Background Roux Y gastric bypass (RYGB) is the preferred bariatric surgical option in patients with Gastro oesophageal reflux disease (GORD). However, de novo GORD after RYGB although uncommon is possible and present challenges in further management. Proposed mechanisms have been a large gastric pouch or a short alimentary limb. Objective Analyse anatomical causes of De Novo GORD post RYGB Methods Data of patients who presented with new onset GORD after RYGB were collected and analysed. Results Specific and remediable anatomical factors contributing to de novo GORD was found in 8 patients post RYGB (3 Males and 5 Females). Onset of symptoms ranged from 1.16-15 years. Mean age was 53.14 and mean BMI 37.39. One patient had R-Y gastric bypass for peptic ulcer disease in the past. Diagnostic work up included; Barium swallow (85.7%), CT Abdomen (42.9%), OGD (57.1%). Diagnosis of candy cane (CC) syndrome was seen in 50 % of cases (n=4) followed by Gastro-gastric fistula (n=1), gastric pouch herniation (n=1) and pouch herniation with CC syndrome (n=2). Excision of excess CC limb achieved resolution in symptoms of reflux. 4 patients are awaiting surgical anatomical correction. Conclusion De novo GORD after RYGB can be challenging. These patients need thorough anatomic and physiologic assessment to identify potentially correctable anatomical causes. A long CC, herniated gastric pouch, gastro-gastric fistula are anatomical causes identified in our study. Identification and evaluation of this sub group of patients has not been reported in the past but are likely to be increasingly encountered.

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