We read with interest the article by Jacobs et al. [1] reviewing the experience of the Jackson Memorial Hospital in Miami, Florida, with laparoscopic sleeve gastrectomy. It is very encouraging to see that centres all around the world are able to present their retrospective material in Surgical Endoscopy. Nevertheless, there are some important issues that should be addressed in the context of this article.

First, the authors claim 82.5 and 83.4% eligibility to follow-up, though in fact the eligibility was only 66.4% (164 out of 247 operated patients). That percentage is much less valid for reasonable conclusions. There is no comment on possible reasons for such low follow-up adherence. Such a finding raises the question of whether the remaining patients decided to quit follow-up because they were dissatisfied with the results of surgery.

That brings us to another important issue, which is the conclusions of the authors. We believe that sleeve gastrectomy should not be considered as a universal therapeutic alternative for all patients. First, it has been previously presented by Wadden that any restrictive procedure demands adequate cooperation of the patient, especially in terms of motivation and psychological ability to follow rigorous postoperative dietary suggestions [2]. It has been presented that lack of such motivation can usually be attributed to inborn personality characteristics as well as skills that can be acquired during psychological seminars, workshops, and even psychotherapeutic meetings [3, 4]. It has already been proven that lack of such preparation, its inadequate character or incorrect recognition of the patient’s motivational capacities leads univocally to failure of bariatric therapy and in some cases even to serious complications [5–7]. Therefore, we strongly suggest psychological evaluation of patients and limiting sleeve gastrectomy only to those who are well motivated to follow dietary restrictions [8], unless sleeve gastrectomy is only planned as the first step of bariatric treatment. Some studies supporting this point of view have provided clear and strong evidence from series of laparoscopic gastric banding and vertical banded gastroplasty patients [9] that restrictive procedures must be augmented by efficient work by the patient. In our centre, patients who do not present adequate motivational capacities are qualified to gastric bypass, as sleeve gastrectomy almost always does not provide adequate long-term weight loss [2, 3, 8].

Secondly, we should emphasise the fact that patients who suffer from gastroesophageal reflux disease and hiatal hernia should definitely not be qualified to sleeve gastrectomy, as this procedure increases the severity of the symptoms [10]. In this context, we always perform gastroscopy in preoperative preparation, and all patients with hiatal hernia or GERD are a priori qualified to gastric bypass [11]. Similar strategy is also employed by other authors [12].

Thirdly, patients with certain eating behaviours such as sweet-eating or binge-eating and who fail to lose them during psychological preparation are also known not to benefit from restrictive procedures such as sleeve gastrectomy or gastric banding [13]. Moreover, their unfavourable eating behaviours may lead to extension of the functional stomach and, in consequence, failure of the treatment [14]. In such cases, reoperation is often mandatory, gastric bypass usually being fashioned [9].

Finally, we would like to comment on the resolution of diabetes reported by the authors. We believe that such a high level of resolution must be associated more with diet maintenance and weight loss achieved by the patients than with any kind of hormonal change. It would be interesting to add information on the time from operation when such resolution was obtained. In gastric bypass patients, due to possible role of incretins [15], such resolution is immediate. To determine the character of the resolution observed by Jacobs et al., more information about the dynamics of the phenomenon should be provided.

In conclusion, we would strongly oppose the suggestion of Jacobs et al. that laparoscopic sleeve gastrectomy can be offered to any patient, especially if this operation is considered to be the final one. Adequate psychological motivational diagnosis, eating behaviours specificity, presence of GERD and hiatal hernia should always be evaluated and should add to the decision on the operation instituted in a particular patient.