Background

Subtle aberrations in the post-sleeve stomach may result in severe gastroesophageal and bile reflux. Cardiopexy of the stomach with the ligamentum teres, initially described in 1964 by Pedinielli, has been used to reinforce the lower esophageal sphincter and hinders mediastinal retraction of the stomach. However, diversion of duodenal contents is required for definitive treatment of bile reflux. The presented video depicts a case of 37 year-old female presenting with frequent regurgitation and reflux refractory to medical therapy 5 years after laparoscopic sleeve gastrectomy. Preoperative endoscopy was consistent with esophagitis and bile within the gastric sleeve. UGI showed delayed reflux and a small sliding hiatal hernia. Retained bile in the proximal sleeve was seen on intraoperative endoscopy. Hiatal dissection revealed laxity of the phrenoesophageal membrane. Retained posterior fundus was discovered with mobilization of the sleeve. The sleeve was transected to define the pouch. The ligamentum was released from the anterior abdominal wall and isolated from the falciform. A gastrotomy was performed to identify the z-line and ensure creation of a small pouch to minimize acid cell mass. A 100cm roux limb was brought in an antecolic, antegastric orientation after creation of a jejunojeunostomy. A hand sewn single layer gastrojejunostomy was performed. Following a leak test, the ligamentum teres was wrapped around the gastroesophageal junction and secured. Endoscopy was repeated to assess the tightness of the wrap. Mesenteric defects were closed. Patient was discharged on clear liquids on post-operative day 2. 60 days post-operatively the patient was without symptoms.