**2.4 Postoperative care**

Patients are encouraged to ambulate and use incentive spirometry. Intravenous fluid is kept until the next day, and the VTE prophylaxis is started 12 h from surgery. A contrast study is done to assess for any leaks or obstructions. If the contrast study is unremarkable, feeding with clear liquids is resumed. A clear discharge plan summarizing the diet program, medications, and follow-up appointments are described to the patient before leaving the hospital.

#### **2.5 Outcome**

As mentioned previously, revision of AGB is inevitable due to different indications. Even if the revision indication was band intolerance or slippage, removing the band only and not conducting another revisional surgery will likely lead to regaining weight. This observation was evident even in patients who follow a healthy diet and perform adequate exercises [16, 18]. Close follow-up for patients who underwent AGB removal and did not have weight regain/insufficient weight loss is crucial to prevent weight regain. There are diverse definitions of bariatric surgery failures from a weight loss perspective that can be used to indicate revision [19]. In the case of weight regain or insufficient weight loss, the type of revisional surgery is debated in the literature, with LSG and RYGB showing comparable results from excessive weight loss and resolution of comorbidities [20, 21]. Various factors can influence the decision on what kind of revision be conducted, including the patient's preference. Since LSG is undoubtfully less demanding from a technical point of view, we suggest choosing it as the revisional surgery for AGB as long as it is safe to be performed and there are no concerns of postoperative issues (severe reflux or band erosion). If severe reflux is evident by EGD (LA classification grade B/C) or band erosion was discovered preoperatively, the choice of RYGB is more appropriate than LSG. Performing the revision as one-stage versus two-stage is also an area of debate, especially with regards to anastomotic/staple line leak. Thickening of the stomach wall and the adherent capsule associated with the band are possible reasons behind the fear of performing the revision in one-stage. Staple line leak rate in one stage revision to LSG ranged from 0 to 6% in selected reports [22–24]. As for revision to RYGB in one-stage, the anastomotic leak rate was around 1% [25, 26]. The decision of one-stage versus two-stage procedure should be taken carefully. A patient's medical background is an important determinant factor. The condition and healthiness of the stomach after band removal should be assessed judiciously. In case of the diseased stomach wall or band erosion, a two-stage procedure might be the safer option [27].

### **3. Revision of laparoscopic sleeve gastrectomy**

Laparoscopic sleeve gastrectomy (LSG) became one of the most common procedures conducted worldwide to combat obesity. Initially, it was introduced as the firststage of a management plan for highly morbid patients with obesity, where another bariatric surgery is planned after weight loss [28]. Since it is increasing in popularity, an international expert panel consensus was introduced to clarify the indications and standardize the technique. The efficacy of LSG compared to other procedures was evident in the literature on weight loss and treating obesity-related diseases [29, 30]. Recently, the literature began to evaluate the long-term effectiveness (>10 years) of LSG, and it showed promising results [31]. With its relative ease compared to other bariatric surgery and the excellent outcomes, LSG became the most common bariatric procedure conducted worldwide. The exploding number of LSGs conducted will undoubtedly lead to an increased revision rate due to complications or weight loss issues, which are becoming more prevalent in the surgical practice.

#### **3.1 Indication of revision**

The failure of LSG from a weight-loss standpoint is multifactorial, including the technique implemented, lifestyle behaviors, and possible sleeve dilatation. The rate


#### **Table 2.**

*Indication of laparoscopic sleeve gastrectomy revision in selected studies.*

of weight regain ranges from 530% [32]. Those who gained weight after an effective restrictive procedure will benefit from the addition of a malabsorptive feature. Reflux disease is a theoretical consequence of LSG. Since the stomach's lumen decreases in size following the procedure, intraluminal pressure increases, leading to a higher chance of gastric secretions backflow to the esophagus [33]. This phenomenon translates to what is known as de novo reflux disease, and it can be significant to the extent of intolerability affecting a patient's quality of life. Following LSG, the chance of hiatal hernia development is noteworthy and can potentiate reflux, which needs to be ruled out by EGD [34]. If the fundus is not resected while conducting LSG, it can also be a culprit in post LSG reflux disease, which an upper contrast study or EGD can discover (**Table 2**) [40]. In case of a twist or a stricture of the sleeve that is not amenable to stent or dilation, conversion to bypass is the best option (**Figure 7**).
