Background

In this video presentation, we present a female patient in her 40s with a past medical history of HTN, pre-diabetes, sleep apnea, heartburn and a prior sleeve gastrectomy who presented with PO intolerance and vomiting. She underwent multiple tests and imaging studies that showed severe proximal angulation of the sleeve with a hiatal hernia. She then underwent a diagnostic laparoscopy with lysis of adhesions and hiatal hernia repair as the proximal angulation was thought to be due to adhesions. Following, the patient continued to have PO intolerance with persistent nausea and vomiting. Repeat EGD showed proximal sleeve stenosis which required balloon dilation. Due to severe malnutrition she also required a feeding tube. After a long discussion with the patient and family a sleeve conversion to bypass was suggested as all other measures were exhausted. This presentation showcases the intricate management of gastric pouch stenosis through a reconstruction process. Noteworthy steps include the resection of the retained fundus which created a blind end along the pouch, and addressing the hiatal hernia concerns. The video emphasizes the surgical technique of performing a gastric myotomy along the pouch to manage the stenotic area, ensuring a clear visualization of the process and facilitating effective reconstruction for the gastric bypass procedure.