case_images: PMC3351257_01
case_images: The proposed technique: A - Surgical anatomy post-RYGB. B - Surgical anatomy post-fundoplication. The LES was reinforced by wrapping the excluded stomach around the lowest portion of the esophagus. C - Endoscopic view of the 3.5-cm pouch and the 13-mm GJ. D - Endoscopic-guided fundoplication delimiting the z-line (arrow shows transillumination with the endoscope). E - Final result of the 360  short, floppy fundoplication. Abbreviations: RYGB - Roux-en-Y gastric bypass; LES - lower esophageal sphincter; GJ - gastrojejunostomy.
case_images: cln-67-05-531-g001.jpg
case_images: PMC3351257_01_cln-67-05-531-g001.jpg
case_images: f1-cln_67p531
case_images: Treitz (Figure1A-E). The gastric pouch was 3.5 cm, and the manually performed gastrojejunostomy was 13 mm, as verified by routine endoscopy one year after the operation (Figure 2A). A loose, short 3-cm wrap was constructed, with assessment of the z-line (Figure 1C) performed under endoscopic guidance (Figure 1D). The excluded stomach (approximately 6 cm) was passed behind the esophagus, and the anterior and posterior excluded stomach lips were sutured together with three interrupted 3.0 polypropylene sutures (Figure 1E).
case_images: Pre - and intraoperative endoscopic view during laparoscopic fundoplication post-RYGB for obesity. A- Patent GJ. Transillumination of the jejunum with the laparoscope can be observed. B - Grade B Los Angeles reflux esophagitis (10-mm longitudinal mucosal breaks). C - Erosion in the pouch near the GJ. Abbreviation: GJ - gastrojejunostomy.
case_images: cln-67-05-531-g002.jpg
case_images: PMC3351257_01_cln-67-05-531-g002.jpg
case_images: f2-cln_67p531
case_images: Treitz (Figure1A-E). The gastric pouch was 3.5 cm, and the manually performed gastrojejunostomy was 13 mm, as verified by routine endoscopy one year after the operation (Figure 2A). A new upper endoscopy post-RYGB revealed a patent gastrojejunostomy (Figure 2A) in addition to grade B Los Angeles reflux esophagitis, with 10-mm longitudinal mucosal breaks (Figure 2B) and no signs of eosinophilic esophagitis. The erosion near the gastrojejunostomy (Figure 2C) healed after the surgery.