Long-term Outcomes of Transoral Outlet Reduction (TORe) for Dumping Syndrome and Weight Regain After Roux-en-Y Gastric Bypass
Background Both weight regain and dumping syndrome (DS) after Roux-en-Y gastric bypass (RYGB) have been related to the dilation of gastro-jejunal anastomosis. The aim of this study is to assess the safety and long-term efficacy of endoscopic transoral outlet reduction (TORe) for DS and/or weight reg...
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| Veröffentlicht in: | Obesity surgery 2023-04, Vol.33 (4), p.1032-1039 |
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| creator | Pontecorvi, Valerio Matteo, Maria Valeria Bove, Vincenzo De Siena, Martina Giannetti, Giulia Carlino, Giorgio Polidori, Giulia Vinti, Laila Angelini, Giulia Iaconelli, Amerigo Familiari, Pietro Raffaelli, Marco Costamagna, Guido Boškoski, Ivo |
| description | Background
Both weight regain and dumping syndrome (DS) after Roux-en-Y gastric bypass (RYGB) have been related to the dilation of gastro-jejunal anastomosis. The aim of this study is to assess the safety and long-term efficacy of endoscopic transoral outlet reduction (TORe) for DS and/or weight regain after RYBG.
Materials and Methods
A retrospective analysis was performed on a prospective database. Sigstad’s score, early and late Arts Dumping Score (ADS) questionnaires, absolute weight loss (AWL), percentage of total body weight loss (%TBWL), and percentage of excess weight loss (%EWL) were assessed at baseline and at 6, 12, and 24 months after TORe.
Results
Eighty-seven patients (median age 46 years, 79% female) underwent TORe. The median baseline BMI was 36.2 kg/m
2
. Out of 87 patients, 58 were classified as “dumpers” due to Sigstad’s score ≥ 7. The resolution rate of DS (Sigstad’s score < 7) was 68.9%, 66.7%, and 57.2% at 6, 12, and 24 months after TORe, respectively. A significant decrease in Sigstad’s score as well as in early and late ADS questionnaires was observed (
p
< 0.001). The median Sigstad’s score dropped from 15 (11–8.5) pre-operatively to 2 (0–12) at 24 months. The %TBWL was 10.5%, 9.9%, and 8.1% at 6, 12, and 24 months, respectively. Further, “dumpers” with resolution of DS showed better weight loss results compared with those with persistent DS (
p
< 0.001). The only adverse event observed was a perigastric fluid collection successfully managed conservatively.
Conclusion
TORe is a minimally invasive treatment for DS and/or weight regain after RYGB, with evidence of long-term efficacy.
Graphical Abstract |
| doi_str_mv | 10.1007/s11695-023-06466-w |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_10079715</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2770120728</sourcerecordid><originalsourceid>FETCH-LOGICAL-c475t-446db8a9fdb1264492255980ec56abecb3fd74b88fbd974ce28a400b4d97a9f3</originalsourceid><addsrcrecordid>eNp9kc1vFCEYxonR2LX6D3gwJF7aAwoMw8fJ1FarySabrJsYT4RhmCnNDKwwY92D_7tst9aPg1wIvL_neXl5AHhO8CuCsXidCeGqRphWCHPGObp5ABZEYIkwo_IhWGDFMZKKVkfgSc7XGFPCKX0MjiouMFWSLMCPZQw9mlwa4WqebBxdhrGDm2RCjskM-9vBTXDt2tlOPgZ4slmt3SnsYoIX87j1oYefdqFNRQpNaOFn5_urvaA3PsCzrnjDdZy_IxfQF3hp8pS8hW93W5PzU_CoM0N2z-72Y7B5_25z_gEtV5cfz8-WyDJRT4gx3jbSqK5tCOWMKUrrWknsbM1N42xTda1gjZRd0yrBrKPSMIwbVk5FVR2DNwfb7dyMrrUuTGU0vU1-NGmno_H670rwV7qP3_T-m5UgdXE4uXNI8evs8qRHn60bBhNcnLOmQmBCsaCyoC__Qa_jnEIZr1CKlyUELxQ9UDbFnJPr7l9D8G1bfUhXl3T1bbr6pohe_DnHveRXnAWoDkAupdC79Lv3f2x_ApbAsfc</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2796666776</pqid></control><display><type>article</type><title>Long-term Outcomes of Transoral Outlet Reduction (TORe) for Dumping Syndrome and Weight Regain After Roux-en-Y Gastric Bypass</title><source>MEDLINE</source><source>SpringerNature Journals</source><creator>Pontecorvi, Valerio ; Matteo, Maria Valeria ; Bove, Vincenzo ; De Siena, Martina ; Giannetti, Giulia ; Carlino, Giorgio ; Polidori, Giulia ; Vinti, Laila ; Angelini, Giulia ; Iaconelli, Amerigo ; Familiari, Pietro ; Raffaelli, Marco ; Costamagna, Guido ; Boškoski, Ivo</creator><creatorcontrib>Pontecorvi, Valerio ; Matteo, Maria Valeria ; Bove, Vincenzo ; De Siena, Martina ; Giannetti, Giulia ; Carlino, Giorgio ; Polidori, Giulia ; Vinti, Laila ; Angelini, Giulia ; Iaconelli, Amerigo ; Familiari, Pietro ; Raffaelli, Marco ; Costamagna, Guido ; Boškoski, Ivo</creatorcontrib><description>Background
Both weight regain and dumping syndrome (DS) after Roux-en-Y gastric bypass (RYGB) have been related to the dilation of gastro-jejunal anastomosis. The aim of this study is to assess the safety and long-term efficacy of endoscopic transoral outlet reduction (TORe) for DS and/or weight regain after RYBG.
Materials and Methods
A retrospective analysis was performed on a prospective database. Sigstad’s score, early and late Arts Dumping Score (ADS) questionnaires, absolute weight loss (AWL), percentage of total body weight loss (%TBWL), and percentage of excess weight loss (%EWL) were assessed at baseline and at 6, 12, and 24 months after TORe.
Results
Eighty-seven patients (median age 46 years, 79% female) underwent TORe. The median baseline BMI was 36.2 kg/m
2
. Out of 87 patients, 58 were classified as “dumpers” due to Sigstad’s score ≥ 7. The resolution rate of DS (Sigstad’s score < 7) was 68.9%, 66.7%, and 57.2% at 6, 12, and 24 months after TORe, respectively. A significant decrease in Sigstad’s score as well as in early and late ADS questionnaires was observed (
p
< 0.001). The median Sigstad’s score dropped from 15 (11–8.5) pre-operatively to 2 (0–12) at 24 months. The %TBWL was 10.5%, 9.9%, and 8.1% at 6, 12, and 24 months, respectively. Further, “dumpers” with resolution of DS showed better weight loss results compared with those with persistent DS (
p
< 0.001). The only adverse event observed was a perigastric fluid collection successfully managed conservatively.
Conclusion
TORe is a minimally invasive treatment for DS and/or weight regain after RYGB, with evidence of long-term efficacy.
Graphical Abstract</description><identifier>ISSN: 0960-8923</identifier><identifier>EISSN: 1708-0428</identifier><identifier>DOI: 10.1007/s11695-023-06466-w</identifier><identifier>PMID: 36702981</identifier><language>eng</language><publisher>New York: Springer US</publisher><subject>Dumping syndrome ; Dumping Syndrome - etiology ; Dumping Syndrome - surgery ; Female ; Gastric Bypass - adverse effects ; Gastric Bypass - methods ; Gastrointestinal surgery ; Humans ; Male ; Medicine ; Medicine & Public Health ; Middle Aged ; Obesity, Morbid - surgery ; Original Contributions ; Questionnaires ; Reoperation - methods ; Retrospective Studies ; Surgery ; Suture Techniques ; Treatment Outcome ; Weight Gain ; Weight Loss</subject><ispartof>Obesity surgery, 2023-04, Vol.33 (4), p.1032-1039</ispartof><rights>The Author(s) 2023</rights><rights>2023. The Author(s).</rights><rights>The Author(s) 2023. This work is published under http://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c475t-446db8a9fdb1264492255980ec56abecb3fd74b88fbd974ce28a400b4d97a9f3</citedby><cites>FETCH-LOGICAL-c475t-446db8a9fdb1264492255980ec56abecb3fd74b88fbd974ce28a400b4d97a9f3</cites><orcidid>0000-0003-4214-5948</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s11695-023-06466-w$$EPDF$$P50$$Gspringer$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s11695-023-06466-w$$EHTML$$P50$$Gspringer$$Hfree_for_read</linktohtml><link.rule.ids>230,314,780,784,885,27924,27925,41488,42557,51319</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/36702981$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Pontecorvi, Valerio</creatorcontrib><creatorcontrib>Matteo, Maria Valeria</creatorcontrib><creatorcontrib>Bove, Vincenzo</creatorcontrib><creatorcontrib>De Siena, Martina</creatorcontrib><creatorcontrib>Giannetti, Giulia</creatorcontrib><creatorcontrib>Carlino, Giorgio</creatorcontrib><creatorcontrib>Polidori, Giulia</creatorcontrib><creatorcontrib>Vinti, Laila</creatorcontrib><creatorcontrib>Angelini, Giulia</creatorcontrib><creatorcontrib>Iaconelli, Amerigo</creatorcontrib><creatorcontrib>Familiari, Pietro</creatorcontrib><creatorcontrib>Raffaelli, Marco</creatorcontrib><creatorcontrib>Costamagna, Guido</creatorcontrib><creatorcontrib>Boškoski, Ivo</creatorcontrib><title>Long-term Outcomes of Transoral Outlet Reduction (TORe) for Dumping Syndrome and Weight Regain After Roux-en-Y Gastric Bypass</title><title>Obesity surgery</title><addtitle>OBES SURG</addtitle><addtitle>Obes Surg</addtitle><description>Background
Both weight regain and dumping syndrome (DS) after Roux-en-Y gastric bypass (RYGB) have been related to the dilation of gastro-jejunal anastomosis. The aim of this study is to assess the safety and long-term efficacy of endoscopic transoral outlet reduction (TORe) for DS and/or weight regain after RYBG.
Materials and Methods
A retrospective analysis was performed on a prospective database. Sigstad’s score, early and late Arts Dumping Score (ADS) questionnaires, absolute weight loss (AWL), percentage of total body weight loss (%TBWL), and percentage of excess weight loss (%EWL) were assessed at baseline and at 6, 12, and 24 months after TORe.
Results
Eighty-seven patients (median age 46 years, 79% female) underwent TORe. The median baseline BMI was 36.2 kg/m
2
. Out of 87 patients, 58 were classified as “dumpers” due to Sigstad’s score ≥ 7. The resolution rate of DS (Sigstad’s score < 7) was 68.9%, 66.7%, and 57.2% at 6, 12, and 24 months after TORe, respectively. A significant decrease in Sigstad’s score as well as in early and late ADS questionnaires was observed (
p
< 0.001). The median Sigstad’s score dropped from 15 (11–8.5) pre-operatively to 2 (0–12) at 24 months. The %TBWL was 10.5%, 9.9%, and 8.1% at 6, 12, and 24 months, respectively. Further, “dumpers” with resolution of DS showed better weight loss results compared with those with persistent DS (
p
< 0.001). The only adverse event observed was a perigastric fluid collection successfully managed conservatively.
Conclusion
TORe is a minimally invasive treatment for DS and/or weight regain after RYGB, with evidence of long-term efficacy.
Graphical Abstract</description><subject>Dumping syndrome</subject><subject>Dumping Syndrome - etiology</subject><subject>Dumping Syndrome - surgery</subject><subject>Female</subject><subject>Gastric Bypass - adverse effects</subject><subject>Gastric Bypass - methods</subject><subject>Gastrointestinal surgery</subject><subject>Humans</subject><subject>Male</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Middle Aged</subject><subject>Obesity, Morbid - surgery</subject><subject>Original Contributions</subject><subject>Questionnaires</subject><subject>Reoperation - methods</subject><subject>Retrospective Studies</subject><subject>Surgery</subject><subject>Suture Techniques</subject><subject>Treatment Outcome</subject><subject>Weight Gain</subject><subject>Weight Loss</subject><issn>0960-8923</issn><issn>1708-0428</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2023</creationdate><recordtype>article</recordtype><sourceid>C6C</sourceid><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><recordid>eNp9kc1vFCEYxonR2LX6D3gwJF7aAwoMw8fJ1FarySabrJsYT4RhmCnNDKwwY92D_7tst9aPg1wIvL_neXl5AHhO8CuCsXidCeGqRphWCHPGObp5ABZEYIkwo_IhWGDFMZKKVkfgSc7XGFPCKX0MjiouMFWSLMCPZQw9mlwa4WqebBxdhrGDm2RCjskM-9vBTXDt2tlOPgZ4slmt3SnsYoIX87j1oYefdqFNRQpNaOFn5_urvaA3PsCzrnjDdZy_IxfQF3hp8pS8hW93W5PzU_CoM0N2z-72Y7B5_25z_gEtV5cfz8-WyDJRT4gx3jbSqK5tCOWMKUrrWknsbM1N42xTda1gjZRd0yrBrKPSMIwbVk5FVR2DNwfb7dyMrrUuTGU0vU1-NGmno_H670rwV7qP3_T-m5UgdXE4uXNI8evs8qRHn60bBhNcnLOmQmBCsaCyoC__Qa_jnEIZr1CKlyUELxQ9UDbFnJPr7l9D8G1bfUhXl3T1bbr6pohe_DnHveRXnAWoDkAupdC79Lv3f2x_ApbAsfc</recordid><startdate>20230401</startdate><enddate>20230401</enddate><creator>Pontecorvi, Valerio</creator><creator>Matteo, Maria Valeria</creator><creator>Bove, Vincenzo</creator><creator>De Siena, Martina</creator><creator>Giannetti, Giulia</creator><creator>Carlino, Giorgio</creator><creator>Polidori, Giulia</creator><creator>Vinti, Laila</creator><creator>Angelini, Giulia</creator><creator>Iaconelli, Amerigo</creator><creator>Familiari, Pietro</creator><creator>Raffaelli, Marco</creator><creator>Costamagna, Guido</creator><creator>Boškoski, Ivo</creator><general>Springer US</general><general>Springer Nature B.V</general><scope>C6C</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8C1</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>M0S</scope><scope>M1P</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0003-4214-5948</orcidid></search><sort><creationdate>20230401</creationdate><title>Long-term Outcomes of Transoral Outlet Reduction (TORe) for Dumping Syndrome and Weight Regain After Roux-en-Y Gastric Bypass</title><author>Pontecorvi, Valerio ; Matteo, Maria Valeria ; Bove, Vincenzo ; De Siena, Martina ; Giannetti, Giulia ; Carlino, Giorgio ; Polidori, Giulia ; Vinti, Laila ; Angelini, Giulia ; Iaconelli, Amerigo ; Familiari, Pietro ; Raffaelli, Marco ; Costamagna, Guido ; Boškoski, Ivo</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c475t-446db8a9fdb1264492255980ec56abecb3fd74b88fbd974ce28a400b4d97a9f3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2023</creationdate><topic>Dumping syndrome</topic><topic>Dumping Syndrome - etiology</topic><topic>Dumping Syndrome - surgery</topic><topic>Female</topic><topic>Gastric Bypass - adverse effects</topic><topic>Gastric Bypass - methods</topic><topic>Gastrointestinal surgery</topic><topic>Humans</topic><topic>Male</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Middle Aged</topic><topic>Obesity, Morbid - surgery</topic><topic>Original Contributions</topic><topic>Questionnaires</topic><topic>Reoperation - methods</topic><topic>Retrospective Studies</topic><topic>Surgery</topic><topic>Suture Techniques</topic><topic>Treatment Outcome</topic><topic>Weight Gain</topic><topic>Weight Loss</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Pontecorvi, Valerio</creatorcontrib><creatorcontrib>Matteo, Maria Valeria</creatorcontrib><creatorcontrib>Bove, Vincenzo</creatorcontrib><creatorcontrib>De Siena, Martina</creatorcontrib><creatorcontrib>Giannetti, Giulia</creatorcontrib><creatorcontrib>Carlino, Giorgio</creatorcontrib><creatorcontrib>Polidori, Giulia</creatorcontrib><creatorcontrib>Vinti, Laila</creatorcontrib><creatorcontrib>Angelini, Giulia</creatorcontrib><creatorcontrib>Iaconelli, Amerigo</creatorcontrib><creatorcontrib>Familiari, Pietro</creatorcontrib><creatorcontrib>Raffaelli, Marco</creatorcontrib><creatorcontrib>Costamagna, Guido</creatorcontrib><creatorcontrib>Boškoski, Ivo</creatorcontrib><collection>Springer Nature OA Free Journals</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Public Health Database</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Obesity surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Pontecorvi, Valerio</au><au>Matteo, Maria Valeria</au><au>Bove, Vincenzo</au><au>De Siena, Martina</au><au>Giannetti, Giulia</au><au>Carlino, Giorgio</au><au>Polidori, Giulia</au><au>Vinti, Laila</au><au>Angelini, Giulia</au><au>Iaconelli, Amerigo</au><au>Familiari, Pietro</au><au>Raffaelli, Marco</au><au>Costamagna, Guido</au><au>Boškoski, Ivo</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Long-term Outcomes of Transoral Outlet Reduction (TORe) for Dumping Syndrome and Weight Regain After Roux-en-Y Gastric Bypass</atitle><jtitle>Obesity surgery</jtitle><stitle>OBES SURG</stitle><addtitle>Obes Surg</addtitle><date>2023-04-01</date><risdate>2023</risdate><volume>33</volume><issue>4</issue><spage>1032</spage><epage>1039</epage><pages>1032-1039</pages><issn>0960-8923</issn><eissn>1708-0428</eissn><abstract>Background
Both weight regain and dumping syndrome (DS) after Roux-en-Y gastric bypass (RYGB) have been related to the dilation of gastro-jejunal anastomosis. The aim of this study is to assess the safety and long-term efficacy of endoscopic transoral outlet reduction (TORe) for DS and/or weight regain after RYBG.
Materials and Methods
A retrospective analysis was performed on a prospective database. Sigstad’s score, early and late Arts Dumping Score (ADS) questionnaires, absolute weight loss (AWL), percentage of total body weight loss (%TBWL), and percentage of excess weight loss (%EWL) were assessed at baseline and at 6, 12, and 24 months after TORe.
Results
Eighty-seven patients (median age 46 years, 79% female) underwent TORe. The median baseline BMI was 36.2 kg/m
2
. Out of 87 patients, 58 were classified as “dumpers” due to Sigstad’s score ≥ 7. The resolution rate of DS (Sigstad’s score < 7) was 68.9%, 66.7%, and 57.2% at 6, 12, and 24 months after TORe, respectively. A significant decrease in Sigstad’s score as well as in early and late ADS questionnaires was observed (
p
< 0.001). The median Sigstad’s score dropped from 15 (11–8.5) pre-operatively to 2 (0–12) at 24 months. The %TBWL was 10.5%, 9.9%, and 8.1% at 6, 12, and 24 months, respectively. Further, “dumpers” with resolution of DS showed better weight loss results compared with those with persistent DS (
p
< 0.001). The only adverse event observed was a perigastric fluid collection successfully managed conservatively.
Conclusion
TORe is a minimally invasive treatment for DS and/or weight regain after RYGB, with evidence of long-term efficacy.
Graphical Abstract</abstract><cop>New York</cop><pub>Springer US</pub><pmid>36702981</pmid><doi>10.1007/s11695-023-06466-w</doi><tpages>8</tpages><orcidid>https://orcid.org/0000-0003-4214-5948</orcidid><oa>free_for_read</oa></addata></record> |
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| identifier | ISSN: 0960-8923 |
| ispartof | Obesity surgery, 2023-04, Vol.33 (4), p.1032-1039 |
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| language | eng |
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| source | MEDLINE; SpringerNature Journals |
| subjects | Dumping syndrome Dumping Syndrome - etiology Dumping Syndrome - surgery Female Gastric Bypass - adverse effects Gastric Bypass - methods Gastrointestinal surgery Humans Male Medicine Medicine & Public Health Middle Aged Obesity, Morbid - surgery Original Contributions Questionnaires Reoperation - methods Retrospective Studies Surgery Suture Techniques Treatment Outcome Weight Gain Weight Loss |
| title | Long-term Outcomes of Transoral Outlet Reduction (TORe) for Dumping Syndrome and Weight Regain After Roux-en-Y Gastric Bypass |
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