Management of Recurrent Weight Gain After Sleeve Gastrectomy: Comparative Effectiveness of Conversion Procedures Versus Obesity Management Medications

Background: Recurrent weight gain after sleeve gastrectomy (SG) is a common long-term challenge, often requiring additional intervention. Management options include conversion surgery—most commonly to Roux-en-Y gastric bypass (RYGB) or One-anastomosis gastric bypass (OAGB), or treatment with obesity management medications (OMMs). Comparative long-term data between these strategies remain limited. This study aimed to evaluate long-term outcomes of OMM therapy versus conversion surgery after SG for recurrent weight gain. Methods: A retrospective analysis of a prospectively maintained registry from a tertiary university hospital was conducted, including patients treated for recurrent weight gain after SG between 2014 and 2024. Patients underwent conversion surgery (OAGB or RYGB) or were treated with OMMs. Results: A total of 195 patients were included: OAGB (n = 69), RYGB (n = 62), and OMM (n = 64). Mean follow-up was 6.4 years. BMI at last follow-up differed significantly between groups (OMM 33.3 ± 5.1 kg/m², OAGB 28.3 ± 4.6 kg/m², RYGB 29.8 ± 4.9 kg/m²; p = 0.0005). Total weight loss (TWL) was also significantly higher in surgical groups (OMM 7.9% ± 8.4, OAGB 25.8%±11.2, RYGB 20.1%±10.5; p = 0.003). TWL ≥ 20% was achieved in 68.1% of OAGB patients, 46.7% of RYGB patients, and 9.4% of OMM patients (p < 0.001). Resolution of type 2 diabetes and hypertension was more frequent following surgical conversion. Revisional surgery rates were low and similar between surgical groups. Conclusions: Conversion surgery following SG was associated with greater long-term weight loss and metabolic improvement compared with OMM therapy alone. Among surgical options, OAGB demonstrated the highest proportion of patients achieving clinically meaningful weight loss.