Case presentation

A 65-year-old female with a history of morbid obesity underwent RYGB in 2007 with an approximate 200-pound weight loss. She later underwent multiple surgical interventions, including hiatal hernia repair and attempted revision of her bypass; however, detailed operative records were unavailable.

For anatomical orientation, Figure 1 provides a schematic comparison of normal gastric anatomy, standard RYGB configuration, and the proposed postoperative anatomy identified in this patient.

Figure 1: Schematic comparison of gastric anatomic configurations. (A) Normal stomach anatomy, with continuity between the esophagus, stomach, and duodenum. (B) Standard RYGB anatomy, showing a small proximal gastric pouch anastomosed to the Roux (alimentary) limb, with the excluded stomach and biliopancreatic limb diverted separately. (C) Suggested postoperative anatomy in this patient, based on endoscopic findings, illustrating an apparent direct transition from the esophagus into jejunal tissue without a discernible gastric pouchFigure created by the authors using CanvaRYGB: Roux-en-Y gastric bypass

The patient developed persistent symptoms clinically consistent with dumping syndrome, including postprandial discomfort, intolerance to multiple foods, and impaired satiety; symptoms occurred in close temporal relation to meals, though formal classification into early versus late dumping was not established. No formal diagnostic testing such as provocative testing or continuous glucose monitoring was performed.

Despite having undergone prior bariatric surgery, she experienced significant weight regain, with a BMI of 46 recorded at the time of evaluation.

Esophagogastrojejunoscopy performed in August 2022 demonstrated normal esophageal mucosa; upon advancement of the scope beyond the esophagus, jejunal mucosa was immediately encountered. No discernible gastric pouch or gastric mucosa was identified. There were no ulcerations, strictures, or inflammatory changes. These findings were interpreted as consistent with markedly altered postoperative anatomy. Representative endoscopic images are shown in Figures 2-3.

Figure 2: Endoscopic view demonstrating the transition zone between visualized mucosa, with arrows outlining the irregular margin along which no discernible gastric pouch or gastric mucosa could be identified.

Figure 3: Endoscopic view showing apparent direct transition from esophagus to jejunal mucosa without a discernible gastric reservoir, consistent with altered postoperative anatomy.

The anatomical configuration was interpreted as consistent with Roux-en-Y reconstruction but without a clearly identifiable gastric reservoir.

The patient was started on tirzepatide 2.5 mg subcutaneously once weekly in 2025, with follow-up scheduled every three months. At the most recent recorded follow-up, her BMI had improved from 46 to 41.9, and she reported marked improvement in postprandial symptoms and improved tolerance to oral intake. Subsequent dose titration and longer-term follow-up data were not available to the authors.