Background <p>Sleeve gastrectomy (SG) is the most common bariatric procedure but requires revision in ~ 30% of cases due to suboptimal response or persistent obesity-related medical problems. Revisional options include re-sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD/DS), and single-anastomosis duodenal switch (SADS), though long-term comparative data are limited.</p> Objectives <p>To assess medium- to long-term outcomes of four revisional surgeries after primary SG for suboptimal weight loss or persistent associated medical problems.</p> Setting <p>University hospital.</p> Methods <p>This retrospective study analyzed a prospectively maintained database of patients who underwent revisional bariatric surgery after SG between 2010 and 2021. Indications included suboptimal clinical response (&lt; 50% excess weight loss), ≥ 20% recurrent weight gain, or persistent non-reflux obesity-related medical problems lasting ≥ 1 year. Revisions included re-sleeve, RYGB, BPD/DS, and SADS. Patients with ≥ 3 years of follow-up were evaluated for weight loss, associated medical problems resolution, and major complications.</p> Results <p>Of 113 eligible patients, 89 (79%) had ≥ 3 years of follow-up (median 70 [35] months). Median pre-revision BMI was 43.0 (8) kg/m², highest in duodenal switch-type procedures (<i>p</i> = 0.005). Median BMI reduction was 6.0 (7) kg/m². BPD/DS showed the highest median total weight loss (20% [12])&#xa0;and diabetes resolution, though not statistically significant (<i>p</i> = 0.148 and 0.089). Major complications beyond 6 months were similar across groups (<i>p</i> = 0.248).</p> Conclusions <p>Revisional surgery after primary SG offers modest long-term benefits. Duodenal switch-type procedures show superior trends with comparable safety.</p>