Clinical presentation and outcomes of revisional Roux-en-Y gastric bypass after failed gastric banding: direct versus sleeve-assisted approach.

BACKGROUND: Following failed adjustable gastric banding (AGB), patients may undergo direct conversion to Roux-en-Y gastric bypass (RYGB) or progress through an intermediate sleeve gastrectomy (SG) prior to revisional bypass. The impact of these differing revisional pathways on clinical presentation and postoperative outcomes remains unclear. METHODS: A retrospective cohort study was performed of adult patients undergoing revisional RYGB after prior AGB between 2013 and 2025 at a single academic center. Patients were categorized into direct AGB-RYGB and two-step AGB-SG-RYGB conversion groups. Clinical presentation, perioperative outcomes, postoperative complications, weight loss trajectories, and comorbidity resolution were compared. RESULTS: Seventy-eight patients underwent revisional RYGB after prior AGB, including 53 direct AGB-RYGB conversions and 25 AGB-SG-RYGB conversions. Patients undergoing direct conversion more commonly presented with weight regain symptoms (81.1 vs 16.0%, p < 0.01) and had higher preoperative BMI (43.1 ± 7.4 vs 36.1 ± 7.2 kg/m2, p < 0.01). In contrast, the AGB-SG-RYGB group more frequently presented with reflux and upper gastrointestinal symptoms, including dysphagia, abdominal pain, and nausea or vomiting (all p < 0.01). Perioperative outcomes, including blood loss, hospital stay, postoperative complications, readmissions, and reinterventions, were comparable between groups. Most procedures were performed robotically. Operative time was slightly longer in the direct AGB-RYGB group (202.2 ± 40.5 vs 193.9 ± 51.3 min, p = 0.05). Patients undergoing direct AGB-RYGB achieved greater % total weight loss and % excess weight loss at 6, 12, and 24 months (all p ≤ 0.03), whereas the AGB-SG-RYGB group demonstrated greater postoperative GERD symptom resolution. Both groups demonstrated postoperative improvement in obesity-related comorbidities. CONCLUSIONS: Patients undergoing revisional RYGB after failed AGB represent distinct clinical populations depending on revisional pathway. Despite differing symptom profiles and operative histories, perioperative outcomes were comparable. Greater early and intermediate weight loss was observed in the direct AGB-RYGB group, whereas the AGB-SG-RYGB pathway demonstrated greater GERD symptom resolution. These findings should be interpreted in the context of differences in baseline BMI and indications for revision between groups.