S4132 Retained Fundic Shelf After Bariatric Surgery: Identification of Disease, Presentation, and Management

Introduction: A retained fundic shelf is a recognized anatomical variant following sleeve gastrectomy, defined as incomplete resection of the gastric fundus during surgery. This residual segment, typically located near the gastroesophageal junction, can be identified on imaging or upper endoscopy. Although sometimes asymptomatic, a retained fundus may promote food pooling and delayed gastric emptying, contributing to worsened gastroesophageal reflux disease (GERD), impaired satiety, and weight regain. These symptoms may be resistant to medical management and ultimately necessitate revisional surgery, which carries greater risk than primary procedures. As the prevalence of obesity continues to rise and more patients undergo metabolic and bariatric surgery, gastroenterologists will increasingly encounter altered post-surgical anatomy during endoscopy. Awareness of these anatomic variants, including the retained fundic shelf, is essential for accurate diagnosis, symptom attribution, and treatment planning. We present a case of a patient who underwent metabolic and bariatric surgery with such complication. Case Description: A 50-year-old woman with sarcoidosis and obesity underwent laparoscopic Roux-en-Y gastric bypass in 2002. Months later, she developed intolerable postprandial epigastric pain and underwent reversal to sleeve gastrectomy with lysis of adhesions. Her symptoms improved for several years but recurred with acute-on-chronic epigastric pain, dysphagia to solids, and the sensation of pills or food lodging in her upper abdomen. Pain typically began 30 minutes after eating and sometimes occurred at night. A computed tomography scan for sarcoidosis surveillance revealed a paraesophageal hernia with the staple line of the sleeve above the diaphragm and mild sleeve angulation. Esophagogastroduodenoscopy revealed Los Angeles Grade B esophagitis and a large intragastric outpouching with retained food, consistent with a retained fundic shelf. Upper GI series confirmed contrast pooling near the gastroesophageal junction, consistent with a diverticulum-like structure. Discussion: This case emphasizes the need to recognize a retained fundic shelf as a cause of refractory symptoms following metabolic and bariatric surgery. The residual segment may impair satiety signals, worsen GERD, and compromise long-term surgical efficacy. Familiarity with this variant supports accurate endoscopic interpretation and informs potential revision strategies, such as completion fundectomy.