Transoral outlet reduction zipper technique for enhanced tissue approximation and potential improved durability

Patients may regain weight despite initial success with Roux-en-Y gastric bypass (RYGB). Patients also may experience dumping syndrome. Traditional solutions include surgical revision. Transoral outlet reduction (TORe) is an endoscopic option for restoration of the restriction of the RYGB. We present an alternative method for the TORe procedure by suturing using a unique zipper technique to enhance tissue approximation with the potential for improved durability.

The patient was a 60-year-old woman with a history of morbid obesity and remote RYGB with weight regain and symptoms consistent with dumping syndrome. We performed a TORe using the traditional purse-string method in which sutures are placed in a clockwise fashion, but after a year, the patient's symptoms returned, and her gastric outlet reopened to a diameter of 40 mm. We then performed a repeat TORe using the zipper technique, in which a continuous suture was placed in a zigzag fashion.

The patient's dumping syndrome symptoms resolved, and her gastric outlet remained stable at a diameter of 11 mm after several months.

This case highlights the effectiveness of an alternative suturing technique in tightening the transoral outlet. The zipper technique has enhanced durability that may reduce need for repeat intervention in similar cases.