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

Thomas R. McCarty; Rashmi Advani; Christopher E. McGowan; Michael B. Ujiki; Sergio Sánchez-Luna; Daniel B. Maselli; Zachary M. Callahan; Christopher C. Thompson; Pichamol Jirapinyo

doi:10.1016/j.gie.2025.11.007

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

Thomas R. McCarty, Rashmi Advani, Christopher E. McGowan, Michael B. Ujiki, Sergio Sánchez-Luna, Daniel B. Maselli, Zachary M. Callahan, Christopher C. Thompson, Pichamol Jirapinyo

Research output: Contribution to journal › Article › peer-review

2 Scopus citations

Abstract

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.

Original language	English (US)
Pages (from-to)	780-785
Number of pages	6
Journal	Gastrointestinal Endoscopy
Volume	103
Issue number	4
DOIs	https://doi.org/10.1016/j.gie.2025.11.007
State	Published - Apr 2026

Keywords

Humans
Clinical Competence
Consensus
Delphi Technique
Gastric Bypass/methods
Natural Orifice Endoscopic Surgery/standards
Suture Techniques/standards

ASJC Scopus subject areas

Radiology Nuclear Medicine and imaging
Gastroenterology

Divisions

Gastroenterology and Hepatology

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10.1016/j.gie.2025.11.007

Cite this

@article{d16fdd3d01d146e284e557283c67a9d2,

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

abstract = "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.",

keywords = "Humans, Clinical Competence, Consensus, Delphi Technique, Gastric Bypass/methods, Natural Orifice Endoscopic Surgery/standards, Suture Techniques/standards",

author = "McCarty, \{Thomas R.\} and Rashmi Advani and McGowan, \{Christopher E.\} and Ujiki, \{Michael B.\} and Sergio S{\'a}nchez-Luna and Maselli, \{Daniel B.\} and Callahan, \{Zachary M.\} and Thompson, \{Christopher C.\} and Pichamol Jirapinyo",

note = "Copyright {\textcopyright} 2025. Published by Elsevier Inc.",

year = "2026",

month = apr,

doi = "10.1016/j.gie.2025.11.007",

language = "English (US)",

volume = "103",

pages = "780--785",

journal = "Gastrointestinal Endoscopy",

issn = "0016-5107",

publisher = "Elsevier",

number = "4",

}

TY - JOUR

T1 - Establishing standards of practice for transoral outlet reduction

T2 - an expert consensus using a modified Delphi method

AU - McCarty, Thomas R.

AU - Advani, Rashmi

AU - McGowan, Christopher E.

AU - Ujiki, Michael B.

AU - Sánchez-Luna, Sergio

AU - Maselli, Daniel B.

AU - Callahan, Zachary M.

AU - Thompson, Christopher C.

AU - Jirapinyo, Pichamol

PY - 2026/4

Y1 - 2026/4

N2 - 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.

AB - 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.

KW - Humans

KW - Clinical Competence

KW - Consensus

KW - Delphi Technique

KW - Gastric Bypass/methods

KW - Natural Orifice Endoscopic Surgery/standards

KW - Suture Techniques/standards

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U2 - 10.1016/j.gie.2025.11.007

DO - 10.1016/j.gie.2025.11.007

M3 - Article

C2 - 41223973

AN - SCOPUS:105029557626

SN - 0016-5107

VL - 103

SP - 780

EP - 785

JO - Gastrointestinal Endoscopy

JF - Gastrointestinal Endoscopy

IS - 4

ER -

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

Abstract

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