A 45 year old woman had undergone a laparoscopic retrocolic retrogastric Roux en Y gastric bypass in 2004 at an outside facility which was complicated by chronic marginal gastrojejunostomy ulcers with a stricture refractory to medical therapy and endoscopic dilations. She was consented for laparoscopic Roux en Y gastric bypass reversal after optimization on G tube feeding via the gastric remnant, and subsequently on TPN while she was admitted with enteritis. The decision to reverse her gastric bypass anatomy as opposed to revising the gastrojejunostomy was based on her active smoking status in addition to nesidioblastosis in the setting of chronic protein-calorie malnutrition. The patient underwent a laparoscopic gastric bypass reversal without any issues with the gastrogastrostomy anastomosis. However, the small bowel became massively dilated as a result of upper intraoperative endoscopy without placing a clamp on the stomach. Although her Roux limb was very short and it was decided not to resect it, it was associated with a small mesenteric defect at the transverse mesocolon that led to a severe small bowel obstruction with volvulus of the unresected Roux limb 6 days later. This complication required emergency laparoscopic converted to open adhesiolysis with reduction and resection of the Roux limb causing the volvulus. The patient was discharged 2 weeks later and is currently recovering well, on a regular diet, with her nesidioblastosis resolved, and on G tube feeding via the G tube placed at the time of emergency exploratory laparotomy.