Our analysis aimed to understand the effects of gastric pouch resizing (GPR) after RYGB on recurrent weight gain, comorbidities, and patient satisfaction. Key findings include that GPR results not only in weight stabilization but also in a mild weight loss of around 10% over a mean follow-up of 5 years. Second, this technique contributes to the bariatric effect of resolving obesity-associated comorbidities. Finally, GPR is a revisional surgery leading to a high level of patient satisfaction at a low complication rate.

Obesity is a chronic disease turning into a lifelong condition for most persons affected and is associated with comorbidities ranging from wearing effects on the musculoskeletal system to slowly progressing organ failure. The rising prevalence of this chronic ailment places a substantial burden on our healthcare system. Besides, the step-up approach for managing obesity, reaching from conservative to pharmacological and surgical strategies, is not supported by the available evidence and is also far from being spared by therapy failure and relapses requiring further treatment [13]. As is typical for chronic diseases, recurrent weight gain is described in a range from 3.9 to 40% of patients following RYGB [5,6,7]. Various risk factors and predictors of anatomical, genetic, dietary, psychiatric, and temporal origin have been described [9, 14, 15]. In most cases, it is not possible to identify a singular etiology, which asks for a multimodal instead of uniform treatment. In this manuscript, we focused on enlarged gastric pouches after primary RYGB facilitating recurrent weight gain. The preoperative workup excluded other major reasons for recurrent weight gain, and a multidisciplinary board finally decided on the surgical procedure (in our cases, GPR) accordingly.

GPR is one of the secondary MBS techniques that intend to “adjust” technical failure, other techniques amplify the primary intention of MBS to re-increase weight loss. The former may lead to an improvement of the primary technique (e.g., resizing gastric pouches), and the latter includes techniques that aim to increase restrictive and/or malabsorptive components of primary MBS. Overall, of all secondary MBS, almost 50% are performed to correct recurrent weight gain or suboptimal weight loss [16]. Those amplifying restriction alone after RYGB, focus mainly on the gastric pouch as in GPR. Whether an additional redo of the gastrojejunostomy is improving the result is not entirely clear. According to Wijngaarden et al. comparing GPR alone versus GPR with a redo of gastrojejunostomy, the only difference is the use of surgical disposable, which is lower for GPR alone [17]. GPR is performed for so-called “dilated” gastric pouches. Iannelli et al. introduced the description of a “primary” or “secondary” dilation of the gastric pouch in 2013 [18]. A primary dilated gastric pouch was described as a technical failure during RYGB. The understanding of a secondary dilatation was probably the idea of a repeated overstretching of the gastric pouch. Nowadays the hypothesis of secondary dilated gastric pouches has vanished, due to the fact that all studies that describe gastric pouch dilatation as a potential mechanism for recurrent weight gain after primary RGYB lack a control immediately after surgery to demonstrate that the gastric pouch was initially non-dilated [19,20,21].

Gastric pouches with a large fundus due to technical failure seem to benefit from a resizing which may lead to weight stabilization or even mild weight loss [18, 21,22,23,24]. The optimal clinical response to secondary MBS must be weighed against the risk of the treatment and the possible side effects. In our study with a follow-up of 5 years, weight stabilization was reached by GPR, and—even more important—a resolution of recurrent obesity–associated comorbidities was achieved in most cases.

However, over the last decade, modifications of GPR techniques were reported with the aim of enhancing restriction by adding gastric bands or minimizer rings. A comparison of four different techniques (GPR, gastric pouch banding, GPR and banding, shortening of the common limb) demonstrated no significant difference in terms of additional weight loss [25]. Signs of malnutrition were only seen in patients with a shortened common limb and dysphagia only after applying rings to the gastric pouch, whereas the complication rate for GPR alone was very low. Amor et al. reported their results after GPR for recurrent weight gain in 48 patients and emphasized that the best results were achieved in carefully selected patients: gastric pouch size > 200 ml and/or GJ anastomosis > 20 mm including extensive preoperative evaluation [20].

The challenge lies in finding the best treatment strategy for recurrent weight gain where the benefits outweigh the risks and side effects. Similar to our results, a recent study with a follow-up over 10 years after GPR found that despite recurrent weight gain, the resolution of comorbidities was maintained over time [26]. However, the cohort was rather small including only 20 patients. In a recent meta-analysis, Koh et al. found high remission rates for comorbidities after secondary MBS, especially after revisional duodenal switch [27]. In line with that, Chierici et al. found biliopancreatic diversion with a duodenal switch to guarantee the best results for weight loss, yet at the cost of increased risk for major morbidity [28]. Finally, our study is the first to use PROMs to investigate patient satisfaction and quality of life after secondary MBS. Against the background of a follow-up period of 5 years and a high response rate, we consider these results as representative. Overall, secondary GPR exerted a positive influence on the quality of life, albeit with a lesser impact compared to the improvement that is observed after primary RYGB. This observation can be attributed to an elevated baseline quality of life following primary RYGB [29,30,31], and the weight loss achieved after secondary MBS typically falls below that attained after initial MBS. Both facts contribute to the surgery’s impact on the patient’s life. Accordingly, over two-thirds of the survey participants expected more weight loss after GPR. It is therefore important that the surgeon manages these expectations. Patients need to know that secondary MBS has a different measure of optimal clinical response than primary MBS. Cessation of recurrent weight gain and resolution of recurrent comorbidities should be considered optimal clinical response. Yet, most survey participants would choose MBS again to treat their obesity, even if they had to undergo several surgeries.

There are limitations to our study. First, we had to deal with heterogenous preoperative workup results, as patients were referred by specialists. Further, both distal and proximal RYGB prior to GPR are included. However, we are confident that this does not confound our findings since distal RYGB is not associated with greater BMI reduction than proximal RYGB [32].