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Article 1 INTERNATIONAL SLEEVE GASTRECTOMY EXPERT PANEL CONSENSUS STATEMENT: BEST PRACTICE GUIDELINES BASED ON EXPERIENCE OF >12,000 CASES CITATION Rosenthal RR. Best practice guidelines for laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2012;8:8–19. PURPOSE OF THE STUDY The purpose of this study is to provide expert guidance and consensus on key aspects of technical surgery, indications and contraindications, and the management and prevention of complications with the laparoscopic sleeve gastrectomy (LSG) procedure. METHODS A questionnaire was sent to all panelists (total 19) prior to the consensus meeting to obtain data on the total number of LSG cases performed by the group. Panelists included experienced surgeons who had performed at least 500 cases in LSG. The total number of LSG cases performed by the group was 12,799 (26% male and 73% female subjects). Four surgeons with vast experience in LSG were selected as chairpersons to set goals and panel inclusion criteria for the consensus meeting. The panel had balanced global representation from different regions, and included surgeons with various product and manufacturer preferences and surgical approaches. An interactive, evidence-based approach was used to obtain consensus statements from panelists regarding patient selection, contraindications, surgical technique, perioperative and postoperative 4S Bariatric Times • June 2012 • Supplement prevention, and management of complications for LSG. A consensus was made during review of the responses when a >70% agreement was made among the group. RESULTS Some of the critical statements of consensus from the panel are as follows: Indications/Contraindications • A 90% consensus was reached on LSG as a valid stand-alone procedure. • LSG is a valid treatment for high- risk patients (96% consensus). • LSG is a valid option for patients with morbid obesity with metabolic syndrome (91%), and in patients with a BMI 30–35 kg/m2 with associated comorbidities (95%). Surgical Technique • It is important to use a bougie to size the sleeve (100% consensus). • Optimal bougie size is 32F–36F (87%). • It is not appropriate to use staples with a closed height less than that of a blue load (1.5mm) on any part of a sleeve gastrectomy (81%). • The use of staple-line reinforcement will reduce bleeding along the staple line (100%). • It is never appropriate to use staples with a closed height less than that of a green load (2.0mm) when using buttressing materials (79% consensus). • It is never appropriate to use staples with a closed height less than that of a green load (2.0mm) when resecting the antrum (87%). General guidance on this area from the panel included 1) nothing less than a green load should be used up to the incisura angularis and when performing revisions; and nothing less than a blue load should be used from the incisura angularis up to the angle of His. • When performing revision surgery, the last firings (across the previous surgery site) should be green or larger (71%). Complications • The smaller the bougie size, the tighter the sleeve, the greater the incidence of leaks (70% consensus). • The smaller the bougie size, the tighter the sleeve, the greater the incidence of strictures (78%). General and Special Considerations • A lack of standardization leads to confusion (100% consensus). • If surgeons followed known best- practice techniques, the outcomes would be better (95%). CONCLUSION The ultimate aim of this consensus is to publish and implement determined best practices from experienced surgeons in LSG. This information is intended to provide guidance to surgeons in clinical practice, surgical technique, and future research regarding LSG.