Endoscopic option for weight recidivism linked to dilated gastro-jejunal anastomosis has been suggested in several experiences to be safe with minimal morbidity. Catalano et al. showed that the injection of sclerotic agents to reduce the size of gastro-jejunal anastomosis result in weight loss after weight regain [25]. Thompson et al. showed that endoscopic suturing was also safe and feasible to reduce the gastrointestinal anastomosis to an average of 10 mm, leading to weight loss in 75 % of RYGBP patients and resulting in loss of 23.4 % of EBWL [23]. Recently, a viable endoscopic alternative to reduce the pouch volume was proposed, with mucosal or total wall plication, reshaping the pouch with dedicated instruments [1, 23]. Eid et al. have reported a randomized clinical trial comparing multiple full-thickness plications to sham endoscopy procedure after weight loss failure of RYGB [26]. They suspended the trial prematurely because preliminary results indicated the failure to achieve the primary efficacy end point at last in 50 % of patients treated with plication.

Parikh et al. suggest resecting the pouch and alimentary loop in a longitudinal fashion. But this procedure was not considered safe and effective enough [27]. Hamdi et al. also suggest resizing the gastric pouch by resection and recreating the gastrojejunostomy. Perioperaitive complication rate was 8 % [28]. After 24 months of follow up they observed 44 % of %EWL. They conclude that this re-do procedure can be performed with significant weight loss, but additional studies are requested [28]. Gumbs et al., in case of tissue suffering from previous scars or fistulas or postoperative leak, suggest an external plication mimicking the longitudinal resection suggested by Parikh, and inspired by the gastric plication technique [1]. This plication was performed with nonabsorbable stitches across a 34 French orogastric tube. This revisional option was safe and attractive in terms of safety, but long-term results of these techniques are not reported.

Another laparoscopic option to treat the pouch enlargement is the positioning of an external ring. Essentially two options have been described. Fobi showed that the addition of ring proximally to the gastrointestinal anastomosis is enough to reduce the food ingestion [29]. More recently were described some patients with an adjustable gastric banding positioned around the upper part of the gastric pouch. Chin et al. described their experience with ten patients who underwent revisional surgery positioning an adjustable gastric banding around the RYGB pouch [30]. After 2 years of follow up the %EWL was 48.7 % (range 21.8–98.1 %) without life threatening complications. Bessler et al. reported their experience with 27 patients who underwent RYGB revision with adjustable gastric band [31]. At 60 months of follow up they observed 47 % of %EWL; also, in this report life threatening complications were absent and two port-related complications and one band slippage were recorded. They conclude that the addiction of the adjustable silicone gastric banding causes significant weight loss in patients with weight recidivism or poor weight loss after RYGB. The absence of anastomosis or changes in limbs length makes this revisional option safe and attractive. Recently, Vijgen reported a review of the studies on the effects of salvage pouch banding after failed RYGB [32]. In their review were included patients with both adjustable and non-adjustable gastric banding operated via laparotomy or laparoscopy. In the seven studies considered, all the authors support the opinion that the adjustable gastric banding around the pouch is a safe and feasible revisional procedure after failed RYGB [32]. Moreover, despite these studies, long-term results on a large patient population who underwent pouch banding are scarce, waiting for an evidence-based confirmation.