Clinical Outcomes, Risks, and Individualized Treatment Selection in Revisional Metabolic and Bariatric Surgery: A Narrative Review

ABSTRACT

Background and Aims

As the use of metabolic and bariatric surgery (MBS) expands, clinicians increasingly encounter weight recurrence, suboptimal response, gastroesophageal reflux disease (GERD), nutritional problems, and procedure‐related complications. Revisional metabolic and bariatric surgery (RMBS) offers several corrective and conversion strategies, but outcomes vary by indication, prior anatomy, procedure, and patient characteristics. This narrative review summarizes current evidence on the benefits, risks, and clinical determinants of RMBS.

Methods

Evidence on indications, procedure selection, weight‐related and metabolic outcomes, GERD, complications, nutritional consequences, reoperation, mortality, and patient‐reported outcomes was narratively synthesized. Greater emphasis was placed on systematic reviews, meta‐analyses, comparative studies, registry analyses, and contemporary consensus guidance.

Results

RMBS can provide additional weight reduction, improve selected obesity‐related comorbidities, and address complications of previous surgery. Roux‐en‐Y gastric bypass is particularly relevant when GERD is a major indication after sleeve gastrectomy, whereas more malabsorptive procedures may provide greater weight‐related benefit in selected patients at the cost of greater nutritional surveillance. Outcomes are influenced by the indication for revision, existing anatomy, nutritional and metabolic status, prior procedures, and procedural complexity. Quality of life improvement is possible but remains inconsistently reported. Pharmacological and endoscopic therapies may also serve as alternatives or adjuncts in selected patients with weight recurrence or suboptimal response.

Conclusion

RMBS should be individualized rather than approached as a uniform treatment. Optimal management requires matching the intervention to the underlying indication, balancing expected benefits against procedural and nutritional risks, and providing multidisciplinary long‐term follow‐up.

1. Introduction

Obesity is a chronic, multifactorial disease associated with substantial metabolic, cardiovascular, functional, and quality of life consequences. Metabolic and bariatric surgery (MBS) is an established treatment for appropriately selected patients with obesity and can provide durable weight reduction and improvement in obesity‐related comorbidities when compared with nonsurgical management [1, 2, 3]. The use and distribution of MBS procedures have evolved considerably over time, with sleeve gastrectomy (SG) becoming the most frequently performed operation worldwide and adjustable gastric banding (AGB) declining in use [4, 5, 6, 7, 8]. As the volume of primary MBS has increased, the management of suboptimal outcomes and procedure‐related complications requiring revisional treatment has become an increasingly important component of bariatric practice [9, 10].

Revisional metabolic and bariatric surgery (RMBS) encompasses surgical procedures undertaken to modify, convert, correct, or reverse a previous bariatric operation. Indications are heterogeneous and may include suboptimal weight reduction, weight recurrence, persistent or recurrent obesity‐related disease, gastroesophageal reflux disease (GERD), anatomical abnormalities, and complications such as stenosis, fistula, marginal ulceration, or clinically important nutritional problems [9, 11, 12, 13]. The indication for intervention should therefore be clearly defined before selecting a revisional strategy, because the optimal procedure differs according to whether the primary objective is additional weight loss, control of GERD, correction of an anatomical complication, or management of a nutritional problem [10].

Terminology used to describe weight‐related outcomes after MBS has historically been inconsistent, limiting comparison across studies. Recent international guidance has increasingly favored standardized concepts such as “suboptimal response” and “weight recurrence,” together with standardized weight‐reporting metrics, rather than imprecise terms such as “failed surgery” or “weight recidivism” [14, 15]. This distinction is particularly relevant to RMBS because the decision to proceed with another intervention should not be based on body weight alone. Evaluation should also consider the indication for the primary procedure, postoperative weight trajectory, existing anatomy, obesity‐related comorbidities, nutritional status, GERD, psychosocial and behavioral factors, and the response to previous nonsurgical treatment [10, 16].

RMBS is technically and clinically distinct from primary MBS. Previous dissection can result in adhesions, distorted tissue planes, altered vascularity, and modified gastrointestinal anatomy, while some patients present with pre‐existing micronutrient or protein deficiencies [9, 13]. These factors may increase operative complexity and influence perioperative and long‐term outcomes. Furthermore, no single revisional procedure is optimal for all patients. Roux‐en‐Y gastric bypass (RYGB), one‐anastomosis gastric bypass (OAGB), biliopancreatic diversion with duodenal switch (BPD/DS), single‐anastomosis duodeno‐ileal bypass with sleeve gastrectomy (SADI‐S), and other corrective or conversion procedures differ in their weight‐related efficacy, reflux profile, morbidity, and nutritional consequences. Consequently, procedural selection should reflect the indication for revision and balance the expected weight and metabolic benefits against reflux and nutritional risks [17, 18].

Despite the expanding literature on RMBS, interpretation and comparison of outcomes remain challenging because studies vary in their definitions of treatment response, indications for revision, index and revisional procedures, follow‐up duration, and reported outcome measures. This heterogeneity complicates direct comparison of weight‐related efficacy, morbidity, reflux outcomes, nutritional consequences, and other clinically relevant endpoints across revisional strategies [14, 19]. A clinically integrated synthesis of these outcomes is therefore needed to clarify the potential benefits and trade‐offs associated with different revisional approaches. Accordingly, this narrative review provides an indication‐based synthesis of RMBS that integrates procedure selection, weight and metabolic outcomes, reflux control, nutritional risk, patient‐reported outcomes, and contemporary pharmacological and endoscopic treatment options, with emphasis on individualized long‐term management.

2. Methods

2.1. Literature Search Strategy

This narrative review was developed using a structured literature search of PubMed/MEDLINE, Scopus, and Web of Science. The original search included studies published through April 2025 and was supplemented by an updated PubMed/MEDLINE search through August 2026 to identify recently published systematic reviews, meta‐analyses, comparative studies, consensus statements, and professional society guidance. Search terms included combinations of “revisional metabolic and bariatric surgery,” “revisional bariatric surgery,” “sleeve gastrectomy,” “Roux‐en‐Y gastric bypass,” “one‐anastomosis gastric bypass,” “single‐anastomosis duodeno‐ileal bypass,” “biliopancreatic diversion,” “weight recurrence,” “suboptimal response,” “gastroesophageal reflux disease,” “complications,” “nutritional deficiency,” “reoperation,” “quality of life,” and related terms.

Peer‐reviewed English‐language studies reporting clinically relevant outcomes after RMBS were considered. When multiple publications addressed the same clinical question, greater interpretive weight was given to systematic reviews and meta‐analyses, professional society or consensus statements, comparative cohort studies, large registry analyses, and studies providing longer‐term outcome data. Evidence addressing revision after SG, AGB, RYGB, and other metabolic and bariatric procedures was considered. Reference lists of relevant articles were also reviewed to identify additional eligible publications. Studies that did not provide clinically interpretable outcomes or were unrelated to revision, conversion, correction, or reversal of previous metabolic and bariatric procedures were excluded.

Because this was a narrative rather than a systematic review, no de novo meta‐analysis or quantitative pooling was performed. Evidence was synthesized according to the indication for revision, patient‐ and procedure‐related determinants of treatment selection, weight‐related outcomes, obesity‐related comorbidities, GERD, complications and nutritional outcomes, mortality, reoperation, and patient‐reported outcomes.

2.2. Preoperative Evaluation and Determinants of Revisional Strategy

Successful RMBS begins with identifying why the primary procedure no longer provides an acceptable clinical outcome. The indication may be predominantly weight‐related, such as a suboptimal postoperative response or weight recurrence, or may arise from GERD, anatomical complications, functional symptoms, nutritional problems, or persistence or recurrence of obesity‐related disease [9, 10, 11, 14]. These indications are not interchangeable because the revisional procedure that best addresses one problem may create disadvantages in another domain.

Assessment should therefore extend beyond current body mass index. Review of the primary operative report, postoperative weight trajectory, previous complications, and prior attempts at medical or behavioral management can clarify the mechanism underlying the current problem. Upper gastrointestinal endoscopy and appropriate imaging may be required when anatomical abnormalities, GERD, obstruction, fistula, stenosis, pouch or sleeve dilatation, or other structural complications are suspected [20, 21, 22, 23, 24]. The choice and extent of diagnostic testing should be guided by the clinical indication rather than applied uniformly to every patient.

Nutritional assessment is particularly important before further surgery because deficiencies may predate revision and can be amplified by procedures that increase malabsorption. Protein status and relevant micronutrients, including iron, vitamin B12, folate, calcium, and vitamin D, should therefore be evaluated and corrected when necessary [18, 25, 26, 27, 28]. Metabolic disease, medication use, cardiopulmonary risk, and previous abdominal operations also contribute to perioperative risk assessment.

Behavioral and psychosocial evaluation forms another component of this assessment but should not be used to attribute a suboptimal surgical outcome solely to patient behavior. Dietary patterns, adherence to supplementation and follow‐up, eating behavior, psychological health, expectations, and available social support may influence postoperative management and long‐term engagement with care [29, 30, 31, 32, 33]. Accordingly, multidisciplinary evaluation involving bariatric surgeons, dietitians, physicians with expertise in obesity and metabolic disease, and mental health professionals when clinically indicated can help distinguish anatomical, metabolic, nutritional, and behavioral contributors to the presenting problem (Figure 1).

Figure 1.

Factors guiding revisional metabolic and bariatric surgery. The choice of revisional strategy should integrate the indication for revision, previous bariatric procedure and current anatomy, medical and metabolic status, nutritional status, weight trajectory and treatment goals, psychological assessment when indicated, lifestyle and social support, operative risk and timing, surgical expertise, and availability of structured long‐term follow‐up.

2.3. Procedure Selection in Revisional Metabolic and Bariatric Surgery

There is no universally preferred revisional procedure. Selection depends primarily on the previous operation and the indication for revision, while also accounting for current anatomy, GERD, metabolic disease, nutritional status, operative history, and institutional expertise [9, 10, 24]. After SG, conversion to RYGB is commonly considered when persistent or severe GERD is a major indication because the procedure can provide both additional weight reduction and effective reflux control. OAGB may provide substantial additional weight loss and has the technical advantage of a single gastrojejunal anastomosis, but concerns regarding bile reflux and postoperative GERD should be incorporated into patient selection. SADI‐S and BPD/DS provide greater malabsorptive and metabolic effects and may be considered in selected patients in whom additional weight reduction is the dominant objective, particularly when nutritional surveillance and long‐term follow‐up can be maintained [34, 35, 36, 37, 38, 39, 40, 41].

More recent comparative evidence reinforces the importance of matching the operation to the clinical objective rather than identifying a single “best” revision. A 2025 network meta‐analysis comparing revisional operations after SG ranked SADI‐S highly for weight‐loss outcomes, while recognizing that comparative evidence remains heterogeneous and is predominantly observational [19]. A 2026 meta‐analysis comparing OAGB with RYGB after SG found broadly comparable pooled GERD resolution, but RYGB remained clinically preferable when definitive reflux control was the principal indication because de novo reflux tended to occur more frequently after OAGB [42]. Long‐term comparative evidence also suggests that the distinction between reflux‐directed and weight‐directed revision is clinically relevant. A systematic review examining RYGB and SADI after SG found broadly comparable long‐term weight and metabolic outcomes, whereas RYGB provided better control of reflux and functional symptoms [43].

After AGB, band removal may be followed by conversion to SG or RYGB, with the choice guided by the indication for revision, reflux symptoms, esophageal function, gastric anatomy, and the expected balance between weight‐related efficacy and perioperative risk [44]. In patients requiring revision after RYGB, management is more heterogeneous and may include pouch or gastrojejunal revision, distalization, or conversion to a more malabsorptive procedure in selected cases. Although more extensive revisions may provide greater additional weight loss, they can also increase operative complexity and nutritional risk, particularly when intestinal bypass is increased [45, 46]. Table 1 summarizes indication‐specific revisional strategies and their principal trade‐offs, whereas Figure 2 provides an overview of common revisional procedures and major clinical considerations (Table 1 and Figure 2).

Table 1.

Clinical considerations in selecting a revisional metabolic and bariatric procedure.

Clinical scenario	Commonly considered strategy	Principal potential benefit	Major considerations and trade‐offs
GERD after SG	Conversion to RYGB	Reflux control with additional weight reduction	Anastomotic complications, marginal ulceration, internal hernia, nutritional surveillance
Suboptimal response or weight recurrence after SG without dominant GERD	RYGB, OAGB, SADI‐S, or selected other procedures	Additional weight reduction and metabolic benefit	Choice depends on reflux status, BMI, metabolic disease, nutritional risk, and follow‐up capacity
Need for greater weight‐related effect after SG	SADI‐S or other more malabsorptive procedures in selected patients	Greater weight and metabolic effect	Higher nutritional surveillance requirements and potential malabsorptive complications
AGB‐related complication or suboptimal outcome	Band removal with or without conversion to RYGB or SG	Correction of band‐related problems and potential additional weight reduction	Reflux, esophageal function, scar tissue, and operative findings should guide conversion
Weight recurrence or anatomical abnormality after RYGB	Anatomical correction, pouch/gastrojejunal revision, distalization, or selected conversion	Treatment directed to identified anatomical or metabolic mechanism	Increasing malabsorption may increase nutritional risk
Severe nutritional or malabsorptive complication	Limb modification, conversion, or reversal in selected patients	Correction of clinically important malabsorption	Potential recurrent weight gain and technical complexity
Weight recurrence without a clear surgical anatomical target	Pharmacological, endoscopic, nutritional, behavioral, or selected surgical treatment	Avoidance or deferral of unnecessary surgical risk	Treatment should be individualized and response reassessed longitudinally

Abbreviations: AGB, adjustable gastric banding; BMI, body mass index; GERD, gastroesophageal reflux disease; OAGB, one‐anastomosis gastric bypass; RYGB, Roux‐en‐Y gastric bypass; SADI‐S, single‐anastomosis duodeno‐ileal bypass with sleeve gastrectomy; SG, sleeve gastrectomy.

Figure 2.

Common procedures used in revisional metabolic and bariatric surgery and major clinical considerations. The figure illustrates procedures that may be used in revisional settings, including (A) Roux‐en‐Y gastric bypass, (B) sleeve gastrectomy, (C) one‐anastomosis gastric bypass, (D) biliopancreatic diversion with duodenal switch, and (E) single‐anastomosis duodeno‐ileal bypass with sleeve gastrectomy. Procedure selection should be based on the indication for revision and the expected balance between weight and metabolic benefits, reflux control, perioperative risk, and nutritional consequences.

2.4. Weight‐Related Outcomes

RMBS can provide clinically meaningful additional weight reduction, but the magnitude of response varies considerably among procedures and indications. Comparisons based on a single pooled estimate are problematic because studies differ in the primary procedure, reason for revision, baseline weight, follow‐up duration, and definition of treatment response. Weight outcomes should therefore be interpreted using procedure‐specific evidence and standardized measures, preferably percentage total weight loss where available [47, 48, 49, 50]. Conversion after SG has received the greatest attention. RYGB, OAGB, SADI‐S, and BPD/DS can all produce additional weight reduction in appropriately selected patients, although their relative efficacy and risk profiles differ. OAGB and SADI‐S may provide greater weight reduction in some comparative analyses, whereas RYGB may offer a more favorable balance when GERD is an important component of the clinical presentation [34, 35, 51, 52].

Recent network and conventional meta‐analyses support this procedure‐specific interpretation. SADI‐S and OAGB have demonstrated favorable weight‐related outcomes after SG in comparative analyses, but differences in study design, baseline characteristics, follow‐up duration, and nutritional surveillance limit direct ranking of procedures [19]. Similarly, recent comparisons of RYGB and OAGB indicate that modest differences in weight outcomes must be considered alongside reflux risk and other procedure‐specific consequences rather than interpreted in isolation [35, 42]. Long‐term weight trajectories remain influenced by biological adaptation, anatomical factors, obesity chronicity, and postoperative management. Accordingly, recurrent weight gain after a revisional operation should prompt renewed evaluation of anatomical, metabolic, pharmacological, nutritional, and behavioral factors rather than an automatic progression to another surgical intervention [53, 54, 55, 56, 57].

2.5. Complications and Nutritional Outcomes

RMBS is generally more technically demanding than primary metabolic and bariatric surgery because previous operations can result in adhesions, distorted tissue planes, altered vascularity, and complex gastrointestinal anatomy. These factors contribute to an increased risk of perioperative complications, although the magnitude of risk varies substantially according to the primary operation, type and complexity of revision, indication, patient characteristics, and institutional experience [9, 58, 59].

The clinically important early complications include anastomotic or staple‐line leak, bleeding, infection, and thromboembolic events, whereas later complications depend strongly on the anatomy created by the revisional procedure. Stricture, marginal ulceration, internal hernia, GERD or bile reflux, and nutritional complications may require endoscopic, medical, or further surgical management. Rather than focusing on isolated incidence estimates derived from heterogeneous populations, the principal clinical message is that complication risk should be considered in relation to the expected benefit of the proposed revision [60, 61, 62, 63, 64].

Nutritional risk warrants particular attention when the revision increases intestinal bypass or malabsorption. Iron, vitamin B12, vitamin D, calcium, and other micronutrient deficiencies may persist or develop after revision, while more extensive malabsorptive procedures may also affect protein status [18, 25, 26, 27, 28]. A recent systematic review of nutritional outcomes following revision after SG confirmed that micronutrient deficiencies remain common across revisional procedures despite routine supplementation [18]. Preoperative correction of deficiencies, procedure‐specific supplementation, biochemical monitoring, and lifelong follow‐up should therefore form part of the treatment pathway.

2.6. Mortality and Reoperation

Mortality after RMBS remains uncommon, but risk is not uniform across revisional procedures. Patient comorbidity, the number and type of previous operations, operative complexity, and the need for extensive reconstruction may influence short‐term outcomes [65, 66, 67, 68]. Experience at the surgeon and institutional levels is also relevant because complex revisional procedures benefit from established bariatric infrastructure and access to multidisciplinary perioperative care [69, 70]. Mortality estimates derived from heterogeneous bariatric cohorts should not be applied as a uniform risk estimate to contemporary RMBS. Recent prospective and large registry‐based studies indicate that short‐term mortality is generally low, whereas perioperative morbidity varies according to the indication and type of revisional or conversion procedure. Risk should therefore be assessed in the context of the planned operation and individual patient characteristics rather than inferred from a single aggregate mortality rate [71, 72].

Further intervention after RMBS may be required for recurrent weight‐related problems, anatomical complications, GERD, internal hernia, marginal ulceration, nutritional complications, or other procedure‐specific adverse outcomes [73, 74, 75]. Reoperation, therefore, represents both an outcome of interest and an indicator of the complexity of long‐term care in this population. Patients should be informed before revision that another operation may become necessary and that continued follow‐up remains important even after an initially successful revisional procedure.

2.7. Improvement in Obesity‐Related Comorbidities

Additional weight reduction and metabolic changes after RMBS may improve obesity‐related conditions, including type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, and obstructive sleep apnea (OSA). However, the magnitude of improvement varies across revisional procedures and study populations [76, 77, 78, 79, 80]. A recent meta‐analysis of revisional SADI‐S demonstrated improvement across these major obesity‐related comorbidities, although comparative analyses did not establish consistent superiority of SADI‐S over RYGB or OAGB for comorbidity resolution [81]. Similarly, a 2025 meta‐analysis comparing OAGB with RYGB after sleeve gastrectomy found comparable remission of T2DM and hypertension despite differences in weight‐related outcomes [82].

Long‐term comparative evidence remains limited. In a 7‐year study of RYGB and SADI‐S as revisional procedures after sleeve gastrectomy, remission or improvement of T2DM, hypertension, and dyslipidemia did not differ significantly between procedures, whereas their nutritional profiles differed [83]. Thus, a greater weight‐loss or malabsorptive effect should not be assumed to result in uniformly superior resolution of obesity‐related comorbidities. Interpretation is further limited by heterogeneous patient populations, small numbers of patients with individual comorbidities, differences in indications for revision, variable definitions of remission and improvement, and inconsistent duration of follow‐up [81, 83]. Comorbidity outcomes should therefore be reported separately from weight outcomes and interpreted in the context of the specific revisional procedure and study population rather than presented as universal expected remission rates.

2.8. Quality of Life and Patient‐Reported Outcomes

Beyond weight‐related and metabolic outcomes, quality of life represents an important dimension of treatment success after RMBS. Improvement may result from successful treatment of the clinical problem that prompted revision rather than from additional weight loss alone. This is particularly evident after conversion of SG to RYGB for GERD, for which contemporary studies have reported improvement in reflux‐related symptoms and quality of life after conversion [84, 85]. A recent systematic review specifically examining quality of life after SG‐to‐RYGB conversion nevertheless identified only four eligible studies involving 196 patients and considerable variation in the instruments used to assess quality of life, indicating that the RMBS‐specific evidence remains limited [84].

Patient‐reported outcomes should therefore be considered separately from conventional measures such as weight loss, complications, and comorbidity remission. Recent consensus work in bariatric care has identified overall quality of life, physical health, mental health, treatment‐related symptoms, and satisfaction as outcomes that are important to patients and healthcare professionals [86]. However, inconsistency in the selection and application of patient‐reported outcome measures (PROMs) continues to limit comparisons across studies. An international multidisciplinary consensus has consequently proposed a core set of PROMs for obesity‐treatment research to improve standardization of quality of life assessment [87].

Psychological outcomes should likewise not be assumed to follow the same trajectory as weight loss or symptom resolution. Recent evidence from MBS populations suggests that depressive symptoms improve on average after surgery, but the magnitude of improvement changes over time and a subgroup of patients may experience persistent or worsening symptoms [88]. Because RMBS‐specific psychological evidence remains comparatively sparse, psychological and behavioral needs should be assessed individually during long‐term follow‐up rather than assuming either uniform improvement or deterioration after revision [86, 88].

2.9. Emerging Role of Multimodal Treatment Before and After Revision

Management of suboptimal response or weight recurrence after MBS is increasingly viewed as a multimodal process rather than an automatic indication for RMBS. Contemporary guidance supports individualized use of obesity‐management medications, endoscopic therapies, nutritional and behavioral interventions, and surgical revision according to the mechanism of treatment failure, previous anatomy, clinical indication, and patient‐specific risks [14, 89]. The 2026 American Society for Metabolic and Bariatric Surgery statement similarly recognizes pharmacological, endoscopic, and surgical approaches as complementary options for patients with suboptimal response or weight recurrence after MBS and emphasizes multidisciplinary, case‐by‐case treatment selection [89].

Recent evidence further supports pharmacotherapy as a clinically relevant component of post‐MBS management. Systematic reviews and meta‐analyses have shown that glucagon‐like peptide‐1 receptor agonists and newer obesity‐management medications, including semaglutide and tirzepatide, can provide additional weight reduction in patients with recurrent weight gain or suboptimal response after MBS [90]. Endoscopic treatment may also provide an intermediate option in selected patients with a suitable anatomical target. Contemporary evidence supports transoral outlet reduction (TORe) for weight recurrence after RYGB, although long‐term durability varies and direct comparative evidence with surgical revision remains limited [91].

The choice among these approaches should therefore be guided by the underlying clinical problem rather than by weight recurrence alone. Pharmacological or endoscopic treatment may be appropriate when additional weight management is required without a compelling indication for major surgical reconstruction, whereas anatomical complications or clinically significant reflux may require procedure‐specific operative management. In contrast, structural complications or clinically significant GERD may warrant procedure‐specific operative management, particularly when correction of the underlying anatomy is necessary [42]. Accordingly, treatment selection should not focus solely on which revisional operation produces the greatest additional weight loss, but rather on which intervention, or combination of interventions, provides the most appropriate balance of weight‐related efficacy, metabolic benefit, symptom control, procedural risk, nutritional consequences, and patient‐reported outcomes.

2.10. Limitations of the Current Evidence and Research Priorities

Evidence concerning RMBS remains limited by substantial clinical and methodological heterogeneity. Most comparative studies are retrospective, definitions of suboptimal response and weight recurrence have varied, and follow‐up is frequently insufficient to characterize long‐term nutritional complications, recurrent weight gain, or subsequent reoperation. Differences in primary procedures, revisional indications, surgical techniques, limb lengths, baseline body mass index, and outcome definitions further complicate comparisons [29, 52, 92, 93].

The increasing adoption of standardized terminology and weight‐reporting metrics should improve comparability across future studies. Prospective multicenter studies should also report outcomes according to the indication for revision rather than combining patients undergoing surgery for weight recurrence, GERD, anatomical complications, and nutritional problems into a single cohort. Long‐term evaluation should include not only weight and perioperative morbidity but also metabolic disease, reflux, nutritional status, reintervention, patient‐reported outcomes, and quality of life [53, 92].

Comparative evaluation of surgery with contemporary pharmacological and endoscopic treatment is another emerging research priority. Such evidence will be important for determining when surgery should be preferred, when it can be deferred, and when combined treatment may provide a better balance of efficacy and risk.

3. Conclusion

RMBS provides an important treatment option for patients with clinically significant problems after a previous metabolic and bariatric procedure, but it should not be regarded as a single intervention with uniform benefits and risks. Outcomes depend on the indication for revision, previous anatomy, chosen procedure, baseline metabolic and nutritional status, and the patient's capacity for long‐term follow‐up. RYGB remains particularly relevant when GERD or functional complications predominate after SG, whereas OAGB, SADI‐S, and other procedures with greater metabolic or malabsorptive effects may provide additional weight‐related benefits in selected patients. These potential benefits must be balanced against procedure‐specific risks, particularly reflux and nutritional complications. The decision to revise should therefore follow a comprehensive evaluation of anatomical, metabolic, nutritional, and patient‐related factors. Contemporary management is increasingly multimodal, incorporating surgical, pharmacological, endoscopic, nutritional, and behavioral strategies according to the mechanism of the suboptimal outcome. Standardized definitions, procedure‐specific reporting, and prospective long‐term comparative studies are needed to refine treatment selection and determine which patients derive the greatest net benefit from RMBS.

Author Contributions

Ramin Ebrahimian Jektaji: investigation, writing – original draft, writing – review and editing, validation, methodology, data curation. Mahta Moghaddam Ahmadi: writing – original draft, writing – review and editing, investigation, methodology, validation, data curation. Leila Shokrgozar: investigation, methodology, writing – review and editing, writing – original draft. Moein Moghaddam Ahmadi: conceptualization, investigation, writing – original draft, writing – review and editing, supervision, methodology.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The corresponding author (Moein Moghaddam Ahmadi) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.