Background

There is a strong association between morbid obesity and gastroesophageal reflux disease (GERD). Worsening GERD is a known complication after vertical sleeve gastrectomy (VSG). Although the current data is varied, the presence of severe GERD is contraindication for most bariatric surgeons to perform VSG. Mechanisms attributed to GERD after VSG are largely related to the restrictive anatomical changes that occur. The narrow tube causes decreased gastric compliance with increased intraluminal pressure. Technical errors include extreme narrowing, twisting of the sleeve, anatomical stenosis and persistent fundus. Retained fundus is responsible for increased acid secretion, regurgitation, nausea and vomiting.

Methods

Case description: 53 year old female presented with severe reflux with persistent nausea and regurgitation of undigested food after VSG. Clinical evaluation revealed a floppy, retained gastric fundus on gastrografin swallow study and endoscopy. It was appropriate to proceed with revision to gastric bypass. Intraoperatively, a large retained gastric fundus was identified and completely resected upon formation of the gastric pouch and conversion to a Roux-en-Y Gastric Bypass. Postoperatively, she reported complete resolution of reflux symptoms.

Results

A retained gastric fundus that leads to intractable reflux is a preventable technical complication. Our case highlights the importance of meticulous dissection to free all existing posterior gastric attachments during the index operation. Ensuring that the fundus is completely resected will prevent anatomic failure and decrease the likelihood of severe reflux necessitating revision.