Weight regain following gastric bypass surgery affects up to 20% of patients, yet many are unaware of the endoscopic treatment options now available to help them lose the extra weight.
“The reason we call it a ‘silent epidemic’ is because patients are often not informed of different interventions which can help them to lose the extra weight,” says gastroenterologist Ishfaq Bhat, MD. “Most will be asked to do lifestyle modifications, which are important, but they will have difficulty losing the extra weight. So they just live with it.”
Recognizing post-bypass weight regain
While some weight regain after gastric bypass is not uncommon, significant regain warrants clinical attention. Providers should monitor patients for key indicators:
- BMI approaching or exceeding 30.
- Return of comorbidities (hypertension, insulin resistance, sleep apnea).
- Patient reports of constant hunger.
- Decreased satiety after meals.
- Ability to consume larger portions.
“Obviously, the most important indicator is weight gain. Their BMI will be approaching 30 or more, in addition to those potentially associated conditions,” Dr. Bhat says.
Another indicator is dumping syndrome, which can signal a widened gastric outlet. “Dumping can be a symptom of patients who have had a wide gastric outlet. They eat, and then essentially, the food goes directly into the small bowel,” Dr. Bhat says. This can cause nausea, cramping and diarrhea.
The TORe solution
Transoral outlet reduction (TORe) offers a minimally invasive alternative between lifestyle modifications and surgical revision. The procedure addresses the anatomical changes that contribute to weight regain.
“Over time the pouch, which was created at the first gastric bypass, becomes wider and bigger, and what we call ‘the outlet’ between the pouch and jejunum becomes wider,” Dr. Bhat says.
During an upper endoscopy, gastroenterologists often find outlets that have expanded from the original 1 centimeter to two to three times that size. When outlets exceed 1.5 centimeters, patients begin losing their sensation of satiety, eat more and gain weight.
How TORe works
The outpatient procedure takes approximately one hour under general anesthesia. Using endoscopic techniques, physicians:
- Apply argon plasma coagulation to expose the superficial lining of the outlet.
- Perform endoscopic suturing in a purse-string fashion.
- Narrow the outlet to 8 to10 millimeters.
“It’s a minimally invasive, same-day procedure,” Dr. Bhat says. “Most patients will have some nausea and discomfort for a day or so, a couple days at most, but they go home the same day.”
Evidence and outcomes
Current data shows promising results for TORe, though long-term studies are still emerging. Research demonstrates:
- 10 to 15% weight loss at 12 months.
- Maintained 10% weight loss at five years.
- Ability to repeat the procedure if needed.
“It’s not a huge weight loss, but it certainly adds to the lifestyle modifications, and in some situations, medications as well,” Dr. Bhat says.
When to refer
Early intervention yields better outcomes, making timely referral crucial. “The general thought is that the longer we wait for patients to have this procedure, the outcome is not as robust,” Dr. Bhat says. “So, the earlier we try to narrow that outlet, patients will have more weight loss.”
Primary care physicians should consider referral when patients demonstrate:
- Significant weight regain after initial success.
- Return of obesity-related comorbidities.
- Symptoms suggesting outlet dilation.
Making the referral
The referral process is straightforward. Physicians can:
- Call endoscopy scheduling at 402.955.4015.
- Submit a referral through the electronic medical record.
- Contact the Gastrointestinal Care program for consultation.
“If a PCP is concerned about weight regain, and the patient is symptomatic, in most situations, they can directly call the endoscopy scheduling,” Dr. Bhat says.
The Gastrointestinal Care team reviews each case individually and can provide consultation even before scheduling procedures. “We don’t necessarily need to directly go to the procedure. We can obviously allay the patient’s concerns or answer the referring physicians’ questions,” Dr. Bhat says.
For more information about TORe procedures or to make a referral, contact the Gastrointestinal Care team at 402.955.4015.