ORIGINAL CONTRIBUTIONS Laparoscopic Sleeve Gastrectomy for Morbid Obesity with Intra-operative Endoscopy: Lessons We Learned After 100 Consecutive Patients Alexandrou Andreas & Michalinos Adamantios & Athanasiou Antonios & Rosenberg Theofilos & Tsigris Christos & Diamantis Theodoros # Springer Science+Business Media New York 2014 Abstract Background Sleeve gastrectomy has become the second most common bariatric operation due to its low rates of morbidity and mortality, satisfactory treatment of patients’ obesity, and resolution of associated co-morbidities. According to standard technique, calibration of the stomach is performed with vary- ing sizes of bougies while use of intra-operative endoscopy has only sparsely been reported. Methods Between 2004 and 2013, 100 patients have under- gone laparoscopic or robotic sleeve gastrectomy with intra- operative endoscopic guidance. Technical aspects of the op- eration, results concerning morbidity, progressive weight loss, and resolution of co-morbidities were retrospectively reviewed. Results Morbidity and mortality was zero. Rates of excess weight loss at 6 months and 1 and 3 years were 52.1, 67.4, and 61.3 %, respectively. Patients’ highest rate of excess weight loss was achieved 18 months post-operatively. These rates were inversely related with preoperative age, body mass in- dex, and the existence of preoperative co-morbidities. Conclusion Sleeve gastrectomy with intra-operative endo- scopic guidance is at least as safe and effective as with the bougie. Given the available expertise and equipment, the use of this technique can increase the intra-operative sense of safety with no compromise or even improvement of the im- mediate or long-term results. Keywords Laparoscopic sleeve gastrectomy . Robotic sleeve gastrectomy . Upper gastrointestinal endoscopy . Excess weight loss . Co-morbidities Introduction Morbid obesity is acknowledged as one of the most significant health problems throughout developed countries during the last 30 years [1] and bariatric surgery is considered its most effective means of treatment. Strategies for the surgical treatment of morbid obesity include restriction of ingested food, malabsorption of its calo- ric potential, or a combination of these mechanisms. Different surgical techniques can vary considerably in their level of difficulty and can have accordingly variable immediate post- operative and long-term results [2]. The use of laparoscopic sleeve gastrectomy (LSG) for the treatment of super morbid obesity was first reported back in 2003 by Regan et al. [3] as the first step of a two-stage surgical strategy. Since then, it has evolved as a safe and effective independent surgical option for the treatment of morbid obesity, characteristics that have made it popular both among patients and surgeons [ 4– 6 ]. Nowadays, it represents the second most commonly per- formed bariatric procedure, following Roux-en-Y gastric by- pass (RYGB). Its rate currently runs at 27.8 %, whereas 3 years ago, it was only 5.3 %, and less than 10 years ago, the operation was considered experimental [1]. In our Department of Surgery, we have been using LSG for the treatment of morbid obesity since 2004. Very early in our experience, we decided to apply intra-operative endoscopic guidance for the calibration of the gastric sleeve instead of the commonly used bougie and we have already reported our initial experience [7]. Since 2008, we have also used the Da A. Andreas (*) : M. Adamantios : A. Antonios : R. Theofilos : T. Christos : D. Theodoros 1st Surgery Department, Laikon General Hospital, National and Kapodistrian University of Athens, Agiou Thoma 17, Athens, Greece e-mail: antreasalexandrou@hotmail.com OBES SURG DOI 10.1007/s11695-014-1524-3