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.
