the creation of pseudo-pyloric opening. A total of one cinch was deployed to keep the suturing material permanently reinforced. No complications occurred throughout the procedure. Post-procedure follow up was normal with complete resolution of the patient's symptoms. DISCUSSION: Transoral endoscopic gastric outlet reduction is an emerging procedure used to manage weight gain after RYGB. The two-fold running suture technique is a novel method that can be used very effectively in this procedure. We have demonstrated that transoral outlet gastric reduction is not only effective for patients who have gained weight after RYGB, but also therapeutic in the improvement of biliary reflux symptoms after Billroth II procedure.Figure 1.: Argon plasma coagulation of the anastomotic margin.Figure 2.: Endoscopic suturing using the Apollo OverStitch device.Figure 3.: Creation of pseudo-pyloric opening.

S1618 Efficacy of Endoscopic Transoral Outlet Reduction (TORe) on Weight Loss Outcomes in Diabetic vs Non-Diabetic Patients Following Roux-en-Y Gastric Bypass

The Osculating Circles Gastroplasty: A Novel Endoscopic Submucosal Resection Enhanced Endoluminal Suturing for Obesity

Tu1914 PRACTICE PATTERNS IN BARIATRIC ENDOSCOPY: A SURVEY OF THE MEMBERS OF THE ASSOCIATION FOR BARIATRIC ENDOSCOPY

Obesity is a major global health challenge associated with significant metabolic and gastrointestinal comorbidities. While metabolic and bariatric surgery remains the gold standard for durable weight loss, the desire for additional options has fueled the development of endoscopic bariatric therapies (EBTs) as another tool for weight loss. This review examines established EBTs, including endoscopic sleeve gastroplasty (ESG), intragastric balloons (IGBs), and transoral outlet reduction (TORe), alongside emerging therapies such as duodenal mucosal resurfacing (DMR), incisionless anastomosis creation, and fully automated endoscopic gastric remodeling systems. ESG has demonstrated durable weight loss, favorable safety, and superior cost-effectiveness compared to pharmacotherapy alone, while combination strategies using EBTs and anti-obesity medications (AOMs), particularly GLP-1 receptor agonists, have resulted in greater total-body weight loss than either modality alone. Genetic variation, particularly within the leptin-melanocortin pathway, may predict response to endoscopic interventions and guide personalized treatment selection. Novel investigational procedures such as DMR, automated or robotic gastric remodeling, and magnetic or ultrasound-assisted gastric bypass show promising early results. Endoscopic therapies are poised to become increasingly central to the personalized, scalable management of obesity and related metabolic diseases.

The development of paediatric rehabilitation has been identified by the World Health Organization as a priority within the Rehabilitation 2030 initiative. The growing number of children with neurological, psycho-emotional, and somatic disorders caused by perinatal complications and the consequences of war has created a need for highly qualified paediatric physical therapy specialists. In Ukraine, there is currently no unified list of competencies for physical therapists working in paediatrics, which complicates the standardisation of educational programmes and clinical practice. The aim of this study was to develop an integrated list of professional competencies for physical therapists in paediatrics, classified by levels of complexity, based on expert consensus using a modified Delphi method. The study was conducted in two rounds using the modified Delphi method, involving 26 experts. Based on an analysis of international models (World Physiotherapy, WHO RCF, APTA, APA), an initial list of 50 competencies was developed and grouped into seven domains. After two rounds, consensus was reached on 55 competencies, organised into seven domains: practice, communication, professional and ethical practice, evidence-informed practice, learning and professional development, teamwork, and leadership and management. The competencies were categorised into three levels: basic, intermediate, and advanced. The integrated list of professional competencies for paediatric physical therapists represents the first systematic approach in Ukraine to standardising the training of such specialists in line with international models. Its structure, based on levels of complexity, provides a foundation for modernising educational programmes, developing assessment systems, supporting continuous professional development, and improving the quality of rehabilitation care for children.

There are currently three thrombopoietin receptor agonists (TPO-RAs) approved in Europe for treating patients with immune thrombocytopenia (ITP): romiplostim (Nplate®), eltrombopag (Revolade®), and avatrombopag (Doptelet®). However, comparative clinical data between these TPO-RAs are limited. Therefore, the purpose of this study was to perform a literature review and seek expert opinion on the relevance and strength of the evidence concerning the use of TPO-RAs in adults with ITP. A systematic search was conducted in PubMed and Embase within the last 10 years and until June 20, 2022. A total of 478 unique articles were retrieved and reviewed for relevance. The expert consensus panel comprised ITP senior hematologists from eight countries across Central Europe. The modified Delphi method, consisting of two survey rounds, a teleconference and email correspondence, was used to reach consensus. Forty articles met the relevancy criteria and are included as supporting evidence, including five meta-analyses analyzing all three European-licensed TPO-RAs and comprising a total of 31 unique randomized controlled trials (RCTs). Consensus was reached on seven statements for the second-line use of TPO-RAs in the management of adult ITP patients. In addition, the expert panel discussed TPO-RA treatment in chronic ITP patients with mild/moderate COVID-19 and ITP patients in the first-line setting but failed to reach consensus. This work will facilitate informed decision-making for healthcare providers treating adult ITP patients with TPO-RAs. However, further studies are needed on the use of TPO-RAs in the first-line setting and specific patient populations.

Femoroacetabular impingement syndrome (FAIS) is a prevalent hip disorder, and arthroscopic surgery has emerged as the preferred treatment modality, which has been rapidly adopted in clinical practice across China. Rehabilitation plays a pivotal role in ensuring functional recovery, normal daily activities, and return to sports for orthopedic surgery patients. However, standardized protocols and evidence-based guidelines for perioperative rehabilitation following FAIS arthroscopic surgery remain lacking in China. This expert group organized specialists to develop a rehabilitation consensus for patients with femoroacetabular impingement syndrome (FAIS) requiring arthroscopic surgery, based on systematic literature review, evidence quality assessment, and clinical rehabilitation practice, using the modified Delphi method. The consensus addresses three key aspects: basic principles and common methods, critical issues in rehabilitation intervention, and considerations for special populations. Specifically, it covers fundamental rehabilitation principles, common assessment methods, preoperative rehabilitation, psychological rehabilitation, and postoperative rehabilitation (including phased rehabilitation and progression criteria, pain management, muscle function training, joint range of motion training, weight-bearing training, the clinical value of platelet-rich plasma injections, and return-to-sport criteria). Additionally, it includes rehabilitation considerations for patients of different age groups and those undergoing various surgical approaches, totaling 13 recommendations. This consensus aims to provide evidence-based guidance for clinicians and rehabilitation therapists, facilitating personalized and comprehensive rehabilitation management for FAIS patients undergoing arthroscopic surgery.