Dear Editor:

It was with great interest that we read the article on laparoscopic sleeve gastrectomy (LSG) published in the November 2015 issue of Obesity Surgery. Nimeri et al. [1] recommend the routine use of intraoperative endoscopy in order to reduce two major complications after LSG, namely postoperative stenosis and gastric leak. The authors have used this technique in 310 consecutive cases with excellent results over a 6-year period. More specifically, a 32-Fr endoscope was used as a bougie at the beginning of the procedure, and after the transection of the stomach, an endoscopy was performed in order to check for leak, bleeding, and stenosis. When the intraoperative endoscopy was positive for stenosis, especially at the incisura that was not appreciated laparoscopically, the surgeons were able to correct stenosis by removing the invagination suture of the stable line.

According to the literature, only a few surgical departments worldwide perform LSG using intraoperative endoscopic guidance instead of the standard bougie [2–4]. In our surgical department, we have been performing sleeve gastrectomy laparoscopically or robotically with the use of intraoperative endoscopy since 2004 with excellent results [5]. We would like to endorse this method and share some additional advantages that we have identified from our experience using this same method.

The use of an endoscope in order to calibrate the diameter of the gastric tube includes numerous advantages which can reduce considerably the morbidity and mortality of patients who underwent LSG. The endoscope allows us to better understand how close we lie to the lesser curvature, as its light facilitates the correct placement of the instrument (Fig. 1a). The endoscope can also be anchored in the first part of the duodenum, and with subsequent slight retraction, the instrument remains securely in this position throughout the procedure. Right before the end of the procedure, we can verify without difficulty the patency of the gastric tube and inspect the inner surface of the stable line for possible bleeding or leak points (Fig. 1b). Additionally, we can check the outer surface of the stable line for leak points with careful insufflation in the remnant stomach and by filling with water the perigastric area. The aforementioned leak check is considered to be better than dye injection in the gastric remnant. Last but not least, intraoperative endoscopy is performed by a member of our surgical team in contrast to the bougie which usually is placed by the anesthesiologists, which means that the possibility for esophageal perforation is eliminated [6, 7].

Fig. 1
figure 1

a Endoscope in proper position and the light at its tip, inside the lumen of the stomach. b View of the gastric tube by intraoperative endoscopic icon. The inner surface of the staple line is at the top side of the icon

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Overall, we strongly believe that the use of the endoscope is crucial not only for the calibration of the gastric sleeve but also for the prevention of significant complications after LSG, such as stenosis and bleeding or even potentially fatal complications such as gastric leak. The routine use of intraoperative endoscopy can be implemented without any significant change in the operation time and the cost of the procedure, and can be considered as a practical addition to the surgical armamentarium.