LRSG is one of the commonly reported procedures following LSG especially in patients with dilated/large gastric pouch [6, 10, 17, 21, 23, 24]. It is based on the principle of adding more restriction hence reducing the RGV. LRSG was first described by Gagner and Rogula in a patient operated for LBPD/DS with a dilated gastric pouch, with excellent results [24]. Baltasar later reported two cases of LRSG with large fundus in one patient and antral dilatation in another [23]. Ianelli et al. showed an increase in %EWL from 46.5 to 71.4 % following LRSG in 13 patients with large gastric fundus and/or body/antrum as noted in upper GI series [6]. Rebibo et al. had shown mean %EWL of 65.95 % at 12 months following LRSG in patients with RGV above 250 cc, with the mean BMI dropping from 43 to 33 [10]. In the series from Dapri et al., seven patients underwent a LRSG achieving a %EWL of 43.7 % with a mean follow up of 23.2 months [21]. Noel et al. reported a %EWL of 58.5 % following LRSG with a mean follow up of 19.9 months [17]. This was specifically performed on patients with higher RGV.

Although the results have been encouraging, the incidence of complications after LRSG have been high. Rebibo et al. had reported two patients (13.3 %) with gastric leak, one patient with post operative bleeding and one post operative death [10]. Dapri et al. had reported one patient (14.2 %) with sleeve leak and Noel et al. had one patient with perigastric hematoma [17, 21]. Trelles et al. had reported a complicated gastrocolic fistula following LRSG in a prior LBPD-DS patient [25]. This incidence was much higher compared to the primary sleeve gastrectomy group [26].

LRYGB is another procedure which has shown promising results in patients with failure of LSG. Revisional LSG to LRYGB was first performed by Regan et al. as a planned first stage procedure for super obese patients [27]. Recent series on LSG conversion to LRYGB for LSG failure has shown excellent results. Idan Carmelli et al. retrospectively reported ten patients who underwent a revisional LSG to LRYGB with % EWL of 66.6 % with a mean follow-up of 16 months [28]. One case of stomal ulcer with bleeding was reported which was managed conservatively. Gautier et al. reported nine patients with revisional LRYGB who had a % EWL of 59 % with a mean followup of 15.5 months [29]. One patient in this series reported small bowel injury with subsequent peritonitis.

Van Rutte et al. reported 37 patients with a revisional LRYGB, of which 14 had the initial sleeve as a staged procedure, 5 after a secondary sleeve and 18 after a primary sleeve with failure [11]. The patients had a % EWL of 45.9, 52.5 and 80.3 % in each of the groups respectively. Their series had one patient with enterocutaneous fistula in the second group, two patients with post operative bleeding, two with anastamotic leakage and one internal hernia in the third group.

The recent systematic review by Cheung et al. on revisional surgery following LSG showed no signifiant difference between patients undergoing LRSG and LRYGB with an %EWL of 48 vs 44 % [30]. However the series of LRSG were specifically performed in patients with a large dilated fundus and those of the LRYGB series had no specific mention. This could be that the patients in the LRYGB group might not have had significant dilatation making LRSG not a feasible option.