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4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY III: Long-term Results Laparoscopic Sleeve Gastrectomy as a Primary Weight Loss Operation: Six-Year Results by EMANUELE LO MENZO, MD, PHD, FACS, FASMBS; SAMUEL SZOMSTEIN, MD, FACS, FASMBS; RAUL J. ROSENTHAL, MD, FACS, FASMBS Bariatric Times. 2013;10(5 Suppl A):A11–A13 AUTHOR AFFILIATIONS: Drs. Lo Menzo, Szomstein, and Rosenthal are from the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida. ADDRESS FOR CORRESPONDENCE: Raul J. Rosenthal, MD, FACS, FASMBS, 2950 Cleveland Clinic Blvd., Weston, FL 33331; Phone: (954) 659-5249; Fax: (954) 659- 5256; E-mail: rosentr@ccf.org FUNDING: No funding was provided. DISCLOSURES: Dr. Rosenthal receives educational grants from Covidien, Baxter, Karl Storz, W.L. Gore, and Ethicon and is on the advisory board of MST. Drs. Lo Menzo and Szomstein report no conflicts of interest relevant to the content of this article. KEY POINTS • Restriction and enteropeptides alteration are responsible for the weight loss after sleeve gastrectomy. • The diameter of the bougie correlates with weight loss. • Revisional procedures result in higher complication rates. • Twenty-three percent of LSG will develop recurrent or de novo GERD. T he modern concept of sleeve gastrectomy (SG) has been described by Marceau et al1 as the restrictive component of the biliopancreatic diversion (BPD) and duodenal switch (DS). Its laparoscopic counterpart (LSG) has been proposed as a first-step procedure in high-risk patients, followed by a second step Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion and duodenal switch (BPD-DS).2 Over the last several years, LSG has evolved into a stand-alone bariatric procedure. The combination of restriction and alteration of ghrelin and other enteropeptides after SG allows individuals to achieve long-term weight loss and resolution of comorbidities, yet minimizing morbidity and mortality.3 METHODS At our institution, patients were selected to undergo LSG1 if the following applied: LSG was the patient's surgery preference;2 the patient was considered high risk;3 patient displayed contraindications for gastric bypass (i.e., inflammatory bowel disease, severe small bowl adhesions);4 patient presented with low BMI (≥35kg/m2) without comorbidities;5 LSG was needed to allow the patient to undergo other nonbariatric operations (e.g., joint replacement);6 patient was a heavy smoker;7 and/or patient was on anticoagulants.5 The patients at the beginning of our experience were enrolled under an institutional review board (IRB) protocol. SURGICAL TECHNIQUE The abdominal cavity was accessed through a 1cm supraumbilical incision using the Optiview trocar™ (Ethicon, Cincinnati, Ohio). Accessory trocars (four 12mm and two 5mm) were inserted in the upper abdomen. The short gastric vessels on the greater curvature of the stomach were divided using ultrasonic energy from a distance 5cm proximal to the pylorus up to the gastroesophageal (GE) junction. Complete mobilization of the fundus with exposure of the left crus and dissection of the posterior wall of the stomach from the pancreas were routinely obtained. The bougie was advanced transorally along the lesser curvature into the pyloric channel, a step facilitated by the ventral retraction of the stomach. Although May 2013 • Supplement A • Bariatric Times A11