LRYGB is the most common revision surgery performed following failure of LAGB [4]. Elnahas et al. in their review comparing revisional LSG, RYGB, BPD have shown that LRYGB can achieve successful weight loss following LAGB with relatively low complication rate [4]. In a systematic review on re-operative bariatric surgery by American society for metabolic and bariatric surgery revision task force the reported incidence of conversion from LAGB to RYGB was between 2 and 28.8 % with the medium-term (upto 4 year) weight loss outcomes comparable to primary RYGB with complication rates being slightly higher than primary RYGB [5]. A systematic review of 15 studies (588 patients) reported an overall complication rate (major and minor) of 8.5 % with anastomotic leak and bleeding rates of 0.9 % and 1.8 %, respectively [6]. Robert et al. in their experience of 85 patients who underwent revisional LRYGB have concluded that conversion to LRYGB currently remains the choice of procedure in case of LAGB failure with satisfactory results and acceptable morbidity [7]. Topart et al. compared the results of revisional RYGB to primary RYGB and concluded that when RYGB is performed after an LAGB failure to restore weight loss or because of a complication, the weight loss curve was similar to that after primary RYGB [8]. Mongols et al. in their experience of 70 revisional RYGB concluded that laparoscopic conversion of LAGB to RYGBP is a technically challenging procedure that can be safely performed with good short-term results [9].

LRYGB also adheres to the principle of adding a malabsorptive component to a failed restrictive procedure. LRYGB also offers the extra advantage of treating reflux in patients with associated GERD [10]. In addition LRYGB may also offer resolution or improvement of glycemic control in patients who had T2DM and did not respond to LAGB [11].

Another consideration during revisional RYGB is whether to perform in one stage or as a two stage procedure. Stroh et al. in their data analysis of the German bariatric surgery registry found that the incidence of anastomotic leak after a one stage RYGB following LAGB was actually lower (1.9 %) than after the two stage procedure (2.6 %) making single stage procedure a more prudent choice [12].

Traditionally LRYGB has been considered the optimal revisional surgery for failed LAGB. LSG by principle is a restrictive procedure and hence considered to be inappropriate for another failed restrictive procedure like LAGB. Elnahas et al. have shown in their systematic review that %EWL after LSG at 2 years follow up is inferior to LRYGB/BPD [4]. But reports from many other authors have challenged this by reporting good outcomes following LSG as well. Also the metabolic effects of LSG have now been well established and it is not considered anymore as a purely restrictive bariatric procedure [13]. In a systematic review on reoperative bariatric surgery by American society for metabolic and bariatric surgery revision task force, conversion of LAGB to LSG was the most commonly performed revision surgery for inadequate weight loss [5].

Yazbek et al. in their review of 90 patients who underwent LSG following failed LAGB have shown that successful weight loss can be achieved with mean postoperative %EWL of 61.3 % (n = 60), 53.0 % (n = 30), 55.3 % (n = 20), and 54.1 % (n = 10) at 1, 2, 3, and 4 years, respectively [14]. Jacobs et al. in their experience of 32 patients of revisional LSG also showed it is a feasible and acceptable alternative for failed LAGB [15]. Khoursheed et al. in a retrospective review of 95 patients who underwent revisional surgery after failed LAGB, 42 patients underwent LSG and 53 underwent LRYGB. They concluded that both the procedures had similar weight loss but LSG may be superior to LRYGB in terms of long term nutritional consequences [16]. Acholonu et al. concluded that LSG could provide good short-term weight loss after previously failed LAGB, but prone to more complications compared to a primary LSG [17]. Alqahtani et al. in their retrospective review comparing revisional LSG after failed LAGB with primary LSG concluded that single stage conversion of LAGB to LSG is a safe and efficient procedure and achieves similar outcomes as primary LSG surgery alone [18].