Hiatal hernia (HH) repair during laparoscopic sleeve gastrectomy (LSG) has been advocated to reduce postoperative gastroesophageal reflux disease (GERD) and/or intrathoracic migration (ITM) incidence. Previous,mid-term results of a prospective, comparative study evaluating posterior cruroplasty concomitant with LSG (group A 48 patients with simple vs. group B 48 reinforced with bioabsorbable mesh) confirmed the safety and effectiveness of simultaneous procedures. Present aim: to report the 60 months follow-up update, evaluating GERD, esophageal lesions’ incidence and HH’s recurrence. Results: Follow-up of was completed in 79.5% of the patients.Recurrent GERD in 6/32 (18.8%, group A) and in 9/44 (20.5%, group B) was registered (p>0.05).Grade A esophagitis and GERD was shown in 2 patients (6.25%), respectively 2 (4.5%) of each groups (p>0.05), and recurrent HH was confirmed later by contrast study and CT scan. Neither Barrett’s lesions nor de novo GERD were found. A total of 12 patients (12.5%, 8 respective 4) were converted within five years for persistent/recurrent GERD, with only 1 case of de novo (group B, shown in the initial 21 months follow-up). Failure of the initial cruroplasty with ITM was recorded in 4 patients (13% for group A and 7.4% for group B); hence, a repeat posterior, reinforced cruroplasty with bioabsorbable mesh was performed. Conclusions: Accurate patient selection (no large HH, no severe esophagitis), proper sleeve technique combined with posterior cruroplasty (simple or reinforced, based on hiatal defect’s dimensions and quality of the crura) ensures effectiveness, with a rate of failure (recurrence) at five years of 9.1%.