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ESTABLISHING STANDARDS OF PRACTICE FOR TRANSORAL OUTLET REDUCTION (TORE): A GLOBAL EXPERT CONSENSUS USING A MODIFIED DELPHI METHOD
Thomas R. McCarty
*1, Rashmi Advani
5, Christopher McGowan
2, Sergio A. Sánchez-Luna
6, Michael Ujiki
2, Zachary M. Callahan
7, Daniel B. Maselli
8, Janese Laster
3, Christopher C. Thompson
4, Pichamol Jirapinyo
41Houston Methodist Hospital, Houston, TX; 2NorthShore University HealthSystem, Evanston, IL; 3MedStar Georgetown University Hospital MedStar Washington Hospital Center Internal Medicine Residency Program, Washington, ; 4Brigham and Women's Hospital, Boston, MA; 5Mount Sinai Health System, New York, NY; 6The University of Alabama at Birmingham, Birmingham, AL; 7Ascension Saint Thomas Hospital West, Nashville, TN; 8True You Weight Loss Georgia LLC, Atlanta, GA
Background: Transoral Outlet Reduction (TORe) is a minimally invasive obesity treatment for patients with recurrent weight gain following Roux-en-Y gastric bypass (RYGB). Despite its increasing adoption, procedural techniques vary and standardized guidelines regarding the TORe procedure are lacking. Therefore, this study aimed to develop a standardized approach to performing TORe.
Methods:This study was conducted by the TORe working group, a subgroup of Endobariatrics Committee members from the Foundation for Interventional and Therapeutic Endoscopy (FITE). A modified Delphi method was used to identify key procedural steps and primarily intended to recommend best practices for the TORe procedure. Global TORe experts were defined as completing ?200 procedures, 2) publishing peer-reviewed articles on TORe, and 3) representing diverse practice settings. Once identified, experts participated in three survey rounds from September 2023 to February 2024. Items with ?70% agreement were included, and those with <70% consensus were discussed. Only items with unanimous final agreement were retained.
Results: Six experts participated, including 5 (83%) gastroenterologists and one (17%) surgeon. Response rates were 83%, 83%, and 100% for rounds 1, 2, and 3, respectively. Final TORe skill standards consisted of 24 statements, divided into two sections: a cognitive skill section with 6 statements (24%) and a technical skill section with 18 statements (76%). The technical skill section was further stratified into two sub-sections: diagnostic endoscopy/pre-suturing steps (95% consensus) and suturing steps (97%). Key areas of agreement included tissue preparation around the gastrojejunal anastomosis (GJA) using argon plasma coagulation (APC), placement of a minimum of 8-12 stitches in a pursestring pattern around the GJA from the jejunal to gastric side, and cinching over an inflated balloon.
Conclusion: These standards provide step-by-step procedural guidance for safe and effective outcomes, aiming to establish best practices for the TORe procedure.
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