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

Area of Science:

• Bariatric Surgery
• Minimally Invasive Procedures
• Gastroenterology

Background:

• Transoral Outlet Reduction (TORe) is a minimally invasive endoscopic procedure for Roux-en-Y gastric bypass (RYGB) patients experiencing weight regain.
• Current TORe techniques lack standardization, leading to variability in clinical practice.
• Standardized guidelines are needed to optimize outcomes and ensure consistency.

Purpose of the Study:

• To develop a standardized, step-by-step approach for performing the TORe procedure.
• To establish consensus among experts on key cognitive and technical skills required for TORe.
• To enhance the safety and efficacy of TORe for managing recurrent weight gain after RYGB.

Main Methods:

• A modified Delphi method involving TORe experts (≥300 procedures) was employed.
• Three rounds of surveys were conducted to achieve consensus on procedural steps.
• Items reaching ≥70% agreement were retained, with final decisions requiring unanimous consensus.

Main Results:

• Six experts participated, with high response rates across survey rounds.
• Consensus was reached on 24 standardized TORe statements, covering cognitive and technical skills.
• Key technical agreements include argon plasma coagulation, 8-12 pursestring sutures around the gastrojejunal anastomosis (GJA), and cinching over a CRE balloon.

Conclusions:

• The developed standards provide comprehensive, step-by-step guidance for TORe.
• These guidelines aim to ensure safe and effective clinical outcomes for patients undergoing TORe.
• Standardization of the TORe procedure is crucial for consistent patient management.