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Page 6 of 8 Spurzem et al. Mini-invasive Surg. 2025;9:10 https://dx.doi.org/10.20517/2574-1225.2024.96

complications after primary MBS, such as post-SG gastroesophageal reflux disease (GERD). For example,
2
conversion from SG to RYGB resulted in a 6.4 kg/m BMI reduction at 1 year in one meta-analysis of 556
[19]
patients . Resolution of GERD after SG to RYGB conversion is also reported to be as high as 85% . Two
[18]
recent expert consensus panels favored biliopancreatic diversion with duodenal switch (BPD/DS) to RYGB
after SG for limited weight loss and weight recidivism [20,21] . However, a recent meta-analysis of 1,771 patients
analyzing weight loss and metabolic outcomes of conversion from SG and gastric band to OAGB found that
mean BMI decreased from an initial average BMI of 45.70 kg/m to 31.52, 31.40, and 30.54 kg/m at 1, 3, and
2
2
[22]
5-year follow-ups, respectively . The drawbacks of each revisional procedure should also be carefully
considered. For example, there is evidence to suggest that OAGB may have a higher rate of cholelithiasis
than purely restrictive procedures, which may require additional operative or medical intervention . When
[23]
considering surgical conversion, it is clear that the indication for revision should factor into the chosen
operative approach and surgeons should be mindful of the unique postoperative complications that may
arise.

The higher morbidity associated with revisional compared to primary MBS is also a significant concern. A
recent international study of 65 bariatric centers and 750 patients found 30-day morbidity and mortality
rates of 10.7% and 0.3%, respectively . Previous studies have reported early morbidity rates of up to 33.9%
[24]
[25]
following revisional surgery . However, there are data suggesting that leveraging advances in robotic
surgery may confer a morbidity benefit in these complex procedures. Our group recently reported an
analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
(MBSAQIP) database, demonstrating lower postoperative morbidity with robotic surgery for revisional
RYGB compared to laparoscopic . There are also several less invasive endoscopic revisional bariatric
[26]
procedures being performed for weight regain with varying results . Close monitoring of these developing
[27]
technologies/techniques and associated outcomes is warranted as their use becomes more widespread.

With the recognition of obesity as a chronic multifactorial disease, it is also important to consider non-
operative treatment options for patients experiencing weight regain, especially in the context of the risks
associated with revisional surgery. While dietary, behavioral, and exercise interventions are the cornerstone
of initial obesity management, these options have demonstrated little to no efficacy in reversing weight
[28]
regain after bariatric surgery . Pharmacologic therapy with GLP-1 receptor agonists, in particular, has
[29]
emerged as a promising treatment for weight regain . There are also several other emerging incretin-based
therapies that are likely to influence the obesity management landscape . Counseling patients on the risks
[30]
and benefits of medical weight loss versus revisional surgery as part of shared decision-making discussions
will become increasingly important with continued advances in these treatment options. To that end,
multidisciplinary collaboration between surgeons, obesity medicine physicians, nutritionists, and
psychologists will be essential as the volume and complexity of bariatric patients increases over time.

There are multiple limitations to this retrospective cohort study. This study is limited to a single institution
with a relatively small sample size, which limits the generalizability of the findings. Our follow-up time is
also limited to 1 year postoperatively, preventing long-term comparisons of each revisional procedure.
Large, prospective randomized trials are warranted to comprehensively evaluate the comparative risks and
benefits of these procedures regarding revisional interventions for weight regain.

In conclusion, revisional bariatric surgery is a useful tool for addressing weight regain and achieving
sustained weight loss. Among the revisional options, converting SG to OAGB was most effective at
promoting significant weight loss at 12 months. These findings highlight the important role of tailored
revisional procedures in the broader context of bariatric care.