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Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis


Background and aims

Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature.


Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used.


130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18 months after TORe was 9.31 ± 6.7 kg (N = 84), 7.75 ± 8.4  kg (N = 70), 8 ± 8.8 kg (N = 46) (p < 0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12 months was 8.4 kg (95% CI 6.5–10.3) with no significant heterogeneity across included studies (p = 0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported.


When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

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Authors and Affiliations


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Correspondence to Barham K. Abu Dayyeh.

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Dr. Todd Wilson has served as consultant for Bard, Olympus, and EndoEvolution. Dr. Erik B. Wilson has served as a consultant to Intuitive Surgical, Ethicon, Gore, and Apollo Endosurgery, and Olympus. Dr. Manoel Galvao Neto has served as a consultant to ALACER Biomedica, SCI Tech/CMS, MI Tech, Ethicon EndoSurgery, GI Dynamics, Apollo EndoSurgery, Fractyl Labs, GI Windows, and Alacer Biomedica. Dr. Natan Zundel is on the advisory board for Apollo Endosurgery and Olympus. Dr. Christopher J. Gostout is chief medical officer for Apollo Endosurgery. Dr. Barham K. Abu Dayyeh has served as a consultant for Apollo Endosurgery, Boston Scientific, and Metamodix. He received research support from GI dynamics, Aspire Bariatrics, and Spatz. Drs. Eric J.Vargas, Fateh Bazerbachi, Andres Acosta, Manpreet S. Mundi, Maria L. Collazo-Clavell, Shah Meera, H. S. Abu-Lebdeh, Todd A. Kellogg, Travis J. McKenzie, Michael L. Kendrick, Mark D. Topazian, Mrs. Monika Rizk and Mr. Paul A. Lorentz have no conflicts of interest or financial ties to disclose.

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Vargas, E.J., Bazerbachi, F., Rizk, M. et al. Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis. Surg Endosc 32, 252–259 (2018).

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  • Endoscopic
  • Bariatric surgery
  • Revision