International Federation for the Surgery and Other Therapies for Obesity (IFSO) global consensus recommendations for optimizing outcomes after sleeve gastrectomy

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Obesity is a global pandemic, with projections indicating that the number of adults who will live with overweight and obesity will reach 3.80 billion by 20501. Metabolic bariatric surgery (MBS) is currently the most effective sustainable treatment for obesity and its associated complications2,3, outperforming non-surgical methods4,5. Sleeve gastrectomy (SG) has been the most widely performed MBS procedure globally for the past decade6,7. However, similarly to other MBS procedures, it may carry less-than-ideal postoperative outcomes. With the currently available knowledge from RCTs8–12, suboptimal initial clinical response and recurrent weight gain may be somewhat accentuated after SG compared with the ‘gold standard’ of Roux-en-Y gastric bypass (RYGB)13. Only two RCTs comparing these two MBS procedures currently have 10-year results available. The SM-BOSS trial showed that 33% of patients who underwent SG had a percentage total weight loss (%TWL) of less than 20% compared with 27% after RYGB and that 4% and 3% had a %TWL of less than 5% respectively10. In the SLEEVEPASS trial, 5% of SG patients had a %TWL below 5% compared with 3% after RYGB11. Suboptimal initial clinical response and recurrent weight gain may result in the recurrence of type 2 diabetes (T2D) and other obesity-related complications14. Relapse should not be interpreted as treatment failure, as even temporary remission is associated with meaningful health benefits. Additionally, recurrence of T2D may occur independently of recurrent weight gain in certain individuals, highlighting the complex pathophysiology of the disease15. At 10-years follow-up, remission rates of T2D after SG were 61% and 26% in the SM-BOSS RCT and the SLEEVEPASS RCT respectively10,11. This variation also underlines the effect of preoperative T2D duration on remission rates, as there were distinct differences between these RCTs at baseline with regard to T2D duration (1 year versus 5 years in the SM-BOSS RCT and the SLEEVEPASS RCT respectively)16. A major issue after SG is de novo gastro-oesophageal reflux disease (GORD) that needs to be taken into account in primary procedure selection. In the SLEEVEPASS RCT and the SM-BOSS RCT, 52% and 43% of patients developed de novo GORD respectively10,11. In the SLEEVEPASS trial, with 77% of the patients undergoing upper gastrointestinal endoscopy at 10 years, there was a difference in the prevalence of oesophagitis after SG compared with RYGB (31% versus 7% respectively)11. In contrast to previous retrospective cohort studies reporting high rates of Barrett’s oesophagus17–19, the SLEEVEPASS trial did not show a difference in the prevalence of Barrett’s oesophagus (4% for both groups)11. Similar percentages of Barrett’s oesophagus were observed in recent prospective cohorts20,21. There are important knowledge gaps in managing suboptimal initial clinical response, recurrent weight gain, and GORD at long-term follow-up after SG14,22.To bridge these knowledge gaps, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) assembled a multidisciplinary panel of international experts in MBS, gastroenterology, internal medicine, endocrinology, and nutrition to develop evidence-based recommendations. Utilizing a Delphi process, the team identified areas of expert consensus after systematically reviewing the existing literature and outlined key areas requiring further research. While preventive strategies are essential in obesity care, this consensus focused on the management of suboptimal outcomes, such as recurrent weight gain and GORD, given the current lack of robust prospective data evaluating preventive interventions at the time of SG. This consensus aimed to develop recommendations for the postoperative management of unfavourable outcomes after SG, including GORD, recurrent weight gain, and suboptimal clinical response. Preventive strategies during the primary procedure were considered outside the scope of this initiative. The 2024 IFSO consensus on definitions and clinical practice guidelines for obesity management defines a suboptimal initial clinical response to MBS as either a total body weight or BMI loss of less than 20% or insufficient improvement in an obesity-related complication (for example T2D) that significantly influenced the decision for surgery14. Additionally, late postoperative clinical deterioration after MBS is characterized by either recurrent weight gain exceeding 30% of the initial surgical weight loss or the worsening of an obesity-related complication that was a key indication for surgery14. The key element of these definitions is their composite nature, capturing both the magnitude of weight loss and the improvement (or deterioration) of obesity-related complications. While weight loss remains the principal driver of all favourable outcomes after MBS, remission of complications and prevention of their recurrence are equally essential measures of surgical success. Despite an initial literature review, the evidence was heterogeneous and insufficient to support strong clinical recommendations. Therefore, a Delphi methodology was selected to integrate multidisciplinary expert opinion where evidence was lacking, a common approach in guideline development when RCT data are scarce. The core scientific committee (R.V.C., M.K., M.L., Y.S., and C.P.) assembled a multidisciplinary team of 42 international experts from important obesity societies, including The Obesity Society (TOS), the World Obesity Federation (WOF), the World Gastroenterology Organisation (WGO), and the European Association for the Study of Obesity (EASO), to formulate evidence-based recommendations. All voting members were carefully selected from academic institutions, with no industry representatives involved, including an internationally recognized Delphi expert (R.L.), alongside specialists in MBS, gastroenterology, internal medicine, endocrinology, and nutrition. See the Collaborators section at the end of this article and the Supplementary material for the names and details of the included experts. The systematic review team (M.K., C.P., and Y.S.) started the review centred on predefined research questions addressing the management of de novo or persistent GORD, suboptimal initial clinical response or recurrent weight gain, and suboptimal remission or recurrence of metabolic syndrome after SG. Considering the objectives of the consensus conference and the limited availability of high-grade evidence in certain areas, the literature review included RCTs, systematic reviews, and observational studies. The literature review was distributed to all participants in preparation for the Delphi process. A detailed description of the systematic review methodology is provided in the Supplementary material. This includes the search strategy, study selection criteria, and summary of included evidence. The initial 53 statements were drafted by the core scientific committee (R.V.C., M.K., M.L., Y.S., and C.P.) based on the predefined research questions and a structured synthesis of the available evidence from the systematic review. Each statement was formulated to reflect either areas of potential consensus or points of known clinical variability. Draft statements were iteratively reviewed and refined by the core group to ensure clarity, clinical relevance, and alignment with the objectives of the consensus. The independent Delphi expert further reviewed the statements for internal consistency and methodological rigor before circulation. Upon completion of the draft consensus document, an independent Delphi process was conducted by an outside expert with some knowledge of all included subspecialties. The modified Delphi methodology followed the RAND/University of California at Los Angeles (UCLA) Appropriateness Method, as outlined in the RAND Methodological Guidance for Conducting and Critically Appraising Delphi Panels23. The Delphi process consisted of two parts, with th