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

Background and Aims Transoral outlet reduction (TORe) is a minimally invasive treatment for patients with Roux-en-Y gastric bypass who experience recurrent weight gain, with proven efficacy and safety. However, procedural techniques vary, and standardized guidelines are currently lacking. This study aimed to develop a standardized approach for performing the TORe procedure to optimize outcomes and ensure consistency in clinical practice. Methods A modified Delphi method was used to identify key TORe steps. TORe experts (≥300 procedures) participated in 3 survey rounds. 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, achieving response rates of 83%, 83%, and 100% for rounds 1, 2, and 3, respectively. The final TORe standards consisted of 24 statements, including 6 on cognitive skills (100% consensus) and 18 on technical skills. The technical skills were further categorized into 6 statements on diagnostic endoscopy/pre-suturing (100% consensus) and 12 statements on suturing steps (100% consensus). Key areas of agreement included performing argon plasma coagulation around the gastrojejunal anastomosis (GJA), placing 8 to 12 stitches in a pursestring pattern around the GJA from the jejunal to gastric side using 1 suture, and cinching the suture over an inflated controlled radial expansion balloon. Conclusions These standards provide step-by-step TORe guidance for safe and effective clinical outcomes.