Introduction: Postoperative intra-thoracic sleeve migration after LSG are increasingly reported in the literature. We are presenting a morbidly obese patient who developed gastric sleeve migration that was managed with conversion to Roux en Y gastric bypass. Presentation: A 21 year old female, 334 pounds at initial presentation (BMI 49) underwent sleeve gastrectomy. 3 years post-operatively, she lost 110 lbs and comorbidities were improved, except for worsening GERD, despite maximal medical management. CT scan showed intrathoracic migration of her gastric sleeve.

Procedure: Hiatal dissection was performed to reduce the herniated gastric sleeve. The hiatal defect was repaired posteriorly with a figure of 8 non-absorbable suture. The abdominal esophagus was fixed with interrupted nonabsorbable suture to the right and left crus of the diaphragm. Then we converted the gastric sleeve to Roux en Y gastric bypass. A 20-ml vertically oriented gastric pouch based on the lesser curvature of the stomach is created by transecting the sleeve 5 cm distal to GEJ with 60 mm endo GIA blue stapler. The jejunum is divided 100 cm distal to the ligament of Treitz. The Roux limb is then brought up in an antecolic antegastric fashion. Gastrojejunostomy is created using a 3.5-mm endo-GIA stapler. The gastrojejunal defect is closed with 2/0 absorbable suture. The integrity of the gastrojejunostomy is tested using methylene blue. The jejunojejunostomy is created 100 cm distal to the gastrojejunostomy. Mesenteric defects (small bowel mesenteric defect and Petersen space) are closed with running non-absorbable sutures. Six month follow up, the patient's GERD symptoms resolved.