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4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY III: Long-term Results TABLE 1. EWL correlation with bougie size BOUGIE SIZE # OF PATIENTS % EWL 12 MONTHS % EWL 24 MONTHS % EWL 36 MONTHS %EWL 48 MONTHS %EWL 60 MONTHS 52 86 55% (n=35) 47% (n=21) 36% (n=15) 34% (n=16) 31% (n=4) 46 236 65% (n=120) 66% (n=57) 62% (n=32) 64% (n=12) N/A 38 149 59% (n=45) 60% (n=4) N/A N/A N/A EWL= excess weight loss our original experience included a range of bougie sizes (46–38Fr), we standardized our technique to a 38 Fr. We proceeded with dividing the stomach using a 60mm endoscopic linear stapler (Endopath®, Ethicon, Cincinnati, Ohio), progressively decreasing staple heights from 4.1mm at the antrum to 3.5mm at the body and fundus of the stomach. The staple line is routinely imbricated with seromuscular 2-0 multifilament absorbable suture while keeping the bougie in place. All patients underwent a gastrograffin study on Postoperative Day 1. RESULTS Over a six-year period, 547 patients (375 women and 172 men) underwent LSG as a primary procedure and final approach for the treatment of morbid obesity. The mean age of this group was 46.0 (range: 12–79) years, the mean BMI was 44.5kg/m2 (range: 29.1–77.9), and the mean excess weight loss (EWL) was 134.7 pounds (range: 51.0–333.6). The mean operative time was 97 minutes (range: 58–180) and mean hospital stay was 3.0 days (range: 1–19). Overall morbidity was 24.8 percent. Two patients (0.3%) had leaks at the proximal part of the A12 staple line, two patients (0.3%) had postoperative bleeding, five patients (0.9%) developed strictures, and 127 patients (23.2%) complained of new onset gastroesophageal reflux disease (GERD) in the postoperative period. Ten patients (1.8%) were converted to RYGB. There was a zero-percent mortality rate in this series. Overall mean %EWL was 34, 54, 62, 61, 54, 47, and 31 percent at 3, 6, 12, 36, 48, and 60 months, respectively. The percentage of EWL was compared to bougie sizes of 52, 46, and 38 (Table 1). For bougie size 52 Fr, the mean EWL was 31, 50, 49, 43, 37, and 48 percent at 3, 6, 12, 24, 36, 48, and 60 months, respectively. For bougie size 46 Fr, the mean EWL was 33, 72, 71, 70, 94 and 70 percent, respectively. Finally, for bougie size 38 Fr, the EWL was 37, 53, 65, 70, 58 and 70 percent, respectively. DISCUSSION The popularity of the LSG over RYGB derives from the preservation of a more physiologic anatomy, while maintaining a high degree of efficacy. On one hand, the resection of the gastric fundus decreases ghrelin production and appetite, whereas on the other hand the pyloric sphincter Bariatric Times • May 2013 • Supplement A preservation decreases the occurrence of dumping syndrome.4,5 Furthermore, the malabsorption of micronutrients is greatly reduced in LSG as compared to the RYGB, as the gastrointestinal transit remains intact. The high intraluminal pressure resulting from the small volume and lesser distensibility of the sleeve is responsible for the early satiety, and, in our experience, the %EWL correlates with bougie size.6 Conversely, in our experience, smaller bougie diameter (<32 Fr) may increase complications, particularly leaks, strictures, and GERD. Staple line disruption after LSG still remains one of the most serious complications. Early in our experience, we had one leak recognized early and treated with reexploration, repair, and drainage. If oversewing of the staple line reduces bleeding and leaks, it could also contribute to stricture development, especially at the incisura.3 Our series demonstrated five strictures (0.9%). One patient required balloon dilatation; two patients required conversion to RYGB; another patient, due to the high location of the stricture, required a laparoscopic Roux-en-Y RY mini GB. The last