Conclusions

This case highlights a rare and clinically complex postoperative presentation in which the apparent absence of a functional gastric pouch was associated with both severe dumping-type symptoms and persistent morbid obesity following RYGB and multiple revisions. The simultaneous occurrence of these two conditions reflects the physiological paradox that can arise when revisional bariatric surgery results in markedly altered gastrointestinal anatomy.

These findings underscore the importance of thorough endoscopic anatomical reassessment in bariatric patients presenting with persistent or atypical postoperative symptoms, particularly those with complex revision histories and unavailable operative records, as standard symptom-based evaluations alone may be insufficient in this population.

The clinical response observed with tirzepatide suggests a potential therapeutic role in patients with severely altered post-bariatric anatomy, likely mediated through its effects on gastric transit, glycemic regulation, and satiety. However, causality cannot be established from a single case, and further prospective study is needed before tirzepatide can be considered an established treatment for dumping syndrome in this setting.