LSG represents a safe and effective procedure to achieve marked weight loss as well as significant reduction of major obesity-related co-morbidities. The procedure reduced the operative risk (ASA score) in super-obese patients undergoing two-stage LBPD-DS.

Nonoperative treatment (percutaneous drainage, endoscopy, stent) is feasible, safe, and effective for staple line leaks in patients undergoing LSG; furthermore, it may avoid more mutilating procedures such as total gastrectomy.

All three bariatric procedures are effective in treating diabetes, with a 3-year follow-up evaluation showing an effect that lasts. The AGB procedure was the least effective. The antidiabetic effect was similarly precocious after GBP and SG compared with AGB. This difference may indicate that a hormonal mechanism may be involved, independent of weight loss.

Restoration of the first phase of insulin secretion and improved insulin sensitivity in diabetic obese patients immediately after SG, before any food passage through the gastrointestinal tract and before any weight loss, seem to be related to ghrelin, GLP-1, and PYY hormonal changes of possible gastric origin and was neither meal- nor weight-change-related. Duration of the disease up to 10.5 years seems to be a major cut off in the pathophysiological changes induced by SG. A "gastric" hypothesis may be put forward to explain the antidiabetes effect of SG.

After SG the improvement of insulin action occurred rapidly and independently of EWL. The results of the present study confirm that a hormonal mechanism may contribute to changes in insulin resistance following SG.

SG is a safe and effective treatment for morbid obesity at mid-term follow-up. SG is effective for comorbidities resolution, especially for the treatment of diabetes. Suture line reinforcement allows a significant reduction of bleeding.

Laparoscopic crural closure in addition to LSG could represent a valuable option for the synchronous management of morbid obesity and HH, providing good outcomes in terms of weight loss and GERD symptoms control.

LF and cruroplasty is feasible and has good results in terms of GERD symptoms control and additional weight loss. The high rate of postoperative complications observed in this series remains a matter of concern. A re-sleeve procedure might be considered as an alternative to RYGB/DS conversion restricted to selected patients.