Advertisement

Weight loss specific to indication, remission of diabetes, and short-term complications after sleeve gastrectomy conversion to Roux-en-Y gastric bypass: a systematic review and meta-analysis

Open AccessPublished:November 11, 2022DOI:https://doi.org/10.1016/j.soard.2022.11.004

      Abstract

      Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. Long-term complications such as insufficient weight loss (IWL) and gastroesophageal reflux disease (GERD) may necessitate SG conversion to Roux-en-Y gastric bypass (RYGB). The aim of this review was to determine the indication-specific weight loss and diabetes remission after SG conversion to RYGB (STOBY). Our objective was to extract all available published data on indication for conversion, weight loss, remission of diabetes, and short-term complications after STOBY. Single- and multicenter cohort studies including university hospitals and tertiary and academic centers. A systematic literature search was conducted to identify studies reporting outcomes following STOBY. A random effects model was used for meta-analysis. The search identified 44 relevant studies. Overall short-term (12-mo) excess weight loss (EWL) was 54.6% (95% confidence interval [CI], 46%–63%) in 23 studies (n = 712) and total weight loss (TWL) was 19.9% (95% CI, 14%–25%) in 21 studies (n = 740). For IWL, short-term (12-mo) pooled weight loss outcomes were 53.9% EWL (95% CI, 48%–59%) in 14 studies (n = 295) and 22.7% TWL (95% CI, 17%–28%) in 12 studies (n = 219), and medium-term (2–5 yr) outcomes were 45.8% EWL (95% CI, 38%–53%) in 7 studies (n = 154) and 20.6% TWL (95% CI, 15%–26%) in 9 studies (n = 206). Overall diabetes remission was 53% (95% CI, 33%–72%), and the perioperative complication rate was 8.2% (95% CI, 7.6%–8.7%). Revisional SG conversion to RYGB for IWL can achieve good weight loss outcomes and diabetes remission.

      Keywords

      Bariatric surgery is an effective treatment of morbid obesity that leads to long-term weight loss and reduction of obesity-related all-cause morbidity and mortality [
      • Buchwald H.
      • Avidor Y.
      • Braunwald E.
      • et al.
      Bariatric surgery: a systematic review and meta-analysis.
      ,
      • Chang S.H.
      • Stoll C.R.
      • Song J.
      • Varela J.E.
      • Eagon C.J.
      • Colditz G.A.
      The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012.
      ,
      • Puzziferri N.
      • Roshek T.B.
      • Mayo 3rd, H.G.
      • Gallagher R.
      • Belle S.H.
      • Livingston E.H.
      Long-term follow-up after bariatric surgery: a systematic review.
      ]. The number of surgical interventions for obesity has steadily increased over the years, with sleeve gastrectomy (SG) being the most frequently performed bariatric operation worldwide [
      • Angrisani L.
      • Santonicola A.
      • Iovino P.
      • et al.
      IFSO Worldwide Survey 2016: primary, endoluminal, and revisional procedures.
      ,
      • Roth A.E.
      • Thornley C.J.
      • Blackstone R.P.
      Outcomes in bariatric and metabolic surgery: an updated 5-year review.
      ]. However, accumulating evidence has demonstrated that SG is associated with significant weight recurrence in up to 75% of patients [
      • Lauti M.
      • Kularatna M.
      • Hill A.G.
      • MacCormick A.D.
      Weight regain following sleeve gastrectomy: a systematic review.
      ] and remission of type 2 diabetes (T2D) is superior following Roux-en-Y gastric bypass (RYGB) [
      • Hofso D.
      • Fatima F.
      • Borgeraas H.
      • et al.
      Gastric bypass versus sleeve gastrectomy in patients with type 2 diabetes (Oseberg): a single-centre, triple-blind, randomised controlled trial.
      ]. Another commonly encountered issue following SG is new onset gastroesophageal reflux (GERD) [
      • Roth A.E.
      • Thornley C.J.
      • Blackstone R.P.
      Outcomes in bariatric and metabolic surgery: an updated 5-year review.
      ,
      • Schauer P.R.
      • Bhatt D.L.
      • Kashyap S.R.
      Bariatric surgery or intensive medical therapy for diabetes after 5 years.
      ,
      • Csendes A.
      • Orellana O.
      • Martinez G.
      • Burgos A.M.
      • Figueroa M.
      • Lanzarini E.
      Clinical, endoscopic, and histologic findings at the distal esophagus and stomach before and late (10.5 years) after laparoscopic sleeve gastrectomy: results of a prospective study with 93% follow-up.
      ,
      • Yeung K.T.D.
      • Penney N.
      • Ashrafian L.
      • Darzi A.
      • Ashrafian H.
      Does sleeve gastrectomy expose the distal esophagus to severe reflux?: a systematic review and meta-analysis.
      ]. This may be complicated with erosive esophagitis or Barrett’s esophagus [
      • Csendes A.
      • Orellana O.
      • Martinez G.
      • Burgos A.M.
      • Figueroa M.
      • Lanzarini E.
      Clinical, endoscopic, and histologic findings at the distal esophagus and stomach before and late (10.5 years) after laparoscopic sleeve gastrectomy: results of a prospective study with 93% follow-up.
      ,
      • Genco A.
      • Soricelli E.
      • Casella G.
      • et al.
      Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication.
      ]. Consequently, routine postoperative endoscopic surveillance has been recommended for all SG patients [
      • Soricelli E.
      • Casella G.
      • Baglio G.
      • Maselli R.
      • Ernesti I.
      • Genco A.
      Lack of correlation between gastroesophageal reflux disease symptoms and esophageal lesions after sleeve gastrectomy.
      ].
      A potential solution to treat these complications is revisional bariatric surgery. In particular, RYGB is considered to be the procedure of choice after failed SG particularly in patients with de novo GERD [
      • Gautier T.
      • Sarcher T.
      • Contival N.
      • Le Roux Y.
      • Alves A.
      Indications and mid-term results of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass.
      ,
      • Khoursheed M.A.
      • Al-Bader I.A.
      • Al-Asfar F.S.
      • Mohammad A.I.
      • Shukkur M.
      • Dashti H.M.
      Revision of failed bariatric procedures to Roux-en-Y gastric bypass (RYGB).
      ,
      • Assalia A.
      • Gagner M.
      • Nedelcu M.
      • Ramos A.C.
      • Nocca D.
      Gastroesophageal reflux and laparoscopic sleeve gastrectomy: results of the first international consensus conference.
      ]. Some evidence suggests that GERD following SG can be treated with conversion to RYGB [
      • Matar R.
      • Monzer N.
      • Jaruvongvanich V.
      • et al.
      Indications and outcomes of conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a systematic review and a meta-analysis.
      ]. However, the majority of revisional procedures are not performed to treat GERD. Approximately 52% of SG revisions are carried out with the indication of weight recurrence/insufficient weight loss (IWL) while only 30% of revisions are performed for GERD [
      • Matar R.
      • Monzer N.
      • Jaruvongvanich V.
      • et al.
      Indications and outcomes of conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a systematic review and a meta-analysis.
      ]. Currently, there is no meta-analysis performed on the effectiveness of revisional SG-to-RYGB (STOBY) in individuals with weight-related complications and only limited retrospective data comparing weight loss after primary RYGB and STOBY. All available meta-analyses presenting outcomes following STOBY do not discriminate between patients with IWL, de novo GERD or failed resolution of co-morbidities. Thus, the aim of this systematic review and meta-analysis was to evaluate the indication-specific outcomes of revisional RYGB after failed SG. The likely degree of weight loss and the odds of T2D remission are important for all obesity specialists advising patients on STOBY.

      Methods

      This systematic review was conducted according to a registered protocol and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) statement [
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      ]. The review was registered on PROSPERO Centre for Reviews and Dissemination (registration number: CRD42021214581).

      Search strategy

      A comprehensive search was performed in electronic databases including PubMed/MEDLINE, Embase/OVID, and the Cochrane library, and they were reviewed within the period from 2010 to August 2022. The literature search included the following MeSH terms used in all possible combinations: “sleeve gastrectomy,” “gastric sleeve,” “LSG,” “laparoscopic sleeve gastrectomy,” “bariatric sleeve surgery,” “Roux-en-Y gastric bypass,” “gastric bypass,” “RYGB,” “revisional surgery,” “conversion surgery,” “repeat surgery,” “sleeve to bypass,” “sleeve gastrectomy to gastric bypass.” Studies identified from the search strategy were entered into Covidence (Victoria, Australia) for bibliographic management, and duplicates were removed. Two authors (S.B. and P.V.) independently identified relevant studies and any discrepancies were resolved by consensus with the help of a third author (M.F.). The exact search strategy has been provided as supplementary material (Sup. 1).

      Inclusion and exclusion criteria

      The inclusion and exclusion criteria were defined before commencement of the literature search. The following criteria were required for inclusion in the study: (1) randomized controlled trials (RCT), prospective or retrospective cohort studies, case (control) studies, cross-sectional studies; (2) patients who had undergone STOBY; (3) reported outcome of interest: resolution of diabetes, weight loss, and perioperative complications; and (4) original, full publications published in English.
      The primary outcome of interest was weight loss following STOBY where conversion was performed for the indication of insufficient weight loss (IWL) and diabetes remission in all STOBY patients. There are several definitions of IWL published previously [
      • Majid S.F.
      • Davis M.J.
      • Ajmal S.
      • et al.
      Current state of the definition and terminology related to weight recurrence after metabolic surgery: review by the POWER Task Force of the American Society for Metabolic and Bariatric Surgery.
      ]. The definition of diabetes remission and IWL were based on the original studies. The terminology suggested by the POWER Task Force [
      • Majid S.F.
      • Davis M.J.
      • Ajmal S.
      • et al.
      Current state of the definition and terminology related to weight recurrence after metabolic surgery: review by the POWER Task Force of the American Society for Metabolic and Bariatric Surgery.
      ] was used throughout the article. To maximize the available data, several attempts were made to contact authors of articles in which indication of STOBY was not published and ask them to provide their data with respect to indication of the conversion. We report weight loss following conversion to RYGB unless otherwise specified. Nonhuman studies, reviews, abstracts, conference presentations, single case reports, editorials, and unpublished studies were excluded from the analysis.

      Data extraction and quality assessment

      A standardized data extraction form was developed on Covidence and 2 authors (S.B. and P.V.) independently extracted all relevant data: study design, sample size, patient sex and age, indication for revisional surgery, preexisting diabetes, mean body mass index (BMI) (pre-SG, before revision, after RYGB), mean percent of excess weight loss (%EWL), mean total weight loss (%TWL) at 12 months (short term) and 2 to 5 years (medium term), resolution of T2D, and postoperative complications. Any discrepancy was resolved by group discussion. All the included studies were nonrandomized; hence, the Newcastle-Ottawa Quality Assessment tool was used to grade them.

      Statistical analysis

      Statistical analysis was performed using Stata Software, version 15.1 (StataCorp). Random effects analysis was used to calculate weighted mean differences and mass effect. All studies were included in the meta-analysis if relevant data were available. Data were pooled using a random effects model and statistical heterogeneity was calculated using I2. We considered an I2 of 30 or less as low, between 30 and 60 to be moderate, and 60 or over as high heterogeneity.

      Results

      Study selection

      The search identified 7784 relevant citations. After removing duplicate results, 6041 articles were screened for titles and abstracts and 249 studies were included for full-text review. A total of 205 articles were excluded after full-length review due to reasons outlined in Fig. 1. Thus, 44 studies were eligible for inclusion in the study [
      • Gautier T.
      • Sarcher T.
      • Contival N.
      • Le Roux Y.
      • Alves A.
      Indications and mid-term results of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass.
      ,
      • Abdemur A.
      • Han S.M.
      • Lo Menzo E.
      • Szomstein S.
      • Rosenthal R.
      Reasons and outcomes of conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass for nonresponders.
      ,
      • Aguilar-Espinosa F.
      • Montoya-Ramirez J.
      • Gutierrez Salinas J.
      • Blas-Azotla R.
      • Aguilar-Soto O.A.
      • Becerra-Gutierrez L.P.
      Conversion to Roux-en-Y gastric bypass surgery through a robotic-assisted hybrid technique after failed sleeve gastrectomy: short-term results.
      ,
      • Aleassa E.M.
      • Hassan M.
      • Hayes K.
      • Brethauer S.A.
      • Schauer P.R.
      • Aminian A.
      Effect of revisional bariatric surgery on type 2 diabetes mellitus.
      ,
      • Landreneau J.P.
      • Strong A.T.
      • Rodriguez J.H.
      • et al.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass.
      ,
      • Al-Sabah S.
      • Al Haddad E.
      • Akrof S.
      • Alenezi K.
      • Al-Subaie S.
      Midterm results of revisional bariatric surgery postsleeve gastrectomy: resleeve versus bypass.
      ,
      • Al-Sabah S.
      • Alsharqawi N.
      • Almulla A.
      • et al.
      Approach to poor weight loss after laparoscopic sleeve gastrectomy: re-sleeve vs. gastric bypass.
      ,
      • Amiki M.
      • Seki Y.
      • Kasama K.
      • et al.
      Revisional Bariatric surgery for insufficient weight loss and gastroesophageal reflux disease: our 12-year experience.
      ,
      • Barajas-Gamboa J.S.
      • Landreneau J.
      • Abril C.
      • Raza J.
      • Corcelles R.
      • Kroh M.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for complications: outcomes from a tertiary referral center in the Middle East.
      ,
      • Boru C.E.
      • Greco F.
      • Giustacchini P.
      • Raffaelli M.
      • Silecchia G.
      Short-term outcomes of sleeve gastrectomy conversion to R-Y gastric bypass: multi-center retrospective study.
      ,
      • Carandina S.
      • Soprani A.
      • Montana L.
      • et al.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study.
      ,
      • Carmeli I.
      • Golomb I.
      • Sadot E.
      • Kashtan H.
      • Keidar A.
      Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm.
      ,
      • Casillas R.A.
      • Um S.S.
      • Zelada Getty J.L.
      • Sachs S.
      • Kim B.B.
      Revision of primary sleeve gastrectomy to Roux-en-Y gastric bypass: indications and outcomes from a high-volume center.
      ,
      • Chiappetta S.
      • Stier C.
      • Scheffel O.
      • Squillante S.
      • Weiner R.A.
      Mini/one anastomosis gastric bypass versus Roux-en-Y gastric bypass as a second step procedure after sleeve gastrectomy-a retrospective cohort study.
      ,
      • Dijkhorst P.J.
      • Boerboom A.B.
      • Janssen I.M.C.
      • et al.
      Failed sleeve gastrectomy: single anastomosis duodenoileal bypass or Roux-en-Y gastric bypass? A multicenter cohort study.
      ,
      • Elshaer M.
      • Hamaoui K.
      • Rezai P.
      • Ahmed K.
      • Mothojakan N.
      • Al-Taan O.
      Secondary bariatric procedures in a high-volume centre: prevalence, indications and outcomes.
      ,
      • Felsenreich D.M.
      • Langer F.B.
      • Bichler C.
      • et al.
      Roux-en-Y gastric bypass as a treatment for Barrett's esophagus after sleeve gastrectomy.
      ,
      • Homan J.
      • Betzel B.
      • Aarts E.O.
      • van Laarhoven K.J.
      • Janssen I.M.
      • Berends F.J.
      Secondary surgery after sleeve gastrectomy: Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch.
      ,
      • Iannelli A.
      • Debs T.
      • Martini F.
      • Benichou B.
      • Ben Amor I.
      • Gugenheim J.
      Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: indications and preliminary results.
      ,
      • Langer F.B.
      • Bohdjalian A.
      • Shakeri-Leidenmuhler S.
      • Schoppmann S.F.
      • Zacherl J.
      • Prager G.
      Conversion from sleeve gastrectomy to Roux-en-Y gastric bypass—indications and outcome.
      ,
      • Lim C.H.
      • Lee P.C.
      • Lim E.
      • et al.
      Resolution of erosive esophagitis after conversion from vertical sleeve gastrectomy to Roux-en-Y gastric bypass.
      ,
      • Malinka T.
      • Zerkowski J.
      • Katharina I.
      • Borbely Y.M.
      • Nett P.
      • Kroll D.
      Three-year outcomes of revisional laparoscopic gastric bypass after failed laparoscopic sleeve gastrectomy: a case-matched analysis.
      ,
      • Marti-Fernandez R.
      • Cassinello-Fernandez N.
      • Cuenca-Ramirez M.D.
      • et al.
      Roux-en-Y gastric bypass as an effective bariatric revisional surgery after restrictive procedures.
      ,
      • Nevo N.
      • Abu-Abeid S.
      • Lahat G.
      • Klausner J.
      • Eldar S.M.
      Converting a sleeve gastrectomy to a gastric bypass for weight loss failure: is it worth it?.
      ,
      • Parmar C.D.
      • Mahawar K.K.
      • Boyle M.
      • Schroeder N.
      • Balupuri S.
      • Small P.K.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass is effective for gastro-oesophageal reflux disease but not for further weight loss.
      ,
      • Poghosyan T.
      • Lazzati A.
      • Moszkowicz D.
      • et al.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: an audit of 34 patients.
      ,
      • Qiu J.
      • Lundberg P.W.
      • Javier Birriel T.
      • Claros L.
      • Stoltzfus J.
      • El Chaar M.
      Revisional bariatric surgery for weight regain and refractory complications in a single MBSAQIP accredited center: what are we dealing with?.
      ,
      • Quezada N.
      • Hernandez J.
      • Perez G.
      • Gabrielli M.
      • Raddatz A.
      • Crovari F.
      Laparoscopic sleeve gastrectomy conversion to Roux-en-Y gastric bypass: experience in 50 patients after 1 to 3 years of follow-up.
      ,
      • Shimon O.
      • Keidar A.
      • Orgad R.
      • Yemini R.
      • Carmeli I.
      Long-term effectiveness of laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with a duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure.
      ,
      • van Wezenbeek M.R.
      • van Oudheusden T.R.
      • de Zoete J.P.
      • Smulders J.F.
      • Nienhuijs S.W.
      Conversion to gastric bypass after either failed gastric band or failed sleeve gastrectomy.
      ,
      • Yilmaz H.
      • Ece I.
      • Sahin M.
      Revisional surgery after failed laparoscopic sleeve gastrectomy: retrospective analysis of causes, results, and technical considerations.
      ,
      • Yorke E.
      • Sheppard C.
      • Switzer N.J.
      • et al.
      Revision of sleeve gastrectomy to Roux-en-Y gastric bypass: a Canadian experience.
      ,
      • Antonopulos C.
      • Rebibo L.
      • Calabrese D.
      • et al.
      Comparison of repeat sleeve gastrectomy and Roux-en-Y gastric bypass in case of weight loss failure after sleeve gastrectomy.
      ,
      • Vanetta C.
      • Dreifuss N.H.
      • Schlottmann F.
      • Baz C.
      • Masrur M.A.
      Bariatric surgery conversions in MBSAQIP centers: current indications and outcomes.
      ,
      • Huynh D.
      • Mazer L.
      • Tung R.
      • Cunneen S.
      • Shouhed D.
      • Burch M.
      Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision.
      ,
      • Frieder J.S.
      • Aleman R.
      • Gomez C.O.
      • et al.
      Outcomes of reoperative surgery in severely obese patients after sleeve gastrectomy: a single-institution experience.
      ,
      • Kraljevic M.
      • Susstrunk J.
      • Kostler T.
      • Lazaridis I.I.
      • Zingg U.
      • Delko T.
      Short or long biliopancreatic limb bypass as a secondary procedure after failed laparoscopic sleeve gastrectomy.
      ,
      • Cheema F.
      • Choi M.
      • Moran-Atkin E.
      • Camacho D.
      • Choi J.
      Outcomes in revisional bariatric surgery: a high-volume single institution experience.
      ,
      • Andalib A.
      • Alamri H.
      • Almuhanna Y.
      • Bouchard P.
      • Demyttenaere S.
      • Court O.
      Short-term outcomes of revisional surgery after sleeve gastrectomy: a comparative analysis of re-sleeve, Roux en-Y gastric bypass, duodenal switch (Roux en-Y and single-anastomosis).
      ,
      • Wilczynski M.
      • Spychalski P.
      • Proczko-Stepaniak M.
      • et al.
      Comparison of the long-term outcomes of RYGB and OAGB as conversion procedures after failed LSG - a case-control study.
      ,
      • Lee M.H.
      • Almalki O.M.
      • Lee W.J.
      • Soong T.C.
      • Chen S.C.
      Outcome of laparoscopic revision of sleeve gastrectomy to Roux-en-Y gastric bypass: different strategies for obese and non-obese Asian patients.
      ,
      • Roach E.
      • Laplante S.
      • Stogryn S.
      • Maeda A.
      • Jackson T.
      • Okrainec A.
      Weight loss outcomes for patients undergoing conversion to Roux-en-Y-gastric bypass after sleeve gastrectomy.
      ,
      • D'Urso A.
      • Vix M.
      • Perretta S.
      • Ignat M.
      • Scheer L.
      • Mutter D.
      Indications and long-term outcomes of conversion of sleeve gastrectomy to Roux-en-Y gastric bypass.
      ,
      • Curell A.
      • Beisani M.
      • Garcia Ruiz de Gordejuela A.
      • et al.
      Outcomes of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass due to GERD-a retrospective analysis of 35 patients.
      ,
      • Dijkhorst P.J.
      • Al Nawas M.
      • Heusschen L.
      • et al.
      Single anastomosis duodenoileal bypass or Roux-en-Y gastric bypass after failed sleeve gastrectomy: medium-term outcomes.
      (Fig. 1)
      Figure thumbnail gr1
      Fig. 1Flow diagram displaying process for the selection of studies. Adapted from the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.

      Study characteristics

      Postoperative weight loss of 1515 STOBY were published during the searched period. For the analysis of complication rates this was complemented with data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database consisting of further 6106 STOBY [
      • Vanetta C.
      • Dreifuss N.H.
      • Schlottmann F.
      • Baz C.
      • Masrur M.A.
      Bariatric surgery conversions in MBSAQIP centers: current indications and outcomes.
      ]. All 44 studies were retrospective cohort studies, including 6 studies that were conducted in a multicenter setting while the rest were single-center studies. The average quality of studies according to the Newcastle-Ottawa scale was good (6.9). Eighty-six percent of these procedures were performed on female individuals, with median age ranging from 35 to 52 years. Mean follow-up time following conversion to RYGB ranged from 8 months to 47 months, with 97% of the procedures completed laparoscopically. The exact characteristics of studies are presented on Table 1. Thirty-one studies reported on the length of time between SG and RYGB which was 40 months (95% confidence interval [CI], 35%–44%; I2 = 100%) (Table 1).
      Table 1Summary of published series of sleeve gastrectomy conversion to Roux-en-Y gastric bypass
      StudySTOBY patients, nIndication for conversion, nAge, mean (SD)Female, % (n)GERD, % (n)Diabetes, % (n)BMI before SG, mean (SD)BMI before STOBY, mean (SD)Time between SG and RYGBMean follow-up time
      Data are reported in months unless otherwise indicated.
      GERDIWLOther (leak, strictest, etc.)
      Abdemur et al. [
      • Abdemur A.
      • Han S.M.
      • Lo Menzo E.
      • Szomstein S.
      • Rosenthal R.
      Reasons and outcomes of conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass for nonresponders.
      ]
      30971450.3 (13.8)73.6% (23)33% (10)33.3 (4.0)43.6 ± 27.5 mo18.3 ± 15.8
      Aguilar-Espinosa et al. [
      • Aguilar-Espinosa F.
      • Montoya-Ramirez J.
      • Gutierrez Salinas J.
      • Blas-Azotla R.
      • Aguilar-Soto O.A.
      • Becerra-Gutierrez L.P.
      Conversion to Roux-en-Y gastric bypass surgery through a robotic-assisted hybrid technique after failed sleeve gastrectomy: short-term results.
      ]
      18313247.38 (7.32)94% (17)50.21 (7.3)51.76 ± 16.8 mo36
      Aleassa et al. [
      • Aleassa E.M.
      • Hassan M.
      • Hayes K.
      • Brethauer S.A.
      • Schauer P.R.
      • Aminian A.
      Effect of revisional bariatric surgery on type 2 diabetes mellitus.
      ]
      1313 (persistent diabetes)49 (6.6)76.9% (10)61.5% (8)45.3 (3.6)34 ± 12.6
      Al-Sabah et al. [
      • Al-Sabah S.
      • Alsharqawi N.
      • Almulla A.
      • et al.
      Approach to poor weight loss after laparoscopic sleeve gastrectomy: re-sleeve vs. gastric bypass.
      ]
      1212123483.3% (10)5248.38.1 ± 6.1
      Al-Sabah et al. [
      • Al-Sabah S.
      • Al Haddad E.
      • Akrof S.
      • Alenezi K.
      • Al-Subaie S.
      Midterm results of revisional bariatric surgery postsleeve gastrectomy: resleeve versus bypass.
      ]
      46351137 (10.7)82.5% (38)19.1% (9)50.6 (10.4)42.67 (6.85)4.1 ± 1.9 yr
      Amiki et al. [
      • Amiki M.
      • Seki Y.
      • Kasama K.
      • et al.
      Revisional Bariatric surgery for insufficient weight loss and gastroesophageal reflux disease: our 12-year experience.
      ]
      2444.6 (10.0)54.2% (13)53.149
      Andalib et al. [
      • Andalib A.
      • Alamri H.
      • Almuhanna Y.
      • Bouchard P.
      • Demyttenaere S.
      • Court O.
      Short-term outcomes of revisional surgery after sleeve gastrectomy: a comparative analysis of re-sleeve, Roux en-Y gastric bypass, duodenal switch (Roux en-Y and single-anastomosis).
      ]
      41311051 (9.2)85.4% (35)41.5% (17)14.6% (6)49.5 (8.7)40.1 (6.97)34 ± 15.5 mo14 ± 13.6
      Antonopulos et al. [
      • Antonopulos C.
      • Rebibo L.
      • Calabrese D.
      • et al.
      Comparison of repeat sleeve gastrectomy and Roux-en-Y gastric bypass in case of weight loss failure after sleeve gastrectomy.
      ]
      838347 (8.2)83.1% (69)30.1% (25)15.7% (13)47.8 (8.4)41.7 (6.3)43.2 ± 23.8 mo12
      Barajas-Gamboa et al. [
      • Barajas-Gamboa J.S.
      • Landreneau J.
      • Abril C.
      • Raza J.
      • Corcelles R.
      • Kroh M.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for complications: outcomes from a tertiary referral center in the Middle East.
      ]
      47212639 (9.8)76.5% (36)61.7% (29)13% (6)37 (8.666.8 ± 42.6 mo16 ± 4.96
      Boru et al. [
      • Boru C.E.
      • Greco F.
      • Giustacchini P.
      • Raffaelli M.
      • Silecchia G.
      Short-term outcomes of sleeve gastrectomy conversion to R-Y gastric bypass: multi-center retrospective study.
      ]
      3015123 (GERD + IWL)41 (10.1)76.7% (23)60% (18)36 (9)33 ± 27.8 mo24 ± 8.9
      Carandina et al. [
      • Carandina S.
      • Soprani A.
      • Montana L.
      • et al.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study.
      ]
      808047.4 (11.3)93.8% (75)100% (80)43.5 (8.7)34.9 (6.7)50.2 ± 24.1 mo14.9 ± 12.3
      Carmeli et al. [
      • Carmeli I.
      • Golomb I.
      • Sadot E.
      • Kashtan H.
      • Keidar A.
      Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm.
      ]
      101045.8 (16.3)70% (7)40% (4)44.5 (5.139.8 (5.7)36.2 ± 17.4 mo15.6 ± 9
      Casillas et al. [
      • Casillas R.A.
      • Um S.S.
      • Zelada Getty J.L.
      • Sachs S.
      • Kim B.B.
      Revision of primary sleeve gastrectomy to Roux-en-Y gastric bypass: indications and outcomes from a high-volume center.
      ]
      48141123 (16 IWL+GERD)44 (12.1)96% (46)66.7% (32)4.2% (2)45.936.8 (7.4)26 ± 17 mo24 ± 10.8
      Cheema et al. [
      • Cheema F.
      • Choi M.
      • Moran-Atkin E.
      • Camacho D.
      • Choi J.
      Outcomes in revisional bariatric surgery: a high-volume single institution experience.
      ]
      4741.7 (9.9)91.5% (43)55.3% (26)19.1% (9)47.8 (9.6)39.8 (6.7)50.4 (25.2) mo24
      Chiappetta et al. [
      • Chiappetta S.
      • Stier C.
      • Scheffel O.
      • Squillante S.
      • Weiner R.A.
      Mini/one anastomosis gastric bypass versus Roux-en-Y gastric bypass as a second step procedure after sleeve gastrectomy-a retrospective cohort study.
      ]
      2146.14 (10.8)90.5% (19)23.8% (5)49.8 (9.3)36.6 (6.9)33.3 ± 22.8 mo33.3 ± 22.8
      Curell et al. [
      • Curell A.
      • Beisani M.
      • Garcia Ruiz de Gordejuela A.
      • et al.
      Outcomes of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass due to GERD-a retrospective analysis of 35 patients.
      ]
      353548.6 (10.9)35 (100%)2 (6.5%)44.2 (4.3)31.4 (5.6)33 (15) mo36 (23.3)
      Dijkhorst et al. [
      • Dijkhorst P.J.
      • Boerboom A.B.
      • Janssen I.M.C.
      • et al.
      Failed sleeve gastrectomy: single anastomosis duodenoileal bypass or Roux-en-Y gastric bypass? A multicenter cohort study.
      ]
      7429396 (GERD+IWL)45.1 (10.9)79.7% (59)32.4% (24)39.3 (7.9)2.8 ± 1.4 yr24
      Dijkhorst et al. [
      • Dijkhorst P.J.
      • Al Nawas M.
      • Heusschen L.
      • et al.
      Single anastomosis duodenoileal bypass or Roux-en-Y gastric bypass after failed sleeve gastrectomy: medium-term outcomes.
      ]
      78393946 (11.1)61 (78.2%)22 (27.7%)53.1 (9.7)39.1 (8)2 (1.35) yr7.8 years (2.2 years)
      D'Urso et al. [
      • D'Urso A.
      • Vix M.
      • Perretta S.
      • Ignat M.
      • Scheer L.
      • Mutter D.
      Indications and long-term outcomes of conversion of sleeve gastrectomy to Roux-en-Y gastric bypass.
      ]
      60303045 (9.7)50 (83.3%)30 (50%)6 (10%)45.9 (7.4)38.1 (7.1)5.6 (2.1) yr30.4 (16.8)
      Elshaer et al. [
      • Elshaer M.
      • Hamaoui K.
      • Rezai P.
      • Ahmed K.
      • Mothojakan N.
      • Al-Taan O.
      Secondary bariatric procedures in a high-volume centre: prevalence, indications and outcomes.
      ]
      74785.7% (6)
      Felsenreich et al. [
      • Felsenreich D.M.
      • Langer F.B.
      • Bichler C.
      • et al.
      Roux-en-Y gastric bypass as a treatment for Barrett's esophagus after sleeve gastrectomy.
      ]
      1010 (Barrett’s)45.8 (14.8)100% (10)100% (10)45.1 (9.2)37.3 (9.2)42.7 ± 14.9 mo33.4 ± 21.1
      Frieder et al. [
      • Frieder J.S.
      • Aleman R.
      • Gomez C.O.
      • et al.
      Outcomes of reoperative surgery in severely obese patients after sleeve gastrectomy: a single-institution experience.
      ]
      7716253649.1 (13.3)68.8% (53)34.5 (7.4)34.4 (31.2) mo
      Gautier et al. [
      • Gautier T.
      • Sarcher T.
      • Contival N.
      • Le Roux Y.
      • Alves A.
      Indications and mid-term results of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass.
      ]
      1869340.9 (8.5)33.3% (6)22.2% (4)55 (9.3)39.45 (5.5)15.5 ± 1.9
      Homan et al. [
      • Homan J.
      • Betzel B.
      • Aarts E.O.
      • van Laarhoven K.J.
      • Janssen I.M.
      • Berends F.J.
      Secondary surgery after sleeve gastrectomy: Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch.
      ]
      18111651 (8.8)44% (8)5.5% (1)50.25 (6.31)36.75 (7.41)32 ± 13.2 mo
      Huynh et al. [
      • Huynh D.
      • Mazer L.
      • Tung R.
      • Cunneen S.
      • Shouhed D.
      • Burch M.
      Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision.
      ]
      414145.2 (9.24)88% (36)12 (29%)41.6 (6.54)33.8 (5.61)38.5 (23.9) mo15.1
      Iannelli et al. [
      • Iannelli A.
      • Debs T.
      • Martini F.
      • Benichou B.
      • Ben Amor I.
      • Gugenheim J.
      Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: indications and preliminary results.
      ]
      40112940.2 (9.5)77.5% (31)22.5% (9)47.5 (6.6)39.3 (6.1)32.6 ± 24.3 mo18.6 ± 11.8
      Kraljevic et al. [
      • Kraljevic M.
      • Susstrunk J.
      • Kostler T.
      • Lazaridis I.I.
      • Zingg U.
      • Delko T.
      Short or long biliopancreatic limb bypass as a secondary procedure after failed laparoscopic sleeve gastrectomy.
      ]
      1251645.2 (10.1)61.50%0 (0%)40.2 (1.44)29.6 (1.68)18.3
      Landreneau et al. [
      • Landreneau J.P.
      • Strong A.T.
      • Rodriguez J.H.
      • et al.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass.
      ]
      8917116147.2 (11.4)78.7% (70)56.2% (50)18 % (16)41.9 (4.1)20.5 ± 3.66 mo19.67 ± 18.08
      Langer et al. [
      • Langer F.B.
      • Bohdjalian A.
      • Shakeri-Leidenmuhler S.
      • Schoppmann S.F.
      • Zacherl J.
      • Prager G.
      Conversion from sleeve gastrectomy to Roux-en-Y gastric bypass—indications and outcome.
      ]
      83535.75 (13.3)50% (4)37.5% (3)36.9 ± 17.4 mo14
      Lee et al. [
      • Lee M.H.
      • Almalki O.M.
      • Lee W.J.
      • Soong T.C.
      • Chen S.C.
      Outcome of laparoscopic revision of sleeve gastrectomy to Roux-en-Y gastric bypass: different strategies for obese and non-obese Asian patients.
      ]
      3633342.9 (9.2)35.3 (5.8)30.0 (4.2)55.3 (39.6) mo
      Lim et al. [
      • Lim C.H.
      • Lee P.C.
      • Lim E.
      • et al.
      Resolution of erosive esophagitis after conversion from vertical sleeve gastrectomy to Roux-en-Y gastric bypass.
      ]
      1414 (erosive oesophagitis)43.69 (9.54)64.3% (9)41.71 (3.78)36.5 ± 18.2 mo16
      Malinka et al. [
      • Malinka T.
      • Zerkowski J.
      • Katharina I.
      • Borbely Y.M.
      • Nett P.
      • Kroll D.
      Three-year outcomes of revisional laparoscopic gastric bypass after failed laparoscopic sleeve gastrectomy: a case-matched analysis.
      ]
      3242.3 (11.5)68.8% (22)65.6% (21)37.5% (12)49.4 (5.3)40.9 (5.6)595 ± 369.9 d
      Marti-Fernandez et al. [
      • Marti-Fernandez R.
      • Cassinello-Fernandez N.
      • Cuenca-Ramirez M.D.
      • et al.
      Roux-en-Y gastric bypass as an effective bariatric revisional surgery after restrictive procedures.
      ]
      181861.73 (8.54)45.67 (8.72)
      Parmar et al. [
      • Parmar C.D.
      • Mahawar K.K.
      • Boyle M.
      • Schroeder N.
      • Balupuri S.
      • Small P.K.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass is effective for gastro-oesophageal reflux disease but not for further weight loss.
      ]
      221011151 (11)72.7% (16)54.5% (12)27.2% (6)36.9 (8.9)16
      Poghosyan et al. [
      • Poghosyan T.
      • Lazzati A.
      • Moszkowicz D.
      • et al.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: an audit of 34 patients.
      ]
      3433144.4 (12)76.5% (26)26.5% (9)33% (11)53.3 (11.5)44.7 (9.8)32 mo36 ± 23
      Qiu et al. [
      • Qiu J.
      • Lundberg P.W.
      • Javier Birriel T.
      • Claros L.
      • Stoltzfus J.
      • El Chaar M.
      Revisional bariatric surgery for weight regain and refractory complications in a single MBSAQIP accredited center: what are we dealing with?.
      ]
      1342.312
      Quezada et al. [
      • Quezada N.
      • Hernandez J.
      • Perez G.
      • Gabrielli M.
      • Raddatz A.
      • Crovari F.
      Laparoscopic sleeve gastrectomy conversion to Roux-en-Y gastric bypass: experience in 50 patients after 1 to 3 years of follow-up.
      ]
      501628639 (8.4)84% (42)32% (16)36.7 (1.3)35.65 (0.89)47.25 ± 9.58 mo36
      Roach et al. [
      • Roach E.
      • Laplante S.
      • Stogryn S.
      • Maeda A.
      • Jackson T.
      • Okrainec A.
      Weight loss outcomes for patients undergoing conversion to Roux-en-Y-gastric bypass after sleeve gastrectomy.
      ]
      333342 (8)88% (29)16 (48%)7 (21%)62 (12)
      Shimon et al. [
      • Shimon O.
      • Keidar A.
      • Orgad R.
      • Yemini R.
      • Carmeli I.
      Long-term effectiveness of laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with a duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure.
      ]
      181843.94 (16.57)55.6% (10)38.9% (7)46.13 (5.2)40.49 (6.2)47 ± 20 mo47.33 ± 15.22
      Vanetta et al. [
      • Vanetta C.
      • Dreifuss N.H.
      • Schlottmann F.
      • Baz C.
      • Masrur M.A.
      Bariatric surgery conversions in MBSAQIP centers: current indications and outcomes.
      ]
      61066780532045.7 (10.4)90.1% (5499)4359 (71.4%)677 (11.1%)39.5 (7.8)
      Van Wezenbeek et al. [
      • van Wezenbeek M.R.
      • van Oudheusden T.R.
      • de Zoete J.P.
      • Smulders J.F.
      • Nienhuijs S.W.
      Conversion to gastric bypass after either failed gastric band or failed sleeve gastrectomy.
      ]
      6811154244.7 (11.1)25% (17)20.6% (14)49.3 (10.7)36.1 (7.7)75.9 ± 31.3 mo
      Wilczynski et al. [
      • Wilczynski M.
      • Spychalski P.
      • Proczko-Stepaniak M.
      • et al.
      Comparison of the long-term outcomes of RYGB and OAGB as conversion procedures after failed LSG - a case-control study.
      ]
      3382541.24 (8.9)81.8% (27)10 (30%)18% (6)38.7 (6.84)60
      Yilmaz et al. [
      • Yilmaz H.
      • Ece I.
      • Sahin M.
      Revisional surgery after failed laparoscopic sleeve gastrectomy: retrospective analysis of causes, results, and technical considerations.
      ]
      96337.3 (9.1)66.7% (6)22.2% (2)15.1 ± 3.3 mo36.1 ± 8.1
      Yorke et al. [
      • Yorke E.
      • Sheppard C.
      • Switzer N.J.
      • et al.
      Revision of sleeve gastrectomy to Roux-en-Y gastric bypass: a Canadian experience.
      ]
      18412241.7 (10.6)77.8% (14)
      STOBY = sleeve gastrectomy to Roux-en-Y gastric bypass; SD = standard deviation; GERD = gastroesophageal reflux disease; BMI = body mass index; SG = sleeve gastrectomy; RYGB = Roux-en-Y gastric bypass; IWL = insufficient weight loss or weight regain.
      Data are reported in months unless otherwise indicated.

      Weight loss after STOBY with the indication of IWL

      Fourteen studies published %EWL and 10 studies published %TWL 12 months after STOBY with the indication of IWL. Overall, we included %EWL of 295 and %TWL of 219 one year after STOBY in individuals with IWL. Random effect analysis demonstrated 53.9% EWL (95% CI, 48%–59%) and 22.7% TWL (95% CI, 17%–28%) 12 months after conversion (Figs. 2 and 3).
      Figure thumbnail gr2
      Fig. 2Forest plot of %EWL 12 months after STOBY with the indication of insufficient weight loss/weight recurrence. %EWL = percent excess weight loss; STOBY = sleeve gastrectomy to Roux-en-Y gastric bypass.
      Figure thumbnail gr3
      Fig. 3Forest plot of %TWL 12 months after STOBY with the indication of insufficient weight loss/weight recurrence. %TWL = total weight loss; STOBY = sleeve gastrectomy to Roux-en-Y gastric bypass.
      There are fewer reports on medium-term weight loss data. We were able to obtain %EWL from 7 studies evaluating 154 patients and %TWL from 9 studies investigating 206 patients after STOBY. Pooled random effect analysis demonstrated 45.8% (95% CI, 38%–53%) EWL and 20.6% (95% CI, 15%–26%) TWL and heterogeneity was low (I2 = 0%) (Fig. 4).
      Figure thumbnail gr4
      Fig. 4Forest plot of medium-term %TWL after STOBY with the indication of insufficient weight loss/weight recurrence. %TWL = total weight loss; STOBY = sleeve gastrectomy to Roux-en-Y gastric bypass.

      BMI before and after SG and following conversion to RYGB in patients with IWL

      There were 16 studies publishing BMI drop before conversion, in total, data from 478 patients were included in this meta-analysis. Pooled random effect analyses demonstrated a 7.4-kg/m2 (95% CI, 8.5–6.3 kg/m2) drop in BMI prior to STOBY. BMI 12 months after conversion dropped by a further 7 kg/m2 (95% CI, 8.8–5.2 kg/m2). An overall 13.5-kg/m2 (95% CI, 15–12 kg/m2) decrease in BMI was observed throughout the whole patient journey from before bariatric surgery (SG) to 12-month follow-up after conversion to RYGB. Heterogeneity was high (I2 = 80.9%) (Fig. 5).
      Figure thumbnail gr5
      Fig. 5Change of BMI from before SG to 12-month follow-up after STOBY. BMI = body mass index; STOBY = sleeve gastrectomy to Roux-en-Y gastric bypass.

      Diabetes remission after STOBY

      There were 17 studies reporting on diabetes remission. Six studies defined diabetes based on National Guidelines such as the French or US guidelines or previous consensus statements [
      • Landreneau J.P.
      • Strong A.T.
      • Rodriguez J.H.
      • et al.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass.
      ,
      • Poghosyan T.
      • Lazzati A.
      • Moszkowicz D.
      • et al.
      Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: an audit of 34 patients.
      ]. There were 3 studies where exact values were used to define diabetes and the search identified 8 studies that did not provide definition of diabetes. Most commonly, in 9 studies, definitions considered complete resolution if patients were able to stop their medication and maintain blood sugar/HbA1C under the level defined by their methods. There were 3 studies where guidelines were referenced to described diabetes remission and 5 studies did not define this at all. All the 11 studies reporting on the type of diabetes reported type 2 in all cases. There were 6 studies where the type of diabetes was not defined. There was only 1 study reporting on insulin use in diabetic patients [
      • Aleassa E.M.
      • Hassan M.
      • Hayes K.
      • Brethauer S.A.
      • Schauer P.R.
      • Aminian A.
      Effect of revisional bariatric surgery on type 2 diabetes mellitus.
      ]. On average 34% of patients remained diabetic following LSG before conversion to RYGB. We were able to extract data from 17 studies on the rate of postconversion T2D remission, including 139 patients who were diabetic before conversion in this meta-analysis. Pooled random effect analysis demonstrated 53% (95% CI, 33%–72%) diabetes remission after conversion. The heterogeneity in this data set was high (I2 = 90.5%) (Fig. 6).
      Figure thumbnail gr6
      Fig. 6Diabetes remission after STOBY for all indications. STOBY = sleeve gastrectomy to Roux-en-Y gastric bypass.

      Overall weight loss

      Extraction of data from all patients irrespective of indication was carried out from 23 studies publishing %EWL and 21 studies publishing %TWL 1 year following STOBY. Pooled random effect analysis of 712 patients demonstrated 54.6% EWL (95% CI, 46%–63%). Random effect analysis of 740 patients demonstrated 19.9% TWL (95% CI, 14%–25%) 12 months after STOBY. The heterogeneity in both analyses were high (respectively, I2 = 83.4% and I2 = 70.9%). In terms of change in BMI, pooled random effect analysis from 25 studies and 732 patients demonstrated a 6.2-kg/m2 (95% CI, 7.2–5.2 kg/m2) drop 1 year after conversion. The heterogeneity was moderate (I2 = 60.4%) in this analysis.
      Medium-term %EWL results were published in 12 articles including 331 patients. Pooled random effect analysis demonstrated 58% EWL (95% CI, 46%–69%) 3 to 5 years after conversion to RYGB. The heterogeneity was high (I2 = 79.9%) (Fig. 7).
      Figure thumbnail gr7
      Fig. 7Forest plot of %EWL 1 year after STOBY for all indications. %EWL = percent excess weight loss; STOBY = sleeve gastrectomy to Roux-en-Y gastric bypass.

      Complications

      There were a high number of studies reporting various short- and long-term complications. Analysis of overall perioperative complications was pooled from 34 studies including 7493 patients. Clavien-Dindo III or higher complications were reported in 8.2% (95% CI, 7.6%–8.7%; I2 = 89%) of all conversions. Gastro-jejunal anastomotic leak rate was report in 19 studies reporting outcomes for 7015 patients. Anastomotic leak occurred in .4% (95% CI, .18%–.623%; I2 = 100%) of these cases. Seventeen studies conducted on 901 patients reported early anastomotic strictures, which were described in .4% (95% CI, 0%–.8%; I2 = 51.1%) of the operations. Hospital stay was reported in 24 studies including 928 patients. Pooled random effect analysis demonstrated 4 days (95% CI, 3.4%–4.6%; I2 = 99.8%) days were spent in hospital following STOBY conversion.

      Discussion

      This systematic review and meta-analysis of studies reports indication-specific weight loss outcomes, diabetes remission, and complications following STOBY. There are no RCTs investigating outcomes of STOBY. Retrospective observational studies report contrary outcomes with some suggesting good results in weight loss and remission of co-morbidities [
      • Al-Sabah S.
      • Alsharqawi N.
      • Almulla A.
      • et al.
      Approach to poor weight loss after laparoscopic sleeve gastrectomy: re-sleeve vs. gastric bypass.
      ,
      • Yan J.
      • Cohen R.
      • Aminian A.
      Reoperative bariatric surgery for treatment of type 2 diabetes mellitus.
      ] while others describing limited improvement [
      • Aleassa E.M.
      • Hassan M.
      • Hayes K.
      • Brethauer S.A.
      • Schauer P.R.
      • Aminian A.
      Effect of revisional bariatric surgery on type 2 diabetes mellitus.
      ,
      • Nevo N.
      • Abu-Abeid S.
      • Lahat G.
      • Klausner J.
      • Eldar S.M.
      Converting a sleeve gastrectomy to a gastric bypass for weight loss failure: is it worth it?.
      ]. Our pooled analysis demonstrated appropriate short-term %TWL and %EWL in patients with IWL with TWL being better in this patient group than STOBY performed for all indications. Patients' BMI remained stable over the medium term, half of diabetic patients went into remission, and overall morbidity and mortality was low.
      As described previously [
      • Matar R.
      • Monzer N.
      • Jaruvongvanich V.
      • et al.
      Indications and outcomes of conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a systematic review and a meta-analysis.
      ] the most common indication of revision of failed SG is IWL followed by novel GERD and failed resolution of T2D or other co-morbidities. The 1-year %TWL is almost 3% higher in patients being converted with the indication of IWL while %EWL is similar to patients undergoing conversion with all indications. There are a limited number of studies describing medium-term weight loss outcomes following STOBY; however, those studies demonstrate minor changes in both EWL and TWL after 1 year suggesting that weight following STOBY remains stable in the medium term.
      Pooled analysis suggested a nearly equal BMI drop following primary SG (7.4 kg/m2) and after revision to RYGB (7 kg/m2) in cases when the indication was IWL. Furthermore, the overall BMI drop in these patients was higher than in patients having conversion for other indications which again highlights the importance of analyzing these patient groups separately.
      Other revisional options for IWL following SG include single-anastomosis duodenal-ileal bypass (SADI-S), duodenal switch (DS), and single-anastomosis gastric bypass (OAGB). There are limited and heterogenous data available on the effect on weight loss and safety of these procedure following conversion of SG [
      • Lee Y.
      • Ellenbogen Y.
      • Doumouras A.G.
      • Gmora S.
      • Anvari M.
      • Hong D.
      Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: a systematic review and meta-analysis.
      ]. The authors of this meta-analysis concluded, however, that there are not enough data on conversion of SG to SADI-S or DS to reliably judge weight loss following these procedures. Some observational studies have reported weight loss outcomes similar to what we found in our pooled analysis following conversion to RYGB (22.7% TWL at 1 year) [
      • Andalib A.
      • Alamri H.
      • Almuhanna Y.
      • Bouchard P.
      • Demyttenaere S.
      • Court O.
      Short-term outcomes of revisional surgery after sleeve gastrectomy: a comparative analysis of re-sleeve, Roux en-Y gastric bypass, duodenal switch (Roux en-Y and single-anastomosis).
      ]. Previous studies demonstrated similar %TWL 1 year following conversion of SG to OAGB with the indication of IWL that we found after STOBY. However, weight recurrence and GERD appears to be a major problem following OAGB with a reported 3-year TWL of 15% and de novo GERD of 7.4% [
      • Kermansaravi M.
      • Shahmiri S.S.
      • DavarpanahJazi A.H.
      • et al.
      One anastomosis/mini-gastric bypass (OAGB/MGB) as revisional surgery following primary restrictive bariatric procedures: a systematic review and meta-analysis.
      ,
      • Bhandari M.
      • Humes T.
      • Kosta S.
      • et al.
      Revision operation to one-anastomosis gastric bypass for failed sleeve gastrectomy.
      ].
      Diabetes resolution is not commonly described as an indication for conversion of SG to RYGB. However, RYGB is associated with a higher rate of remission of T2D compared with SG [
      • Salminen P.
      • Helmio M.
      • Ovaska J.
      • et al.
      Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
      ]. Furthermore, reoccurrence of diabetes following SG is commonly seen. We analyzed data from 17 studies investigating 139 patients who had diabetes before conversion. Our pooled analysis demonstrated a 53% resolution of diabetes following conversion matching the frequency of remission that has been described following revisional bariatric surgery [
      • Koh Z.J.
      • Chew C.A.Z.
      • Zhang J.J.Y.
      • et al.
      Metabolic outcomes after revisional bariatric surgery: a systematic review and meta-analysis.
      ] and comparable to results seen after primary RYGB [
      • Borgeraas H.
      • Hofso D.
      • Hertel J.K.
      • Hjelmesaeth J.
      Comparison of the effect of Roux-en-Y gastric bypass and sleeve gastrectomy on remission of type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials.
      ].
      The potential mechanism that may make STOBY work well, particularly for diabetes remission, includes the combination of a mainly restrictive procedure (SG) with a metabolic procedure (RYGB). Bariatric surgery, besides weight loss, improves diabetes by weight-independent factors such as changes to gut hormones (GLP-1, PYY, etc.) and gut microbiota [
      • Affinati A.H.
      • Esfandiari N.H.
      • Oral E.A.
      • Kraftson A.T.
      Bariatric surgery in the treatment of type 2 diabetes.
      ]. Performing SG first may precondition the metabolism for the BRAVE effects of RYGB (bile flow changes, restriction of stomach size, anatomic gastrointestinal rearrangement, vagal manipulation, enteric hormonal modulation) by inducing weight loss. Reducing the stomach size in 2 steps and changing vagal signaling twice could also be associated with an improved cascade effect on gut microbiome and local metabolism (intestinal gluconeogenesis and adipokine fluxes) [
      • Ashrafian H.
      • Athanasiou T.
      • Li J.V.
      • et al.
      Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass.
      ].
      There are several studies reporting complications following STOBY with the report on the MBSAQIP database being the largest reporting on 6106 STOBY [
      • Vanetta C.
      • Dreifuss N.H.
      • Schlottmann F.
      • Baz C.
      • Masrur M.A.
      Bariatric surgery conversions in MBSAQIP centers: current indications and outcomes.
      ]. This is the only data set reporting 7 deaths (.1%). As previously recommended, the Clavien-Dindo classification was used to categorize postoperative complications. We used one of the largest meta-analyses recording outcomes of 161,000 primary bariatric operations as a benchmark to compare STOBY with primary RYGB [
      • Chang S.H.
      • Stoll C.R.
      • Song J.
      • Varela J.E.
      • Eagon C.J.
      • Colditz G.A.
      The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012.
      ]. A significant diversion of normal postoperative course (Clavien-Dindo ≥III complications) was reported 3% more frequently in STOBY than after primary operations (8.2% vs 5%). However previous meta-analysis investigating revisional surgery to RYGB described a complication rate higher (11.7%) [
      • Tran D.D.
      • Nwokeabia I.D.
      • Purnell S.
      • et al.
      Revision of Roux-en-Y gastric bypass for weight regain: a systematic review of techniques and outcomes.
      ] than what we found after STOBY by incorporating the data from MBSAQIP database. Revisional bariatric surgery in general is associated with a higher leak rate compared with primary operations [
      • Smith M.D.
      • Adeniji A.
      • Wahed A.S.
      • et al.
      Technical factors associated with anastomotic leak after Roux-en-Y gastric bypass.
      ]. However, this new pooled data of GJ anastomotic leak after STOBY demonstrated a low leak rate comparable to primary procedures (.4%).
      In summary, mortality and overall complications are rare following STOBY and comparable to what has been previously described after primary RYGB. Comparing STOBY with other revisional procedures of SG suggests similar perioperative safety and short-term weight loss. However, medium-term weight loss is better following STOBY. Half of patients with diabetes who already had SG enter remission following conversion to RYGB.
      The strength of this study includes the large pool of articles included in the original search, contacting authors to maximize available data, and reporting results in homogenous patient groups by taking indications of STOBY into account. The limitations include the lack of RCTs and prospective data collection, small series of cases, large heterogeneity in some analysis, limited number of studies reporting medium-term results and no studies reporting long-term outcomes.

      Conclusion

      Based on this pooled analysis, failed diabetes resolution after SG can be successfully treated with RYGB in 53% of the cases. Patients with insufficient weight loss after SG can expect a further 7-kg/m2 drop in their BMI over the short and medium terms. STOBY might be a new method to treat IWL and failed diabetes resolution after SG with low mortality and morbidity.

      Acknowledgments

      The authors thank Philip Barlow for his invaluable help and support with the literature search.

      Disclosures

      The authors have no commercial associations that might be a conflict of interest in relation to this article.

      References

        • Buchwald H.
        • Avidor Y.
        • Braunwald E.
        • et al.
        Bariatric surgery: a systematic review and meta-analysis.
        JAMA. 2004; 292: 1724-1737
        • Chang S.H.
        • Stoll C.R.
        • Song J.
        • Varela J.E.
        • Eagon C.J.
        • Colditz G.A.
        The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012.
        JAMA Surg. 2014; 149: 275-287
        • Puzziferri N.
        • Roshek T.B.
        • Mayo 3rd, H.G.
        • Gallagher R.
        • Belle S.H.
        • Livingston E.H.
        Long-term follow-up after bariatric surgery: a systematic review.
        JAMA. 2014; 312: 934-942
        • Angrisani L.
        • Santonicola A.
        • Iovino P.
        • et al.
        IFSO Worldwide Survey 2016: primary, endoluminal, and revisional procedures.
        Obes Surg. 2018; 28: 3783-3794
        • Roth A.E.
        • Thornley C.J.
        • Blackstone R.P.
        Outcomes in bariatric and metabolic surgery: an updated 5-year review.
        Curr Obes Rep. 2020; 9: 380-389
        • Lauti M.
        • Kularatna M.
        • Hill A.G.
        • MacCormick A.D.
        Weight regain following sleeve gastrectomy: a systematic review.
        Obes Surg. 2016; 26: 1326-1334
        • Hofso D.
        • Fatima F.
        • Borgeraas H.
        • et al.
        Gastric bypass versus sleeve gastrectomy in patients with type 2 diabetes (Oseberg): a single-centre, triple-blind, randomised controlled trial.
        Lancet Diabetes Endocrinol. 2019; 7: 912-924
        • Schauer P.R.
        • Bhatt D.L.
        • Kashyap S.R.
        Bariatric surgery or intensive medical therapy for diabetes after 5 years.
        N Engl J Med. 2017; 376: 1997
        • Csendes A.
        • Orellana O.
        • Martinez G.
        • Burgos A.M.
        • Figueroa M.
        • Lanzarini E.
        Clinical, endoscopic, and histologic findings at the distal esophagus and stomach before and late (10.5 years) after laparoscopic sleeve gastrectomy: results of a prospective study with 93% follow-up.
        Obes Surg. 2019; 29: 3809-3817
        • Yeung K.T.D.
        • Penney N.
        • Ashrafian L.
        • Darzi A.
        • Ashrafian H.
        Does sleeve gastrectomy expose the distal esophagus to severe reflux?: a systematic review and meta-analysis.
        Ann Surg. 2020; 271: 257-265
        • Genco A.
        • Soricelli E.
        • Casella G.
        • et al.
        Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication.
        Surg Obes Relat Dis. 2017; 13: 568-574
        • Soricelli E.
        • Casella G.
        • Baglio G.
        • Maselli R.
        • Ernesti I.
        • Genco A.
        Lack of correlation between gastroesophageal reflux disease symptoms and esophageal lesions after sleeve gastrectomy.
        Surg Obes Relat Dis. 2018; 14: 751-756
        • Gautier T.
        • Sarcher T.
        • Contival N.
        • Le Roux Y.
        • Alves A.
        Indications and mid-term results of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass.
        Obes Surg. 2013; 23: 212-215
        • Khoursheed M.A.
        • Al-Bader I.A.
        • Al-Asfar F.S.
        • Mohammad A.I.
        • Shukkur M.
        • Dashti H.M.
        Revision of failed bariatric procedures to Roux-en-Y gastric bypass (RYGB).
        Obes Surg. 2011; 21: 1157-1160
        • Assalia A.
        • Gagner M.
        • Nedelcu M.
        • Ramos A.C.
        • Nocca D.
        Gastroesophageal reflux and laparoscopic sleeve gastrectomy: results of the first international consensus conference.
        Obes Surg. 2020; 30: 3695-3705
        • Matar R.
        • Monzer N.
        • Jaruvongvanich V.
        • et al.
        Indications and outcomes of conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a systematic review and a meta-analysis.
        Obes Surg. 2021; 31: 3936-3946
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Majid S.F.
        • Davis M.J.
        • Ajmal S.
        • et al.
        Current state of the definition and terminology related to weight recurrence after metabolic surgery: review by the POWER Task Force of the American Society for Metabolic and Bariatric Surgery.
        Surg Obes Relat Dis. 2022; 18: 957-963
        • Abdemur A.
        • Han S.M.
        • Lo Menzo E.
        • Szomstein S.
        • Rosenthal R.
        Reasons and outcomes of conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass for nonresponders.
        Surg Obes Relat Dis. 2016; 12: 113-118
        • Aguilar-Espinosa F.
        • Montoya-Ramirez J.
        • Gutierrez Salinas J.
        • Blas-Azotla R.
        • Aguilar-Soto O.A.
        • Becerra-Gutierrez L.P.
        Conversion to Roux-en-Y gastric bypass surgery through a robotic-assisted hybrid technique after failed sleeve gastrectomy: short-term results.
        Rev Gastroenterol Mex. 2020; 85: 160-172
        • Aleassa E.M.
        • Hassan M.
        • Hayes K.
        • Brethauer S.A.
        • Schauer P.R.
        • Aminian A.
        Effect of revisional bariatric surgery on type 2 diabetes mellitus.
        Surg Endosc. 2019; 33: 2642-2648
        • Landreneau J.P.
        • Strong A.T.
        • Rodriguez J.H.
        • et al.
        Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass.
        Obes Surg. 2018; 28: 3843-3850
        • Al-Sabah S.
        • Al Haddad E.
        • Akrof S.
        • Alenezi K.
        • Al-Subaie S.
        Midterm results of revisional bariatric surgery postsleeve gastrectomy: resleeve versus bypass.
        Surg Obes Relat Dis. 2020; 16: 1747-1756
        • Al-Sabah S.
        • Alsharqawi N.
        • Almulla A.
        • et al.
        Approach to poor weight loss after laparoscopic sleeve gastrectomy: re-sleeve vs. gastric bypass.
        Obes Surg. 2016; 26: 2302-2307
        • Amiki M.
        • Seki Y.
        • Kasama K.
        • et al.
        Revisional Bariatric surgery for insufficient weight loss and gastroesophageal reflux disease: our 12-year experience.
        Obes Surg. 2020; 30: 1671-1678
        • Barajas-Gamboa J.S.
        • Landreneau J.
        • Abril C.
        • Raza J.
        • Corcelles R.
        • Kroh M.
        Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for complications: outcomes from a tertiary referral center in the Middle East.
        Surg Obes Relat Dis. 2019; 15: 1690-1695
        • Boru C.E.
        • Greco F.
        • Giustacchini P.
        • Raffaelli M.
        • Silecchia G.
        Short-term outcomes of sleeve gastrectomy conversion to R-Y gastric bypass: multi-center retrospective study.
        Langenbecks Arch Surg. 2018; 403: 473-479
        • Carandina S.
        • Soprani A.
        • Montana L.
        • et al.
        Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study.
        Surg Obes Relat Dis. 2020; 16: 732-737
        • Carmeli I.
        • Golomb I.
        • Sadot E.
        • Kashtan H.
        • Keidar A.
        Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm.
        Surg Obes Relat Dis. 2015; 11: 79-85
        • Casillas R.A.
        • Um S.S.
        • Zelada Getty J.L.
        • Sachs S.
        • Kim B.B.
        Revision of primary sleeve gastrectomy to Roux-en-Y gastric bypass: indications and outcomes from a high-volume center.
        Surg Obes Relat Dis. 2016; 12: 1817-1825
        • Chiappetta S.
        • Stier C.
        • Scheffel O.
        • Squillante S.
        • Weiner R.A.
        Mini/one anastomosis gastric bypass versus Roux-en-Y gastric bypass as a second step procedure after sleeve gastrectomy-a retrospective cohort study.
        Obes Surg. 2019; 29: 819-827
        • Dijkhorst P.J.
        • Boerboom A.B.
        • Janssen I.M.C.
        • et al.
        Failed sleeve gastrectomy: single anastomosis duodenoileal bypass or Roux-en-Y gastric bypass? A multicenter cohort study.
        Obes Surg. 2018; 28: 3834-3842
        • Elshaer M.
        • Hamaoui K.
        • Rezai P.
        • Ahmed K.
        • Mothojakan N.
        • Al-Taan O.
        Secondary bariatric procedures in a high-volume centre: prevalence, indications and outcomes.
        Obes Surg. 2019; 29: 2255-2262
        • Felsenreich D.M.
        • Langer F.B.
        • Bichler C.
        • et al.
        Roux-en-Y gastric bypass as a treatment for Barrett's esophagus after sleeve gastrectomy.
        Obes Surg. 2020; 30: 1273-1279
        • Homan J.
        • Betzel B.
        • Aarts E.O.
        • van Laarhoven K.J.
        • Janssen I.M.
        • Berends F.J.
        Secondary surgery after sleeve gastrectomy: Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch.
        Surg Obes Relat Dis. 2015; 11: 771-777
        • Iannelli A.
        • Debs T.
        • Martini F.
        • Benichou B.
        • Ben Amor I.
        • Gugenheim J.
        Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: indications and preliminary results.
        Surg Obes Relat Dis. 2016; 12: 1533-1538
        • Langer F.B.
        • Bohdjalian A.
        • Shakeri-Leidenmuhler S.
        • Schoppmann S.F.
        • Zacherl J.
        • Prager G.
        Conversion from sleeve gastrectomy to Roux-en-Y gastric bypass—indications and outcome.
        Obes Surg. 2010; 20: 835-840
        • Lim C.H.
        • Lee P.C.
        • Lim E.
        • et al.
        Resolution of erosive esophagitis after conversion from vertical sleeve gastrectomy to Roux-en-Y gastric bypass.
        Obes Surg. 2020; 30: 4751-4759
        • Malinka T.
        • Zerkowski J.
        • Katharina I.
        • Borbely Y.M.
        • Nett P.
        • Kroll D.
        Three-year outcomes of revisional laparoscopic gastric bypass after failed laparoscopic sleeve gastrectomy: a case-matched analysis.
        Obes Surg. 2017; 27: 2324-2330
        • Marti-Fernandez R.
        • Cassinello-Fernandez N.
        • Cuenca-Ramirez M.D.
        • et al.
        Roux-en-Y gastric bypass as an effective bariatric revisional surgery after restrictive procedures.
        Obes Facts. 2020; 13: 367-374
        • Nevo N.
        • Abu-Abeid S.
        • Lahat G.
        • Klausner J.
        • Eldar S.M.
        Converting a sleeve gastrectomy to a gastric bypass for weight loss failure: is it worth it?.
        Obes Surg. 2018; 28: 364-368
        • Parmar C.D.
        • Mahawar K.K.
        • Boyle M.
        • Schroeder N.
        • Balupuri S.
        • Small P.K.
        Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass is effective for gastro-oesophageal reflux disease but not for further weight loss.
        Obes Surg. 2017; 27: 1651-1658
        • Poghosyan T.
        • Lazzati A.
        • Moszkowicz D.
        • et al.
        Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: an audit of 34 patients.
        Surg Obes Relat Dis. 2016; 12: 1646-1651
        • Qiu J.
        • Lundberg P.W.
        • Javier Birriel T.
        • Claros L.
        • Stoltzfus J.
        • El Chaar M.
        Revisional bariatric surgery for weight regain and refractory complications in a single MBSAQIP accredited center: what are we dealing with?.
        Obes Surg. 2018; 28: 2789-2795
        • Quezada N.
        • Hernandez J.
        • Perez G.
        • Gabrielli M.
        • Raddatz A.
        • Crovari F.
        Laparoscopic sleeve gastrectomy conversion to Roux-en-Y gastric bypass: experience in 50 patients after 1 to 3 years of follow-up.
        Surg Obes Relat Dis. 2016; 12: 1611-1615
        • Shimon O.
        • Keidar A.
        • Orgad R.
        • Yemini R.
        • Carmeli I.
        Long-term effectiveness of laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with a duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure.
        Obes Surg. 2018; 28: 1724-1730
        • van Wezenbeek M.R.
        • van Oudheusden T.R.
        • de Zoete J.P.
        • Smulders J.F.
        • Nienhuijs S.W.
        Conversion to gastric bypass after either failed gastric band or failed sleeve gastrectomy.
        Obes Surg. 2017; 27: 83-89
        • Yilmaz H.
        • Ece I.
        • Sahin M.
        Revisional surgery after failed laparoscopic sleeve gastrectomy: retrospective analysis of causes, results, and technical considerations.
        Obes Surg. 2017; 27: 2855-2860
        • Yorke E.
        • Sheppard C.
        • Switzer N.J.
        • et al.
        Revision of sleeve gastrectomy to Roux-en-Y gastric bypass: a Canadian experience.
        Am J Surg. 2017; 213: 970-974
        • Antonopulos C.
        • Rebibo L.
        • Calabrese D.
        • et al.
        Comparison of repeat sleeve gastrectomy and Roux-en-Y gastric bypass in case of weight loss failure after sleeve gastrectomy.
        Obes Surg. 2019; 29: 3919-3927
        • Vanetta C.
        • Dreifuss N.H.
        • Schlottmann F.
        • Baz C.
        • Masrur M.A.
        Bariatric surgery conversions in MBSAQIP centers: current indications and outcomes.
        Obes Surg. 2022; 32: 3248-3256
        • Huynh D.
        • Mazer L.
        • Tung R.
        • Cunneen S.
        • Shouhed D.
        • Burch M.
        Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision.
        Surg Obes Relat Dis. 2021; 17: 1681-1688
        • Frieder J.S.
        • Aleman R.
        • Gomez C.O.
        • et al.
        Outcomes of reoperative surgery in severely obese patients after sleeve gastrectomy: a single-institution experience.
        Surg Obes Relat Dis. 2020; 16: 983-990
        • Kraljevic M.
        • Susstrunk J.
        • Kostler T.
        • Lazaridis I.I.
        • Zingg U.
        • Delko T.
        Short or long biliopancreatic limb bypass as a secondary procedure after failed laparoscopic sleeve gastrectomy.
        Obes Surg. 2021; 31: 170-178
        • Cheema F.
        • Choi M.
        • Moran-Atkin E.
        • Camacho D.
        • Choi J.
        Outcomes in revisional bariatric surgery: a high-volume single institution experience.
        Surg Endosc. 2021; 35: 3932-3939
        • Andalib A.
        • Alamri H.
        • Almuhanna Y.
        • Bouchard P.
        • Demyttenaere S.
        • Court O.
        Short-term outcomes of revisional surgery after sleeve gastrectomy: a comparative analysis of re-sleeve, Roux en-Y gastric bypass, duodenal switch (Roux en-Y and single-anastomosis).
        Surg Endosc. 2021; 35: 4644-4652
        • Wilczynski M.
        • Spychalski P.
        • Proczko-Stepaniak M.
        • et al.
        Comparison of the long-term outcomes of RYGB and OAGB as conversion procedures after failed LSG - a case-control study.
        J Gastrointest Surg. 2022; 26: 2255-2265
        • Lee M.H.
        • Almalki O.M.
        • Lee W.J.
        • Soong T.C.
        • Chen S.C.
        Outcome of laparoscopic revision of sleeve gastrectomy to Roux-en-Y gastric bypass: different strategies for obese and non-obese Asian patients.
        Asian J Surg. 2022 Jul 14; (Epub)
        • Roach E.
        • Laplante S.
        • Stogryn S.
        • Maeda A.
        • Jackson T.
        • Okrainec A.
        Weight loss outcomes for patients undergoing conversion to Roux-en-Y-gastric bypass after sleeve gastrectomy.
        Surg Endosc. 2022 Aug 18; (Epub)
        • D'Urso A.
        • Vix M.
        • Perretta S.
        • Ignat M.
        • Scheer L.
        • Mutter D.
        Indications and long-term outcomes of conversion of sleeve gastrectomy to Roux-en-Y gastric bypass.
        Obes Surg. 2021; 31: 3410-3418
        • Curell A.
        • Beisani M.
        • Garcia Ruiz de Gordejuela A.
        • et al.
        Outcomes of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass due to GERD-a retrospective analysis of 35 patients.
        Obes Surg. 2021; 31: 4100-4106
        • Dijkhorst P.J.
        • Al Nawas M.
        • Heusschen L.
        • et al.
        Single anastomosis duodenoileal bypass or Roux-en-Y gastric bypass after failed sleeve gastrectomy: medium-term outcomes.
        Obes Surg. 2021; 31: 4708-4716
        • Yan J.
        • Cohen R.
        • Aminian A.
        Reoperative bariatric surgery for treatment of type 2 diabetes mellitus.
        Surg Obes Relat Dis. 2017; 13: 1412-1421
        • Lee Y.
        • Ellenbogen Y.
        • Doumouras A.G.
        • Gmora S.
        • Anvari M.
        • Hong D.
        Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: a systematic review and meta-analysis.
        Surg Obes Relat Dis. 2019; 15: 556-566
        • Kermansaravi M.
        • Shahmiri S.S.
        • DavarpanahJazi A.H.
        • et al.
        One anastomosis/mini-gastric bypass (OAGB/MGB) as revisional surgery following primary restrictive bariatric procedures: a systematic review and meta-analysis.
        Obes Surg. 2021; 31: 370-383
        • Bhandari M.
        • Humes T.
        • Kosta S.
        • et al.
        Revision operation to one-anastomosis gastric bypass for failed sleeve gastrectomy.
        Surg Obes Relat Dis. 2019; 5: 2033-2037
        • Salminen P.
        • Helmio M.
        • Ovaska J.
        • et al.
        Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
        JAMA. 2018; 319: 241-254
        • Koh Z.J.
        • Chew C.A.Z.
        • Zhang J.J.Y.
        • et al.
        Metabolic outcomes after revisional bariatric surgery: a systematic review and meta-analysis.
        Surg Obes Relat Dis. 2020; 16: 1442-1454
        • Borgeraas H.
        • Hofso D.
        • Hertel J.K.
        • Hjelmesaeth J.
        Comparison of the effect of Roux-en-Y gastric bypass and sleeve gastrectomy on remission of type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials.
        Obes Rev. 2020; 21e13011
        • Affinati A.H.
        • Esfandiari N.H.
        • Oral E.A.
        • Kraftson A.T.
        Bariatric surgery in the treatment of type 2 diabetes.
        Curr Diab Rep. 2019; 19: 156
        • Ashrafian H.
        • Athanasiou T.
        • Li J.V.
        • et al.
        Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass.
        Obes Rev. 2011; 12: e257-e272
        • Tran D.D.
        • Nwokeabia I.D.
        • Purnell S.
        • et al.
        Revision of Roux-en-Y gastric bypass for weight regain: a systematic review of techniques and outcomes.
        Obes Surg. 2016; 26: 1627-1634
        • Smith M.D.
        • Adeniji A.
        • Wahed A.S.
        • et al.
        Technical factors associated with anastomotic leak after Roux-en-Y gastric bypass.
        Surg Obes Relat Dis. 2015; 11: 313-320