Pouch dilation is a frequent finding after LRYGB even in patients who maintain good weight loss [6]. This procedure involves placing a LAGB on the gastric pouch of the RYGB in an attempt to promote greater gastric restriction for the patient especially recommended for hyperphagic patients. The safety and efficacy of LAGB for failed LRYGB has been well demonstrated wherein LAGB provides external reinforcement to help regulate the pouch size over time [6–9]. As a result, it may reduce hunger and increase satiety in patients who fail to lose weight [10]. Bessler et al. found that LAGB after LRYGB produced an EWL of 38 % and 44 % at 12 and 24 months, respectively [6]. A larger study by Irani et al. reported a mean EWL of 38.3 % on 42 patients with a mean follow-up of 26 months (range 6–66) after LAGB placement [11]. However complications of LAGB (erosion/slippage) were to an extent of 10 %. The study also noted a higher complication rate compared with primary LAGB patients, which was expected given that band placements were part of a revisional procedure. It is also to be noted that salvage banding is technically challenging due to dense adhesions carrying significant morbidity. This approach may still be an option in carefully selected patients who have a dilated pouch and/or stoma following RYGB [12].

Some small series have shown that pouch resizing and anastomotic revision can be performed safely with reasonably good outcomes [13–15]. Surgical or endoluminal re-creation versus banding allows addressing all the dilated components i.e. the pouch, stoma and the alimentary limb, all of which function as one unit. These revisions have been performed in many different ways. Muller et al. reported a technique of dividing the pouch proximal to the anastomosis and resection the anastomosis with a portion of the alimentary limb and creating a new gastro-jejunostomy [16]. This technique has been shown to help in further weight loss and also improvement of symptoms related to poor pouch emptying. Parikh et al. evaluated another type of revisional procedure, termed “gastro-jejunal sleeve reduction.” wherein an orogastric bougie (e.g., 40F) is guided into the jejunum and a linear stapler is serially fired trimming the alimentary limb, gastrojejunostomy (GJ) and the gastric pouch toward the left crus. However this technique did not appear to offer any significant therapeutic benefit with only 12 % EWL at 1 year [17]. León et al. had demonstrated a technique of gastro-jejunal reduction by performing a hand-sewn double-layer gastro-jejunal plication (GJP) [14].

A few endoscopic techniques have also been described to revise pouches. Spaulding et al. had performed circumferential sclerotherapy injections (1 mL of 5 % morrhuate sodium) into the muscular wall at the gastrojejunostomy to decrease the diameter [18]. Although this was 100 % successful in reducing the size of the stoma, more than one session was often required and the clinical effect in terms of weight loss was only marginal. The risk of chemical esophagitis, stricture, or fatal hemorrhage if injected into the aorta has to be considered.

Endoscopic suturing devices have also been developed to endoluminally reduce the pouch or stoma size after LRYGB [19]. This was shown to be effective in the short term [20]. However the long-term benefits are still unknown as the sutures could be lost within a year and the stoma likely re-distends [21]. A large prospective trial by Horgan et al. using expandable tissue anchors made of biocompatible, nonabsorbable suture and nitinol to create stomal and pouch tissue folds had shown that 88 % of patients had stopped regaining weight at 6 months of follow-up, with an average EWL of 18 % [19]. Early results of Stomaphy X, another new surgical endoscopic device has demonstrated 19.5 % EWL at 1 year. This device suctions the surrounding tissue and fires polypropylene H-fasteners to form a circular pleat of tissue slightly proximal to the anastomosis resulting in a reduced stomal diameter [22]. Although recent studies have demonstrated that the above-mentioned endoscopic techniques are safe and effective, further evaluation is necessary given that their long-term benefits are unknown.

Revision of LRYGB to a Laparoscopic distal Roux-en-Y gastric bypass (LDRYGB) has been the most common revision performed for inadequate weight loss after LRYGB which works by increasing the malabsorptive element and is preferred in polyphagic patients [23]. In a conventional LRYGB, the Roux limb is between 75 and 150 cm, preserving most of the small bowel for absorption of nutrients. In a LDRYGB the alimentary is made longer and the length of the common channel is significantly reduced thereby increasing the malabsorption. However, this is associated with a higher risk of developing protein malnutrition and significant diarrhea [24]. Therefore, patients who undergo revisional LDRYGB require more frequent monitoring and nutritional supplementation. It has also been recommended to supplement fat-soluble vitamins and calcium to prevent night blindness and osteoporosis. Patients can also develop symptoms of bacterial overgrowth (i.e., diarrhea, fever, and malaise) in their bypassed intestine [25]. Sugerman et al. converted LRYGB patients with less than 40 % EWL to a distal gastric bypass achieving an EWL of 61 % at 1 year and 69 % at 5 years after revision [25]. The common channel was 50 cm from the ileocecal valve in five patients and 150 cm from the ileocaecal valve in 22 patients. Malnutrition occurred in all five patients with a 50 cm “common tract” requiring further parenteral nutrition and revision back to long-limb LRYGB. Two of these patients died of hepatic failure. Three of 22 patients with a 150 cm common channel required revision for malnutrition. Therefore, the study concluded that a 50 cm common channel LDRYGB should not be used because of an unacceptable morbidity and mortality henceby recommending a 150 cm common tract. Even with 150 cm common channel, it is important to recognize that revision to a LDRYGB is also potentially dangerous and mandates a close follow up in the long-term. A recent study by Caruana et al. had concluded that revision of RYGB to distal bypass when it is <70 % of a patient’s total small bowel length results in an acceptable balance of weight loss with safety.