[24] Sundbom M, Karlson BM. Low mortality in bariatric surgery 1995 through 2005 in Sweden, in spite of a shift to more complex proce- dures. Obes Surg 2009;19:1697–701. [25] Kyzer S, Raziel A, Landau O, Matz A, Charuzi I. Use of adjustable silicone gastric banding for revision of failed gastric bariatric opera- tions. Obes Surg 2001;11:66 –9. [26] Bessler M, Daud A, DiGiorgi MF, Olivero-Rivera L, Davis D. Ad- justable gastric banding as a revisional bariatric procedure after failed gastric bypass. Obes Surg 2005;15:1443– 48. [27] Morton JM. Weight gain after bariatric surgery as a result of large gastric stoma: endotherapy with sodium morrhuate to induce stomal stenosis may prevent the need for surgical revision. Gastrointest Endosc 2007;66:246 –7. [28] Catalano MF, Rudic G, Anderson AJ, Chua TY. Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision. Gas- trointest Endosc 2007;66:240 –5. [29] Brolin RE, Cody RP. Adding malabsorption for weight loss failure after gastric bypass. Surg Endosc 2007;21:1924 –26. [30] Parikh M, Pomp A, Gagner M. Laparoscopic conversion of failed gastric bypass to duodenal switch: technical consideratpions and preliminary outcomes. Surg Obes Relat Dis 2007;3:611–18. Editorial comment Comment on: Long-term follow-up in patients undergoing open gastric bypass as a revisional operation for previous failed restrictive procedures As the field of bariatric surgery evolves, there will be an increasing number of patients presenting with interest in revision for unintended consequences or weight regain after their initial bariatric procedure. Thus, it is imperative that we study the risks and benefits of revision procedures. In this report, Hedberg et al. report on the conversion of 121 patients who initially underwent a restrictive or gastric-only procedure to gastric bypass. The 5-year weight loss is re- ported for 106 patients. The authors conclude that despite the greater perioperative risks, the long-term weight loss is good and the patients are satisfied. Thus, gastric bypass is a suitable procedure after failed restrictive procedures. The questions to be answered are whether this is the correct conclusion and what else can we learn from these data. In this report, the average starting body mass index (BMI) was 37.7 kg/m 2 (class II obesity). The self-re- ported BMI at 5 years was 30.7 kg/m 2 . There were 10 early reoperations, 4 for documented leaks. Although there was no mortality, these are certainly disconcerting complications. Thus, a reasonable question to ask is whether revision bariatric surgery should be indicated for class II obesity, if there was a 4% leak rate and a net improvement of 7 BMI units. I believe that we would have never seen the expansion in bariatric surgery that we have seen with these results. These outcomes should make every bariatric surgeon think carefully before per- forming a revision for inadequate weight loss or weight regain. In this report, a portion of the patients required surgery for severe esophagitis, megaesophagus, band ero- sion, and other related pathologic features. For others, the primary indication was inadequate weight loss or weight regain. However, even though we know we can do these procedures, this study has not answered what indications justify the increased complication rate. I doubt that many would offer a procedure with a 4% leak rate for most patients with class II obesity. Perhaps the most important message is to think about what the best long-term operation should be for each indi- vidual patient. There is never going to be a perfect proce- dure or one that does not have failure or weight regain. However, obesity is a chronic problem, and revision surgery is complex with a greater risk. Thus, it is imperative that we maximize our effort to select the proper procedure for the initial operation. A factor that should enter into the decision- making process is consideration of the future options. If a patient has a high BMI and wants an adjustable gastric band, the likelihood of long-term success and the complexity of removing the band and converting to another procedure need to be considered. In contrast, if sleeve gastrectomy results in inadequate weight loss, it can be converted to duodenal switch or gastric bypass without dealing with the previously manipulated area. Although vertical banded gas- troplasty has been abandoned, adjustable gastric bands rep- resent approximately 40 –50% of the total of bariatric pro- cedures currently performed in the United States. If a substantial number of these patients will require a difficult reconstruction, this information needs to be quantified and be part of the informed consent process. Another important corollary is that these are not revers- ible operations, only removable devices. This is a point that I first heard articulated by Dr. Raul Rosenthal. Although many have highlighted that the band is a reversible proce- dure, this is not true. The band can be removed, but the patient will have undergone a failed weight loss procedure. Should the patient wish to undergo revision to a more effective weight loss operation, the foreign body reaction and the altered changes in the stomach will need to be managed. It is not the same as a delete key in a computer. At present, although there are data that support a lower incidence of significant complications in the early postop- erative period with laparoscopic adjustable gastric band no study has considered long term, on an intent to treat basis, 701 Open Gastric Bypass after Failed Procedures / Surgery for Obesity and Related Diseases 8 (2012) 696 –702