A 45-year-old female patient presented herself to my weight loss surgery clinic with severe heartburn and food regurgitation of two-year duration. She underwent sleeve gastrectomy 7 years ago by a bariatric surgeon in Houston who is no longer in practice. Patient did well initially and lost around 100 pounds. However, over the past 4 years she started experiencing acid reflux symptoms. Her acid reflux was initially managed with medications and lifestyle changes. However, over the past two years GERD symptoms have gotten worse and difficult to control even with high dose proton pump inhibitors. Patient reports excellent restriction and good appetite control. She still maintains her 100-pound weight loss.

Upper endoscopy, performed in Houston by a general gastroenterologist with limited experience in bariatric surgery, showed moderate gastritis and distal esophagitis. No description of hiatal hernia, sleeve shape, gastric fundus size, incisura diameter mentioned. I performed an UGI that showed a dumbbell shape gastric sleeve with significant narrowing at the level of the incisura angularis and gastric body. Gastric fundus was dilated and appeared like a perfect circle with air fluid level on the X-ray pictures. Contrast emptying from stomach into duodenum appeared to be accelerated but there was contrast pooling in the gastric fundus. I repeated the upper endoscopy to confirm upper GI findings and demonstrate significant laxity at the diaphragmatic opening. There was also narrowing and twisting at the level of the incisura angularis creating a functional obstruction.

Aggressive gastric sleeve resection over a small bougie size results in a narrowed incisura angularis. A narrowed incisura angularis leads to functional gastric sleeve obstruction; as a result, gastric fundus, cardia and hiatal opening dilate over time. This slowly leads to hiatal hernia formation and a dumbbell looking gastric sleeve. A dilated gastric fundus in the setting of a hiatal hernia results in severe heartburn and food regurgitation. Treatment requires surgical correction of hiatal hernia and conversion of gastric sleeve to gastric bypass. Gastric bypass alleviates the functional obstruction at the level of the incisura. In certain cases, adhesion formation around the incisura angularis form and narrow this area. Scar tissue resection at this level alleviates the obstruction. The associated hiatal hernia still needs to be repaired to control acid reflux symptoms. The dilated gastric fundus is either resected or plicated around the distal esophagus.