Revisional bariatric surgery after adjustable gastric band: a multicenter Polish Revision Obesity Surgery Study (PROSS)
BMC Surgery volume 23, Article number: 94 (2023)
Adjustable gastric band (AGB) hadbeen the preferred treatment for morbid obesity because it is minimally invasive and reversible. But now it seems to be slowly becoming a historic procedure due to the disappointing effects. The aim of the study was to systematize and present the available data on revisional bariatric surgery (RBS) after AGB among Polish patients.
It is a multicenter, retrospective analysis of patients undergoing laparoscopic RBS after AGB in 12 Polish bariatric centers. The database included patient demographics, comorbidities and surgical outcomes.
The group consisted of 234 patients who underwent AGB, which accounted for 29% of revisional cases recorded in the Polish Revisional Obesity Surgery Study (PROSS). 195 were women (83%), and 39 were men (17%). One hundred seventy-five patients after AGB experienced a weight regain (74.5%), 36 patients a gastric band slippage (15.0%), 14 patients had gastric band intolerance (6.0%). Types of RBS included 116 sleeve gastrectomies (SG) (49.4%), 86 Roux-en Y gastric by-passes (RYGB) (36.6%), 20 one anastomosis gastric by-passes (OAGB) (8,5%). The highest weight loss expressed as %EBMIL was observed after OAGB (63.5 ± 32.4%).
The main indication for RBS after AGB was weight regain. SG was the most frequently chosen type of RBS after AGB. RBS after AGB leads to weight loss and improvement in type 2 diabetes and hypertension with an acceptable low risk of complications.
Obesity is a growing problem worldwide and the number of bariatric surgeries continues to increase . Currently, there are more than 20 types of procedures tailored to the obese patient . Not every method of surgical treatment of obesity has turned out to be as effective as originally thought and planned. Following the widespread use of laparoscopy in bariatric surgery, the laparoscopic adjustable gastric band (AGB) had become one of the most performed procedures. This was due to its short operative time, relatively easy to perform, and preliminary results were promising .
AGB -was the preferred treatment for morbid obesity because it was minimally invasive and reversible. This led to many surgeries. But now it seems to be slowly becoming a historic procedure due to the disappointing effects of weight loss and weight regain . Currently, thousands of patients require bariatric revision due to unsatisfactory metabolic outcomes or postoperative complications after AGB [3, 4]. The band removal procedure is relatively easy and willingly performed by many bariatric surgeons. The problem is the type of revisional bariatric surgery (RBS) that should be performed on the patient. It often depends on the reason of the reoperation or the habits of the surgeons. The aim of the study was to systematize and present the available data on RBS after AGB among Polish patients.
It is a multicenter, retrospective, non-randomised analysis of the collected data between 2019 and 2020 under the patronage of Metabolic and Bariatric Surgery Chapter and Videosurgery Chapter of the Association of Polish Surgeons. In each department, authors involved in the surgical treatment of obesity entered data on bariatric patients undergoing laparoscopic RBS to build a comprehensive database. The inclusion criteria for this study met the bariatric surgery eligibility criteria . In the absence of overarching guidelines for patient eligibility for RBS, each center has its own criteria. Patients with missing or inconsistent data were excluded from the study.
The database included patient demographics: sex, age, maximum body weight, weight before primary surgery, weight before RBS, height, and body mass index (BMI). It also contained information on comorbidities in patients: type 2 diabetes (T2D) and hypertension (HT) and their remission according to standardized outcomes reporting . Additionally, it included data on AGB (length of hospital stay (LOS), complications, outcomes) and data on RBS (indications for RBS, LOS, type of surgery, complications, outcomes). Recurrence of obesity was defined as a regain of weight after initial successful weight loss (defined as percentage of excess weight loss (EWL%) > 50%) or a failure to achieved a successful weigh loss .
Surgical technique and perioperative care
Surgical technique and protocol of perioperative care, including preoperative, intraoperative, and postoperative interventions, were standard at each participating center. Patients were treated by a multidisciplinary team of surgeons, physicians, nurses, dieticians, and psychologists at each bariatric center.
The analysis was performed using SAS® On Demand for Academics software (SAS Institute, Cary, NC, USA). Continuous variables were expressed using mean and standard deviation. Categorical variables were presented using percentage. For analysis of variance, general linear model was used. Categorical variables were compared using Fisher's exact tests. Statistical significance was set at p < 0.05.
The data were completely anonymized. The study was conducted in accordance with the ethical standards of Helsinki Declaration of 1964 and its subsequent amendments (Fortaleza). The protocol was registered at clinical trials.gov (NCT05108532, 05/11/2021). The study was closely monitored by the principal investigator who processed and verified any missing or unclear data submitted to the central database. The study was approved by the Bioethics Committee of the Regional Chamber of Physicians, District of Warmia and Mazury, Poland (23/2021/VIII).
Study group characteristics
The group consisted of 234 patients who underwent AGB, which accounted for 29% of revisional cases recorded in the Polish Revisional Obesity Surgery Study (PROSS). 195 were women (83%), and 39 were men (17%). The mean age was 47.7 ± 9.7 years. Seventy-six patients had HT and 13% had T2D. Alcohol consumption was reported in 32% and 17% reported smoking prior to bariatric treatment. 18% of patients used NSAIDs more than once a week. The mean follow-up time was 23.0 ± 29.6 months, Table 1.
Indications for RBS
After AGB, 175 patients experienced a weight regain (74.5%), that met the bariatric criteria, 36 patients experienced a gastric band slippage (15.0%), 14 patients had gastric band intolerance (6.0%), 7 patients developed gastric outlet obstruction (3.0%). Two patients had gastric band migration (1%) and one patient had esophageal perforation (0.5%), Table 2.
Types of RBS
Types of RBS included 116 sleeve gastrectomies (SG) (49.4%), 86 Roux-en Y gastric by-passes (RYGB) (36.6%), 20 one anastomosis gastric by-passes (OAGB) (8,5%), and other procedures (5.4%) Table 1.
The mean BMI before AGB was 43.9 ± 6.6 kg/m2. The mean lowest BMI after AGB was 33.2 ± 7.4 kg/m2. Before RBS, the mean BMI was 40.6 ± 6.9 kg/m2. After RBS, the mean BMI was 32.4 ± 5.8 kg/m2 (Table 1). After AGB, the percentage of excess BMI loss (EBMIL%) and delta BMI (dBMI) were 15.39 ± 31.29 and 3.32 ± 5.77, respectively. EBMIL% and TWL% after RBS were 47.86 ± 59.48% and25.4 ± 12.9%. The highest weight loss expressed as %EBMIL and TWL% was observed after RBS in patients who underwent OAGB (63.5 ± 32.4% and 27.5 ± 11.4%, respectively). %EBMIL and TWL% in RYGB group were 53.2 ± 29.3% and 24.1 ± 12.2%. %EBMIL and TWL% in SG patients were: 52.6 ± 42.6% and 26.98 ± 13.2%. The lowest weight loss was observed in patients who underwent subsequent AGB—%EBMIL and TWL% were 41.9 ± 55.9% and 22.1 ± 17.8%, Table 3.
Remission of obesity-related comorbidities
T2D was diagnosed in 31 patients (13.2%) before RBS. Follow-up data were available for 28 patients. After RBS, 8 patients (28.6%) achieved complete remission, 7.2% partial remission of T2D. Improvement in T2D was observed in the group of 8 patients. Preoperative HT was diagnosed in 76 patients (32.3%). Follow-up data were available for 59 patients. Complete remission of HT was observed in 31.7%. Improvement in HT was observed in 31.7%. No effect was found in 35%, Table 4.
Complications and LOS after RBS
Complications after RBS are described in Table 5. The RBS with the highest complication rate was SG. 24.1% experienced leakage, bleeding, ileus or GERD. The median LOS was 3.2 days after RBS. The shortest for SG (2.9 days) and the longest after subsequent AGB (4.0 days), Table 5.
Our study is a retrospective analysis of 234 patients undergoing RBS after AGB. This study includes data on the largest group of patients undergoing RBS in Poland, collected as a part of PROSS project . According to an IFSO Survey, there was a huge drop in AGB’s performance from 42,3% to 1,4% between 2008 and 2018 . Furthermore, a meta-analysis by Koh et al. reported that AGB is one of the most common bariatric surgeries requiring revision . So we believe that our work will be a useful in clinical practice of RBS analysis.
Recent analysis showed that AGB has a high removal rate, up to 50% 15 years after surgery [3, 4, 9]. On the other hand, we can also find papers with lower rate. O’Bien et al. reported approximately 6% of band removal over 15 years of follow-up, but 76% of patients required surgical band replacement due to complications . So the removal rate may vary depending on the management policy in the case of band failure. Nevertheless, all the papers found reported an exceptionally high rate of RBS requirement. This contributed to the drastic decline in the use of AGB .
The main cause of RBS in our study was a weight regain (74.5%) and secondly gastric band slippage and intolerance (15%, 6% respectively). The weight regain or insufficient weigh loss is also a main reason for band removal in other reports, but the proportion is not dominated by this [3, 10, 11]. The reason for this difference can be found in our study design. We analyzed not all the AGB inserted at this time, but only the cases requiring RBS, unlike the papers that examined the AGB in general [3, 10,11,12].
Almost half of the analyzed patients underwent SG as a revisional procedure, followed by RYGB and OAGB. We found various tendencies in the literature [3, 11,12,13,14]. Rafols et al. reported that three-quarters of their patients undergone RYGB as RBS, while Chansaroy et al. performed nearly half of OAGB [11, 12]. It can therefore be concluded that the choice of RBS depends on the experience and habits of a given center. It is also worth noting that OAGB gains over SG, which we find in the risk of GERD [1, 15]. According to the latest data, OAGB has a similar effect in reducing GERD symptoms as RYGB, evidenced by patient assessment of upper gastrointestinal disorder-symptom severity index (PAGI-SYM) standardized questionnaire, upper endoscopy, 24-h pH monitoring and manometry .
If weight regain is one of the main causes of band removal, weight loss after RBS is an especially important factor when choosing revisional surgery. In our study, OAGB achieved the best results expressed as %EBMIL, which was 63.5% at the time of follow-up, followed by RYGB and LSG, both around 53% each. Other authors also observed comparable results in favor of the OAGB [11, 12].
RBS after AGB can be performed in both a one-step and two-step procedure [17,18,19,20]. Unfortunately, our data cannot determine which type was selected. Nevertheless, a recent meta-analysis by Zadeh et al. showed that there does not appear to be a significant difference in the overall leak rate between one- and two-step AGB conversions . In our study, the perioperative complications requiring intervention were less than 3%. 4 patients (1.7%) experienced a leak, and 3 patients (1.3%) experienced postoperative bleeding.
The limitation of the study is its retrospective character. Some procedures were performed selectively, such as subsequent AGB, so their statistical comparison can be misleading. In addition, we do not have a universal protocol for revisional surgery, therefore the indications and the choice of procedure may differ depending on the center.
The main indication for RBS after AGB was weight regain. SG was the most frequently chosen type of RBS after AGB. RBS after AGB leads to weight loss and improvement in T2D and HT with an acceptable low risk of complications.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
AGB adjustable gastric band
RBS revisional bariatric surgery
Polish Revisional Obesity Surgery Study
Roux-en Y gastric by-pass
One anastomosis gastric bypass
Type 2 diabetes
Length of hospital stay
Body mass index
Percentage of excess weight loss
Percentage of excess BMI loss
Angrisani L, Santonicola A, Iovino P, et al. Bariatric Surgery Survey 2018: Similarities and Disparities Among the 5 IFSO Chapters. Obes Surg. 2021;31:1937–48.
Bhandari M, Fobi MA, Buchwald J. Bariatric Metabolic Surgery Standardization (BMSS) Working Group Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement. Obes Surg. 2019;29:309–45.
Carandina S, Tabbara M, Galiay L, et al. Long-term outcomes of the laparoscopic adjustable gastric banding: weight loss and removal rate. A single-center experience on 301 patients with a minimum follow-up of 10 years. Obes Surg. 2017;27:889–95.
Kowalewski PK, Olszewski R, Kwiatkowski AP, et al. Revisional bariatric surgery after failed laparoscopic adjustable gastric banding – a single-center, long-term retrospective study. Videosurgery Miniinv. 2017;12:32–6.
Szeliga J, Wyleżoł M, Major P, et al. Metabolic and Bariatric Surgery Chapter of the Association of Polish Surgeons. Bariatric and metabolic surgery care standards. VSJ. 2020;15:391–4.
Brethauer AS, Kim J, el Chaar M, et al. Standardized outcomes reporting in metabolic and bariatric surgery. Surg Obes Relat Dis. 2015;11:489–506.
Major P, Zarzycki P, Rymarowicz J, et al. Revisional operations among patients after surgical treatment of obesity: a multicenter Polish Revision Obesity Surgery Study (PROSS). Videosurgery Miniinv. 2022;17:372–9.
Koh ZJ, Chew CAZ, Zhang JJY, et al. Metabolic outcomes after revisional bariatric surgery: a systematic review and meta-analysis. Surg Obes Relat Dis. 2020;16:1442–54.
Victorzon M, Tolonen P. Mean fourteen-year, 100 % follow-up of laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Relat Dis. 2013;9:753–7.
O’Brien PE, Hindle A, Brennan L, et al. Long-term outcomes after bariatric surgery: a systematic review and meta-analysis of weight loss at 10 or more years for all bariatric procedures and a single-centre review of 20-year outcomes after adjustable gastric banding. Obes Surg. 2019;29:3–14.
Chansaenroj P, Aung L, Lee W-J, Chen C, Chen J-C, Ser K-H. Revision procedures after failed adjustable gastric banding: comparison of efficacy and safety. Obes Surg. 2017;27:2861–7.
Musella M, Bruni V, Greco F, et al. Conversion from laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) to one anastomosis gastric bypass (OAGB): preliminary data from a multicenter retrospective study. Surg Obes Relat Dis. 2019;15:1332–9.
Pujol-Rafols J, Al Abbas AI, Devriendt S, et al. Roux-en-Y gastric bypass, sleeve gastrectomy, or one anastomosis gastric bypass as rescue therapy after failed adjustable gastric banding: a multicenter comparative study. Surg Obes Relat Dis. 2018;14:1659–66.
Wu C, Wang FG, Yan WM, et al. Clinical outcomes of sleeve gastrectomy versus Roux-En-Y gastric bypass after failed adjustable gastric banding. Obes Surg. 2019;29:3252–63.
Małczak P, Pisarska-Adamczyk M, Zarzycki P, et al. Hiatal Hernia Repair during Laparoscopic Sleeve Gastrectomy: Systematic Review and Meta-analysis on Gastroesophageal Reflux Disease symptoms changes. Pol Przegl Chir. 2021;93:1–5.
Eskandaros MS, Abbass A, Zaid MH, et al. Laparoscopic One Anastomosis Gastric Bypass Versus Laparoscopic Roux-en-Y Gastric Bypass Effects on Pre-existing Mild-to-Moderate Gastroesophageal Reflux Disease in Patients with Obesity: a Randomized Controlled Study. Obes Surg. 2021;31:4673–81.
Pujol-Rafols J, Al Abbas AI, Devriendt S, et al. Conversion of Adjustable Gastric Banding to Roux-en-Y Gastric Bypass in One or Two Stages: What Is the Best Approach? Analysis of a Multicenter Database Concerning 832 Patients. Obes Surg. 2020;30:5026–32.
Alratrout H, Almuttawa A, Siciliano I, et al. Laparoscopic Roux-en-Y gastric bypass for failed gastric banding: one-step or two-step revisional surgery? Obes Surg. 2021;31:646–53.
Thomopoulos T, Podetta M, Studer AS, et al. Efficiency of laparoscopic one-step revision of failed adjusted gastric banding to gastric sleeve: a retrospective review of 101 consecutive patients. Obes Sur. 2019;29:3868–73.
Demouron M, Rebibo L, DavarpanahJazi AH, et al. Sleeve gastrectomy as a rescue of failed gastric banding: comparison of 1- and 2-step approaches. Surg Obes Relat Dis. 2020;16:1045–51.
Zadeh J, Le C, Ben-David K. Safety of adjustable gastric band conversion surgery: a systematic review and meta-analysis of the leak rate in 1- and 2-stage procedures. Surg Obes Relat Dis. 2020;16:437–44.
All members of the “PROSS – Collaborative Study Group”: Piotr Major1, Michał Pędziwiatr1, Justyna Rymarowicz1, Piotr Zarzycki1, Tomasz Stefura1, Karol Ciszek1, Piotr Małczak1, Piotr Myśliwiec2, Hady Razak Hady2, Paulina Głuszyńska2, Monika Proczko-Stepaniak3, Michał Szymański3, Maciej Walędziak4, Michał Janik4, Andrzej Kwiatkowski4, Magdalena Materlak4, Katarzyna Bartosiak4, Łukasz Czyżykowski4, Maciej Mawlichanów4, Piotr Kowalewski4, Jacek Szeliga5, Wojciech Kupczyk5, Natalia Dowgiałło-Gornowicz6, Paweł Lech6, Anna Harań6, Grzegorz Kowalski7, Rafał Mulek8, Michał Krefft8, Michał Wysocki9, Michał Orłowski10, Paula Franczak10, Artur Binda11, Wiesław Tarnowski11, Paweł Jaworski11, Mateusz Kamiński12, Maciej Pastuszka13, Wojciech Lisik14, Paweł Szymański15, Bartosz Katkowski15, Michał Leśniak15, Michał Łabul16.
1 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
2 1st Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
3 Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
4 Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
5 Department of General, Gastroenterological, and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Torun, Poland
6 Department of General, Minimally Invasive and Elderly Surgery, University of Warmia and Mazury in Olsztyn, Poland
7 Surgery Clinic Mazan, Katowice, Poland
8 Department of general and endoscopic surgery, EuroMediCare Specialist Hospital and Clinic in Wroclaw, Wroclaw, Poland
9 Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
10 Department of General and Oncological Surgery, Ceynowa Hospital, Wejherowo, Poland
11 Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orłowski Hospital, Warsaw, Poland
12 Department of General, Transplant, Gastroenterological and Oncological Surgery, Medical University of Lodz, Lodz, Poland
13 Department of General and Minimally Invasive Surgery, Independent Public Health Care Center in Leczna, Leczna, Poland
14 Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
15 Department of General and Vascular Surgery, Specialist Medical Center in Polanica Zdroj, Polanica Zdroj, Poland
16 Department of General Surgery, Specialist Hospital in Legnica, Legnica, Poland
No funding to declare.
Ethics approval and consent to participate
The study was conducted in accordance with the ethical standards of Helsinki Declaration of 1964 and its subsequent amendments (Fortaleza). The study was approved by the Bioethics Committee of the Regional Chamber of Physicians, District of Warmia and Mazury, Poland (23/2021/VIII). Informed consent was obtained from all patients.
Consent for publication
The authors declare no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Dowgiałło-Gornowicz, N., Janik, M., Lech, P. et al. Revisional bariatric surgery after adjustable gastric band: a multicenter Polish Revision Obesity Surgery Study (PROSS). BMC Surg 23, 94 (2023). https://doi.org/10.1186/s12893-023-02002-w