Transoral Outlet Reduction (TORe)

Transoral outlet reduction (TORe) is the most commonly performed endoscopic suturing procedure for obesity in the United States and was the first endoscopic suturing procedure ever performed to treat obesity, dating to 2004 (Acosta et al., AGA POWER White Paper, 2017). Although Roux-en-Y gastric bypass (RYGB) produces durable weight loss in most patients, a meaningful minority — roughly a quarter — experience clinically significant weight regain over time, and one of the most common and correctable reasons is dilation of the gastrojejunal anastomosis (GJA), the connection between the small gastric pouch and the intestine (Da Canal et al., Journal of Gastrointestinal Surgery, 2026). As this outlet stretches, food empties too quickly, satiety is lost, and weight returns.

TORe addresses this directly. Using a flexible endoscope passed through the mouth — no incisions, no laparoscopy — a full-thickness suturing device places stitches around the dilated outlet to narrow it back toward its original caliber. In the largest long-term series, the GJA was reduced from an average of 23.4 mm to 8.4 mm (Jirapinyo et al., Gastrointestinal Endoscopy, 2020). The procedure has been validated by level-one (randomized, sham-controlled) evidence and is formally endorsed as a treatment for post-RYGB weight regain by the International Federation for the Surgery of Obesity and Metabolic Disorders (Haddad et al., IFSO Position Statement, Obesity Surgery, 2024).

In 2025, a joint Association for Bariatric Endoscopy / American Society for Gastrointestinal Endoscopy assessment confirmed that TORe meets the established PIVI thresholds for both effectiveness and safety, supporting its clinical adoption (Jirapinyo et al., Gastrointestinal Endoscopy, 2025). TORe also effectively treats post-bypass dumping syndrome, another consequence of a dilated outlet (Pontecorvi et al., Obesity Surgery, 2023).

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Weight regain after gastric bypass is often anatomical, not simply behavioral. When the gastrojejunal outlet dilates, the "brake" that slows food leaving the pouch is lost — meals empty rapidly, hunger returns sooner, and the restriction that drove the original weight loss fades (Da Canal et al., Journal of Gastrointestinal Surgery, 2026).

TORe re-establishes that brake. By placing full-thickness sutures in a purse-string pattern around the anastomosis — and often reinforcing the pouch itself — the outlet is narrowed, gastric emptying is slowed, and satiety is prolonged (Jirapinyo et al., Gastrointestinal Endoscopy, 2020). Argon plasma coagulation (APC) is typically applied around the rim of the anastomosis before suturing; the controlled cautery promotes scar contraction that tightens and strengthens the repair over the following weeks, improving durability (Maselli et al., American Journal of Gastroenterology, 2024).

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• No incisions and no new anatomy — TORe is performed entirely through the mouth, preserving the existing bypass anatomy (Maselli et al., American Journal of Gastroenterology, 2024).

• Markedly safer than surgical revision — the pooled serious adverse event rate is approximately 1.5%, versus roughly 14% for surgical revision of RYGB (Jirapinyo et al., Gastrointestinal Endoscopy, 2025; Jirapinyo & Thompson, Gastrointestinal Endoscopy, 2023).

• Outpatient, same-day recovery — most patients go home the same day and return to normal activity within days.

• Renews weight loss — pooled 12-month total weight loss is about 8.9%, meeting the established efficacy benchmark (Jirapinyo et al., Gastrointestinal Endoscopy, 2025).

• Stops active weight gain — in the foundational studies, more than 90% of patients who were actively regaining weight had cessation of weight gain after TORe (Acosta et al., AGA POWER White Paper, 2017).

• Treats dumping syndrome — symptomatic remission was achieved in roughly 62% of patients at 12 months (Da Canal et al., Journal of Gastrointestinal Surgery, 2026).

• Repeatable — because it is anatomy-sparing, TORe can be repeated or combined with medication if needed (Jirapinyo et al., Gastrointestinal Endoscopy, 2020).

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TORe is designed for patients who have previously undergone Roux-en-Y gastric bypass and are experiencing weight regain or inadequate weight loss in the setting of a dilated gastrojejunal anastomosis (Jirapinyo et al., Gastrointestinal Endoscopy, 2020). The ideal candidate has:

• A prior RYGB with documented weight regain from a post-surgical nadir, or insufficient initial weight loss.

• A dilated gastrojejunal outlet — many programs use a threshold of roughly 25 mm or greater diameter on endoscopy or upper GI fluoroscopy (Vansteenbrugge et al., Obesity Surgery, 2023).

• A demonstrated commitment to ongoing dietary and lifestyle follow-up, typically with a minimum period of structured pre-procedure bariatric visits (Vansteenbrugge et al., Obesity Surgery, 2023).

• Post-bypass dumping syndrome attributable to the dilated outlet is an additional qualifying indication (Pontecorvi et al., Obesity Surgery, 2023).

TORe is generally not appropriate when the anastomosis is already narrow (under about 1.5 cm), when an active marginal ulcer is present, or when there is a large hiatal hernia — these are screened for and excluded on diagnostic endoscopy before proceeding (Reicher et al., Obesity Surgery, 2023).

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TORe is performed under general anesthesia with endotracheal intubation, using an esophageal overtube and CO₂ insufflation (Reicher et al., Obesity Surgery, 2023). A diagnostic endoscopy is first performed to confirm the dilated anastomosis and rule out contraindications. Argon plasma coagulation is applied circumferentially around the rim of the gastrojejunal anastomosis to prepare the tissue. A full-thickness endoscopic suturing device (e.g., Apollo OverStitch) is then used to place stitches — expert consensus favors 8 to 12 stitches in a purse-string pattern around the anastomosis, placed with a single suture, then cinched over an inflated controlled-radial-expansion balloon to standardize the final outlet diameter (McCarty et al., Gastrointestinal Endoscopy, 2026). The pouch may be reinforced with additional sutures. The entire procedure is incisionless and typically completed in under an hour.

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TORe has a strong safety profile — the pooled serious adverse event rate is approximately 1.5%, and large long-term series have reported no severe adverse events, no leaks, no need for surgery, and no mortality (Jirapinyo et al., Gastrointestinal Endoscopy, 2025; Jirapinyo et al., Gastrointestinal Endoscopy, 2020). The most common issues are transient and self-limited:

• Temporary throat (pharyngeal) pain, epigastric pain, nausea, and vomiting in the days after the procedure (Acosta et al., AGA POWER White Paper, 2017).

• Rarely, ulceration with self-limited bleeding (Acosta et al., AGA POWER White Paper, 2017).

• As with any upper endoscopy under anesthesia, there are small general risks of bleeding, perforation, and anesthetic reaction.

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Recovery is fast because there are no incisions. Most patients are discharged the same day or after overnight observation (Reicher et al., Obesity Surgery, 2023). Mild sore throat, nausea, and upper-abdominal discomfort are common for a few days and are managed symptomatically. Patients advance through a staged diet — clear liquids, then full liquids, then pureed and soft foods — over several weeks to protect the suture line as the outlet scars and tightens, before returning to a regular bariatric eating pattern.

TORe produces meaningful, durable weight loss in appropriately selected patients, with the clearest benefit in the first 1–3 years. In the largest long-term cohort, patients achieved 8.5%, 6.9%, and 8.8% total weight loss at 1, 3, and 5 years (Jirapinyo et al., Gastrointestinal Endoscopy, 2020). A pooled meta-analysis likewise showed about 8% total weight loss at 24 months, with attenuation of effect by 36 months — reinforcing that TORe is most powerful when embedded in long-term obesity care rather than treated as a one-time fix (Ortega et al., Obesity Surgery, 2026). Importantly, results are heterogeneous: some patients continue to regain weight after TORe, which is why ongoing medical and nutritional management is essential (Da Canal et al., Journal of Gastrointestinal Surgery, 2026). A key predictor of 5-year success is the amount of weight lost at 1 year, and the addition of a second endoscopic therapy or medication further improves durability (Jirapinyo et al., Gastrointestinal Endoscopy, 2020).

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More in Endoscopic Weight-Loss Procedures

Related procedures: Gastric Balloon, Orbera Intragastric Balloon, Allurion Balloon, Endoscopic Balloon Removal, Medical Weight Loss Program. For an overview of all options, see Endoscopic Sleeve Gastroplasty.

Conditions treated: Obesity, Overweight, Weight Regain, Metabolic Adaptation.

Part of Revisional Bariatric Surgery, which explains all the options after a previous weight-loss operation.

Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM, has been performing bariatric endoscopy since 2007 with the early ROSE Procedures; the precursor to the ESG. His clinical experience is buoyed by his research experience which has had him as a Principal Investigator for 6 different bariatric endoscopic FDA pivotal trials.

Dr. de la Cruz-Muñoz is a board-certified metabolic and bariatric surgeon who offers the full spectrum of weight-loss options, from endoscopic therapies like TORe and ESG through primary and revision surgery, which means candidates receive an unbiased, individualized recommendation and, critically, a seamless pathway to redo ESG or surgical conversion should their needs change over time.

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Dr. de la Cruz-Muñoz has been performing bariatric surgery for over 25 years and has completed more than 9,000 bariatric operations — a volume few surgeons reach.

• 12 months: pooled total weight loss of approximately 8.9% across 12 studies (1,154 patients), meeting the established 5% efficacy benchmark (Jirapinyo et al., Gastrointestinal Endoscopy, 2025).

• Suture pattern matters: a purse-string pattern achieves about 12.8% TWL, versus 6.5% for non-purse-string patterns — which is why technique selection is critical (Jirapinyo et al., Gastrointestinal Endoscopy, 2025).

• 3–5 years: roughly 7–9% TWL maintained in the largest cohort (Jirapinyo et al., Gastrointestinal Endoscopy, 2020).

• With medication added: combining TORe with anti-obesity medication yields about 15.2% TWL at 12 months — comparable to surgical revision (Jirapinyo & Thompson, Gastrointestinal Endoscopy, 2023).

These are averages; individual results vary with anatomy, suture technique, adherence, and adjunctive therapy.

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Renewed weight loss after TORe supports improvement in the obesity-related conditions that commonly recur alongside weight regain after gastric bypass. Because the degree of metabolic benefit tracks with weight lost, patients who achieve the greater weight loss seen with purse-string technique and combination therapy can expect correspondingly greater improvement in glycemic control, blood pressure, and lipids (Jirapinyo & Thompson, Gastrointestinal Endoscopy, 2023). TORe also resolves post-bypass dumping syndrome in the majority of affected patients — about 62% at 12 months — which improves day-to-day quality of life and eating tolerance (Da Canal et al., Journal of Gastrointestinal Surgery, 2026).

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TORe stops active weight gain in more than 90% of patients who are regaining, but the most durable results come from pairing the procedure with a structured, long-term plan (Acosta et al., AGA POWER White Paper, 2017). The evidence strongly supports combination therapy: adding anti-obesity medication (commonly topiramate, phentermine/topiramate, or a GLP-1 agonist such as liraglutide) around the time of TORe produces significantly greater weight loss than either TORe or medication alone, with similar safety (Jirapinyo & Thompson, Gastrointestinal Endoscopy, 2023). Prospective data support the addition of GLP-1 therapy after TORe specifically (Lahooti et al., Obesity Surgery, 2025). Ongoing dietary follow-up, behavioral support, body-composition tracking, and — when indicated — repeat TORe form the backbone of relapse prevention (Jirapinyo et al., Gastrointestinal Endoscopy, 2020).

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TORe is performed on patients who already have Roux-en-Y gastric bypass anatomy, which is itself the most reflux-protective bariatric configuration — the small pouch produces little acid and the long Roux limb diverts bile, making RYGB the antireflux procedure of choice in patients with obesity (Katz et al., ACG Clinical Guideline, 2022). Because TORe narrows the outlet below the pouch without altering the gastroesophageal junction, it does not create the acid-reflux risk associated with sleeve-based procedures. Any pre-existing reflux or marginal ulceration is evaluated on the diagnostic endoscopy before TORe, and an active marginal ulcer must be treated first, as it is a contraindication to suturing (Reicher et al., Obesity Surgery, 2023). In patients with one-anastomosis gastric bypass, TORe has additionally been used to treat bile (non-acid) reflux (Reicher et al., Obesity Surgery, 2023).

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TORe is itself an endoscopic revision option, and it fits on a spectrum of choices for weight regain after gastric bypass:

• TORe alone — anatomy-sparing, lowest-risk; best first-line option for a dilated outlet (Jirapinyo et al., Gastrointestinal Endoscopy, 2020).

• TORe plus anti-obesity medication — matches the weight loss of surgical revision with far lower risk (2.1% vs 14.3% serious adverse events) (Jirapinyo & Thompson, Gastrointestinal Endoscopy, 2023).

• Repeat TORe — feasible because the procedure preserves anatomy (Jirapinyo et al., Gastrointestinal Endoscopy, 2020).

• Surgical revision of RYGB — reserved for patients who are not candidates for or do not respond to endoscopic and medical therapy, given its higher complication rate (Haddad et al., IFSO Position Statement, Obesity Surgery, 2024).

The right sequence is individualized; current evidence supports starting with the least invasive effective option (Haddad et al., IFSO Position Statement, Obesity Surgery, 2024).

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As with any weight-loss intervention, the goal of TORe is loss of fat mass while preserving lean muscle. Because renewed weight loss can again mobilize both fat and muscle, patients are counseled on adequate protein intake and resistance training throughout the post-TORe period, with body-composition monitoring (rather than scale weight alone) used to track progress. This is especially important when TORe is combined with appetite-suppressing medications, which can reduce overall intake — making deliberate protein targets and strength training essential to protect the metabolically active muscle mass that helps prevent future regain.

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Coverage for TORe varies by payer and often requires documentation that distinguishes a correctable anatomic problem (dilated anastomosis with weight regain) from behavioral regain alone. Commonly required elements include: documented prior Roux-en-Y gastric bypass; objective weight regain from the post-surgical nadir or inadequate initial weight loss; an endoscopic or fluoroscopic measurement confirming a dilated gastrojejunal anastomosis; and a period of structured, supervised pre-procedure bariatric and dietary follow-up (Vansteenbrugge et al., Obesity Surgery, 2023). Pre-authorization and a documented multidisciplinary evaluation are typically needed; specific criteria should be confirmed with each individual plan.

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Diagnostic upper endoscopy and/or upper GI series to confirm the dilated anastomosis and exclude marginal ulcer, stricture, and large hiatal hernia (Reicher et al., Obesity Surgery, 2023).

Treatment of any active marginal ulcer before scheduling, as it is a contraindication (Reicher et al., Obesity Surgery, 2023).

A period of structured pre-procedure bariatric visits with dietary and lifestyle optimization (Vansteenbrugge et al., Obesity Surgery, 2023).

Standard pre-anesthesia evaluation and fasting per the anesthesia team.

Review of medications, including a plan for any anti-obesity medication to be used in combination with TORe.

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Nutrition after TORe follows a staged bariatric progression to protect the fresh suture line while the outlet scars down: clear liquids first, then full liquids, then pureed and soft foods, advancing to regular textures over several weeks. Emphasis is placed on adequate hydration and prioritizing protein at every stage to preserve lean mass during renewed weight loss. Because the outlet is intentionally narrowed, patients are coached on small portions, thorough chewing, and separating liquids from solids. Lifelong bariatric vitamin and mineral supplementation established after the original gastric bypass is continued, with periodic lab monitoring.

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Because TORe is incisionless, there are no wound or lifting restrictions, and most patients resume normal daily activity within a few days. Light activity such as walking is encouraged immediately. Structured exercise — combining aerobic activity with resistance (strength) training at least twice weekly — is reintroduced as tolerated and is specifically encouraged to preserve muscle mass and protect the metabolic rate during renewed weight loss, which is central to preventing future regain.

TORe is an outpatient endoscopic procedure, so patients from abroad usually need two to three days in Miami. Records from your original gastric bypass are helpful. Nutrition and weight follow-up continue virtually.