A 46-year-old white woman presented to the clinic in September 2009 with intermittent abdominal epigastric pain accompanied by nausea, heartburn and frequent crises of asthma and cough for one year. Her past medical history revealed obesity-related arthropathy and a lumbar discal hernia with chronic NSAID use and no history of smoking. She underwent laparoscopic Roux-en-Y gastric bypass (RYGB) in September 2004 for morbid obesity (body mass index (BMI) 41.02 kg/m2) to construct a vertically oriented proximal gastric pouch, with a 120-cm jejunal Roux limb and jejunojejunostomy 50 cm beyond the ligament of 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 routine pre-operative upper endoscopy prior to the RYGB was normal. Two years after the RYGB, she was also submitted to laparoscopic adhesiolysis for small bowel obstruction. In September 2009, her weight decreased to 75.6 kg (166.3 lbs), which corresponded to a BMI of 26.79 (28% weight loss). Abdominal ultrasound and computed tomography ruled out any pancreatic or hepatobiliary disease. As the patient's symptoms did not improve despite extended trials of antacids and double doses of proton-pump inhibitors for over a year, investigations with 24-h esophageal pH monitoring (24-h pH testing) and manometry were conducted. 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. There was no evidence of hiatal herniation or Barrett's esophagus. Based on a 24-h pH test performed prior to fundoplication, the DeMeester score was 67.8 mmHg, with acid reflux occurring greater than 10% of the time both in supine (42.3%) and upright (16.9%) positions. The DeMeester reflux score was 67.8 (normal <14.72, 95th percentile). Manometry showed a lower esophageal sphincter pressure (LES) of 9 mmHg (normal range from 14.3 to 34.5 mmHg), and the contraction amplitude of the proximal and middle region was greater than 30 mmHg (50.6 mmHg). A biopsy showed grade 2 esophagitis. The upper gastrointestinal (GI) series revealed proper emptying of the gastric pouch but free gastroesophageal reflux disease (GERD). Therefore, the management of intractable postoperative reflux was performed with a laparoscopic 360° fundoplication to reinforce the lower esophageal sphincter by wrapping the excluded stomach around the lowest portion of the esophagus. This technique has not been previously described. Hiatal dissection and repair were performed, and the crura were approximated with three interrupted 2.0 polypropylene sutures. The excluded stomach was carefully isolated and used to construct the fundoplication, and the short gastric vessels were divided using the harmonic scalpel from the inferior pole of the spleen to the superior aspect of the excluded stomach. A loose, short 3-cm wrap was constructed, with assessment of the z-line (Figure 1C) performed under endoscopic guidance (Figure 1D). A 32-Fr intra-esophageal bougie was also used to calibrate the wrap. 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). The muscular wall of the anterior esophagus was incorporated in the sutures while carefully avoiding injury to the anterior vagus nerve. The fundoplication was not anchored to the crura. Reflux symptoms were scored using the Visick classification and a validated GERD questionnaire published elsewhere (1) before and after fundoplication (six months post-operation). There was marked improvement of preoperative symptoms and well-being in the post-operatory period (change in Visick classification from 3 to 1 and change in reflux symptoms score from 33 to 2). The patient tolerated the operation with no complications and experienced successful resolution of GERD symptoms. She was discharged on postoperative day two, tolerating a liquid diet without reflux or dysphagia. We were able to compare 24-h pH testing and manometry pre- and post-operatively. The erosion near the gastrojejunostomy (Figure 2C) healed after the surgery. She continues to be asymptomatic without reflux or dysphagia six months later.