BACKGROUND:Reoperations account for approximately 11% of annual metabolic and bariatric surgery cases in the United States. Indications vary and include weight-related and complication-related issues. The number of American Society for Metabolic and Bariatric Surgery (ASMBS)-endorsed procedures has grown in popularity since the original 2014 ASMBS publication on reoperative metabolic and bariatric surgery (rMBS). OBJECTIVES:This paper was created as one of a 2-part update to the 2014 ASMBS publication on rMBS. SETTING:A literature review was conducted by the American Society of Metabolic and Bariatric Surgery's Clinical Issues Committee. Available literature from 2014 to present was included. METHODS:A search was performed using Ovid MEDLINE and PubMed databases looking for studies related to surgical treatments for chronic complications after metabolic and bariatric surgery. Relevant studies were screened for inclusion by the authors. RESULTS:rMBS serves an important role in the care of chronic complications after all ASMBS-endorsed procedures. In many cases, data are limited in quality to retrospective case series. Prevention is essential to limiting chronic complications and their associated morbidity and mortality. Mesenteric defect closure in all anastomotic MBS procedures is of paramount importance. Once chronic complications occur, a step-wise multidisciplinary approach is recommended, beginning with medical therapy, followed by endoscopic interventions, and ultimately rMBS when indicated. CONCLUSIONS:Surgeons should treat each patient presenting for rMBS on an individualized basis. Patient management should follow a structured escalation of care that prioritizes nonoperative treatments before progressing to rMBS.

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.

INTRODUCTION:Residual weight stigma refers to lingering negative attitudes, judgment, and/or stereotypes that persist towards individuals even after they have achieved significant weight loss. This study aimed to identify the types of residual weight stigma reported by patients following metabolic and bariatric surgery (MBS), and to examine the relationships between residual weight stigma, internalized weight bias, and weight loss outcomes in this population. METHODS:Adults who underwent MBS completed a one-time electronic survey at a post-operative follow-up visit. The survey included the modified version of the Weight Bias Internalization Scale (WBIS-M), history of experienced weight stigma, and questions developed for this study to assess residual weight stigma since losing weight. Postoperative body weight was recorded on the date of the survey. RESULTS:Participants (N = 128) completed a one-time survey at 44.5 ± 42.6 months after MBS, and achieved total percent weight loss of 19.1 ± 11.0 after sleeve gastrectomy, 24.8 ± 9.3 after Roux-en-Y gastric bypass, 19.7 ± 13.3 after adjustable gastric banding, and 15.1 ± 11.0 after conversion surgery. Among the 128 participants, 33.9% reported being judged for "taking the easy way out" by losing weight through surgery and 26.1% concealed their surgery from others. While 57.8% of participants reported increased confidence based on how other people treated them since losing weight, 39.2% reported feeling more self-critical about their weight based on how others treated them since losing weight. Higher internalized weight bias was associated with significantly less total percent weight loss following surgery, controlling for surgery type (p = 0.003). CONCLUSION:A substantial portion of MBS patients in this study experienced residual weight stigma following weight loss, and higher internalized weight bias was associated with less weight loss. The broader impact of residual stigma on weight loss and other patient-centered outcomes after MBS warrants further investigation.

Residual weight stigma refers to lingering negative attitudes, judgment, and/or stereotypes that persist towards individuals even after they have achieved significant weight loss. This study aimed to identify the types of residual weight stigma reported by patients following metabolic and bariatric surgery (MBS), and to examine the relationships between residual weight stigma, internalized weight bias, and weight loss outcomes in this population. Adults who underwent MBS completed a one-time electronic survey at a post-operative follow-up visit. The survey included the modified version of the Weight Bias Internalization Scale (WBIS-M), history of experienced weight stigma, and questions developed for this study to assess residual weight stigma since losing weight. Postoperative body weight was recorded on the date of the survey. Participants (N = 128) completed a one-time survey at 44.5 ± 42.6 months after MBS, and achieved total percent weight loss of 19.1 ± 11.0 after sleeve gastrectomy, 24.8 ± 9.3 after Roux-en-Y gastric bypass, 19.7 ± 13.3 after adjustable gastric banding, and 15.1 ± 11.0 after conversion surgery. Among the 128 participants, 33.9

The Clavien–Dindo classification (CDC) grades complications based on required interventions, yet prior MBSAQIP studies used arbitrary assignments, limiting standardization. Comparative safety between robotic (RSG) and laparoscopic sleeve gastrectomy (LSG) remains inconsistent. We assigned CDC grades using treatment-level data and compared 30-day outcomes between RSG and LSG. We conducted a retrospective cohort study using MBSAQIP data (2020–2023) comparing primary laparoscopic and robotic sleeve gastrectomy. Clavien–Dindo grades were assigned using treatment-level data, including reoperation, reintervention, readmission, and ICU care. Cumulative morbidity was assessed with the Comprehensive Complication Index (CCI), with CCI ≥26.2 indicating significant morbidity. Multivariable regression evaluated associations between surgical approach and CDC grades. Among 480,280 patients, 73

BACKGROUND:Individuals who undergo metabolic and bariatric surgery (MBS) are often encouraged to prioritize moderate-to-vigorous physical activity (MVPA) to improve outcomes. However, this approach overlooks other important daily movement behaviors, including light-intensity physical activity, sedentary behaviors, and sleep. The 24-hour paradigm, which recognizes these behaviors as interdependent, guides research and practice in type 2 diabetes and cancer and may offer similar uses and benefits in the context of MBS. OBJECTIVES:(1) Review studies examining movement behaviors, individually or combined, in the context of MBS and clinical outcomes and (2) present rationale and recommendations for integrating the 24-hour movement paradigm into MBS research and practice. SETTING:International collaboration of MBS researchers, clinicians, and stakeholders. METHODS:A narrative review examined how MBS patients engage in movement behaviors beyond MVPA, how these behaviors may be associated with MBS outcomes, and interventions targeting them. This evidence was used to shape the rationale and recommendations for integrating the 24-hour movement paradigm into MBS research and practice. RESULTS:Few studies have examined the 24-hour movement behaviors, and none have explored their interactions. Similarly, few research interventions have targeted behaviors beyond MVPA in MBS patients. There is a clear need to determine how to effectively integrate the 24-hour movement paradigm into MBS practice to improve weight and health outcomes. Several suggestions are offered to help integrate this approach to enhance healthier 24-hour movement patterns. CONCLUSION:Integrating the 24-hour movement paradigm into MBS research and clinical care can yield a more complete view of how daily movement patterns affect clinical outcomes and guide personalized interventions that address all behaviors collectively rather than each one in isolation.

BACKGROUND:Marginal ulcers (MU) are a significant postoperative complication following anastomotic metabolic and bariatric surgeries including Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), and biliopancreatic diversion with duodenal switch (BPD/DS). This review summarizes current knowledge on MU risk factors, screening, and prophylactic strategies. OBJECTIVES:The goal of this review is to examine technical and patient-related risk factors for MU, assess screening strategies, and recommend prophylactic approaches to reduce MU incidence after anastomotic metabolic and bariatric surgery (MBS). SETTING:A comprehensive review was conducted by members of the American Society for Metabolic and Bariatric Surgery (ASMBS) Clinical Issues Committee, based on available literature from 2000 to the present. METHODS:A systematic search was performed using Ovid MEDLINE and PubMed databases. Relevant studies were screened for inclusion. Technical and patient-related factors were evaluated, and recommendations for MU prevention were formulated. RESULTS:Several risk factors for MU were identified, including large gastric pouch size, circular stapled anastomoses, use of nonabsorbable sutures, smoking, nonsteroidal anti-inflammatory drugs use, and immunosuppression. While prophylactic proton pump inhibitor (PPI) therapy is widely recommended, its optimal duration remains debated. The role of Helicobacter pylori in MU development is not clearly defined. CONCLUSIONS:Prophylactic PPI therapy for at least 3 months postsurgery significantly reduces the risk of MU. Risk stratification and individualized treatment plans are essential to minimize postoperative complications. Further research is needed to clarify the role of H. pylori and optimize prophylactic strategies.

Endoscopic sleeve gastroplasty (ESG) reduces gastric volume via endoscopic suturing, offering a less invasive alternative to laparoscopic sleeve gastrectomy (LSG). However, their comparative safety remains inadequately explored. This study evaluates 30-day postoperative outcomes between ESG and LSG using a national database. A retrospective analysis of the MBSAQIP database (2020–2023) was conducted comparing primary ESG and LSG procedures. Propensity score matching (1:4) was performed for 16 baseline variables, including demographics, BMI, ASA class, and comorbidities. Major complications were defined as significant postoperative adverse events, including reoperation, reintervention, unplanned ICU admission, intubation, or severe organ dysfunction. Outcomes were analyzed using t-test/rank-sum and Chi-square/Fisher’s exact tests. Risk factors for major complications in ESG patients were identified using LASSO regression and multivariate logistic regression. Among 207,984 patients, 1

BACKGROUND:The safety of concurrent Heller myotomy (HM) and metabolic bariatric surgery (MBS) remains underexplored, with existing literature limited to case reports. This study aimed to evaluate the 30-day postoperative outcomes of concurrent HM-MBS vs MBS alone. METHODS:A retrospective analysis of the 2020-2023 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was conducted. HM-MBS cases were identified. To minimize confounding, propensity score matching (1:3) was performed using 25 preoperative characteristics. The 30-day postoperative outcomes and complications, categorized using the Clavien-Dindo classification (CDC), were compared between the HM-MBS and MBS groups using independent samples t tests/rank-sum and chi-square tests/Fisher exact tests. Subgroup analyses were performed for the primary and conversion procedures. RESULTS:After matching, 336 patients (HM-MBS: n = 84; MBS: n = 252; mean age: 52.3 ± 10.9 years; 85.4% female) were analyzed, including 236 primary and 100 conversion procedures. Compared with the MBS group, the HM-MBS group had significantly prolonged operative times (123.6 ± 59.8 vs 210.9 ± 72.3 minutes, respectively; P <.001) and hospital stays (1.56 ± 1.20 vs 3.60 ± 6.90 days, respectively; P =.007). Overall complications were higher in the HM-MBS group than in the MBS group (27.4% vs 10.7%, respectively; P <.001), including increased gastrointestinal bleeding (3.6% vs 0.0%, respectively; P =.015), surgical site infections (6.0% vs 1.2%, respectively; P =.026), ventilator support (3.6% vs 0.0%, respectively; P =.015), and sepsis (6.0% vs 0.4%, respectively; P =.004). The rates of severe complications (CDC grade ≥ IIIa) were higher in the HM-MBS group than in the MBS group (overall: 16.7% vs 2.8%, respectively; P <.001; reoperation: 8.3% vs 1.6%, respectively; P =.007; reintervention: 8.3% vs 1.2%, respectively; P =.003). Subgroup analyses revealed similar patterns across the primary and conversion procedures. CONCLUSION:Concurrent HM-MBS is associated with significantly higher postoperative morbidity, suggesting the need for careful consideration of surgical timing in patients who require both procedures.

Bile acids (BAs) play a crucial role in metabolic regulation and weight loss, especially in the context of metabolic bariatric surgery (MBS). BAs contribute to the body’s hormonal response to meals, influencing glucose metabolism, lipid regulation, and energy expenditure. Changes in BA homeostasis following MBS have been associated with metabolic improvements. Conversely, cholecystectomy (CCx) disrupts the rhythmic secretion of bile and has been linked to metabolic disturbances, including non-alcoholic fatty liver disease and metabolic syndrome. The impact of CCx performed prior to or concurrently with MBS on weight loss remains unclear. We conducted a retrospective analysis of MBS patients (2016–2023), categorizing them by CCx status and type of primary MBS. Weight loss outcomes were assessed at 30 days, 6 months, and 1 year postoperatively. Linear mixed models were used to evaluate percent total weight loss (

Understanding how to incorporate exercise into metabolic and bariatric surgery programs to optimize treatment outcomes is of great interest, as evidenced by 11 reviews published on this topic in 2022 alone. This overview of reviews was conducted to create a single cohesive resource to aid clinicians and researchers by exploring the effects of pre- and post-operative exercise training on health outcomes. A literature search of 7 electronic databases was performed (updated 09/2023) and 24 reviews met preset PICOS eligibility criteria and were included: 4 exploring preoperative exercise training, 13 postoperative, and 7 both. Comparing reviews, outcome results were organized as concordant, discordant, or inconclusive, and then categorized into "what we currently know", "what we think we know" and "what we still don't know". We do not currently know the effects of pre- or post-operative exercise training on any outcomes, but we think we know that preoperative exercise training has a positive effect on BMI and 6-minute walking test distance, and postoperative exercise training has a positive effect on body weight and BMI, waist circumference, bone mineral density, 6-minute walking test distance, muscle strength, and systolic blood pressure. Despite the abundance of research, much still needs to be done in terms of enhancing methodological rigor and reporting to achieve greater confidence in our conclusions; recommendations for the next research steps are made.

BACKGROUND:Same-day discharge (SDD) in sleeve gastrectomy (SG) is becoming increasingly common but requires careful patient selection. OBJECTIVES:To evaluate the risk profile of patients undergoing primary SG with SDD and assess 30-day serious adverse events (SAEs) in SDD and next-day discharge (NDD). SETTING:MBSAQIP 2020-2023 (United States). METHODS:SDD and NDD patients were categorized as low-risk (LR) [age<65 years, body mass index [BMI] <50 kg/m2, and no history of foregut surgery, diabetes, sleep apnea, cardiovascular disease, kidney disease, immunosuppression or thromboembolic events], and high-risk (HR) [patients with at least one of these conditions]. Logistic regression models assessed odds of SAE (i.e., Comprehensive Complication Index ≥26.2) between SDD and NDD based on risk categories and cumulative number of risk factors (RFs). RESULTS:Forty thousand three hundred eighty-seven SDDs (50.4% LR, 49.6% HR) and 281,718 NDD (41.2% LR, 58.8% HR) were identified. The odds of HR patients experiencing SAE were higher in the SDD versus NDD (odds ratio [OR]: 1.26, confidence interval [CI]: 1.09-1.45, P < .001). Among high-risk SDD, 66.9% patients had one RF, 25.7% had two and 7.4% had ≥ 3. Compared to patients with a single RF, those with 2 RFs and ≥3RFs were more likely to experience SAEs (OR = 1.40 and 2.10, respectively; P < .01). CONCLUSIONS:This study demonstrates that 50% of the SDD SG patients were considered high-risk and 32% had multiple RFs. Performing SG with SDD in high-risk patients is associated with a greater likelihood of SAE. Results warrant implementation of risk stratification models to ensure patient safety while maximizing the benefits of SDD.

The body mass index was first described almost 200 years ago and has since been used as a measure of obesity. This review describes the history, advantages, disadvantages, and alternatives to the body mass index in the care of the metabolic and bariatric surgical patient. (Surg Obes Relat Dis 2025;21:199-206.) (c) 2025 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/ licenses/by/4.0/).

Marginal ulcers (MUs) encompass a group of mucosal disruptions and subsequent inflammatory changes and their sequala found after Roux-en-Y gastric bypass (RYGB) oneanastomosis gastric bypass (OAGB), and, less commonly, after biliopancreatic diversion with duodenal switch (BPD/DS) or single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S). Prevalence of MU after RYGB ranges from .6%–16%. This review summarizes the current knowledge about the treatment options available for MU after MBS for providers who treat them.

We evaluated preoperative weight loss and days from initial consult to surgery in patients with BMI ≥50 kg/m2 who were and were not enrolled in medical weight management (MWM) prior to laparoscopic sleeve gastrectomy. We retrospectively identified patients with BMI ≥50 kg/m2 who had primary sleeve gastrectomy between 2014 and 2019 at two bariatric surgery centres in our healthcare system. Patients presenting after 2017 that received preoperative MWM (n = 28) were compared to a historical cohort of non-MWM patients (n = 118) presenting prior to programme initiation in 2017 on preoperative percent total body weight loss (%TBWL) and days from initial consult to surgery. A total of 151 patients (MWM, 33; non-MWM, 118) met inclusion criteria. BMI was significantly greater in MWM versus non-MWM (p = .018). After propensity score matching, median BMI at initial consult in non-MWM versus MWM no longer differed (p = .922) neither were differences observed on the basis of weight, age, sex, race or ethnicity. After PSM, MWM had significantly lower BMI at surgery (p = .018), lost significantly more weight from consult to surgery (p < .001) and achieved significantly greater median %TBWL from consult to surgery (p < .001). We noted no difference between groups on 6-month weight loss (p = .533). Days from initial consult to surgery did not differ between groups (p < .863). A preoperative MWM programme integrated into multimodal treatment for obesity in patients with a BMI ≥50 kg/m2 resulted in clinically significant weight loss without prolonging time to surgery.

Revisional bariatric surgery after an index adjustable gastric band (AGB) may be indicated to remedy weight relapse or band-related complications. We examined outcomes five years following revision from AGB to laparoscopic sleeve gastrectomy (AGB-LSG) or to Roux-en-Y gastric bypass (AGB-RYGB). We conducted a retrospective review to identify patients (men and women, age 18–80) who underwent one revisional bariatric procedure with AGB as the index procedure at two medical centers in our healthcare system between January 2012 and February 2017. We only included patients with a pre-revision BMI > 30 kg/m2 for whom 5-year follow-up data were available. We compared 5-year weight loss and remission of comorbidities in patients undergoing AGB-LSG and AGB-RYGB conversion. A total of 114 patients met inclusion criteria (65 AGB-LSG, 49 AGB-RYGB). At 5-year post-revision, percent total weight loss (3.4