Abstract
Background
Metabolic and bariatric surgery (MBS) is the most effective treatment for severe obesity, producing durable weight loss and improvement in obesity-related comorbidities. However, a subset of patients experience inadequate weight loss (non-response, NR) or weight recurrence (WR), which can lead to persistence or recurrence of metabolic disease, diminished quality of life, and warrants for further treatment interventions.
Objectives
This review summarizes current treatment options for NR and WR after MBS, including surgical revisions, endoscopic therapies, and obesity modifying medications (OMMs).
Methods
A comprehensive literature review was performed, incorporating recent systematic reviews, meta-analyses, and retrospective series evaluating outcomes of revisional procedures, endoscopic approaches, and pharmacotherapy for patients with NR and WR following MBS.
Results
Revisional surgical options after Roux-en-Y gastric bypass (RYGB) include pouch revision, banding, distalization, and conversion to biliopancreatic diversion–duodenal switch or single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S). After sleeve gastrectomy, revisional strategies include re-sleeve, conversion to RYGB, SADI-S, or one-anastomosis gastric bypass. Endoscopic therapies such as transoral outlet reduction and argon plasma coagulation offer modest but clinically meaningful weight loss with low complication rates. OMMs, particularly glucagon-like peptide-1 (GLP-1) receptor agonists (semaglutide) and dual gastrointestinal peptide/GLP-1 receptor agonists (tirzepatide), have demonstrated weight loss in post-MBS patients. Across all modalities, variability in outcomes and high loss to follow-up limit data quality.
Conclusions
NR and WR after MBS require individualized, multidisciplinary management on a case-by-case basis. Surgical, endoscopic, and pharmacologic options all play important roles, and emerging OMMs represent a major advance. Standardized outcome reporting and prospective studies are needed to refine treatment algorithms.
Authors
- R. Wesley Vosburg, MD
- Jonathan Carter, MD
- Dan Azagury, MD
- Abdelrahman Nimeri, MD
- C. Joe Northup, MD
- Daniel Eisenberg, MD
- Ann M. Rogers, MD
- Pavlos Papasavas, MD