a 24-year - old female , who had undergone laparoscopic greater curvature plication ( lgcp ) 6 months earlier , presented to the emergency room with 1 day history of severe epigastric pain , associated with nausea .
she also complained of yellow discoloration of skin and dark urine . on examination , she was jaundiced .
vital signs were as follows : temperature 38c , heart rate 120 bpm , blood pressure 140/87 .
abdominal examination revealed marked tenderness at the epigastric and peri - umbilical areas , with guarding .
total bilirubin was elevated at 74.1 mmol / l , and the reminder of liver function test was within normal .
an ultrasound of abdomen showed distended gallbladder with no calculi , dilated cbd and mild intra - hepatic biliary radicles dilatation .
the ct scan of the abdomen showed gastric outlet obstruction with an abnormal position of gastro - duodenal junction .
gastric mucosal prolapsed with mass effect on duodenum ( and ampulla of vater ) and secondary dilatation of the biliary and pancreatic ducts .
upper gi endoscopy showed the status post gastric plication with herniation of gastric fold into the duodenum .
an attempt was made to manipulate the fold but was not successful ( fig .  1 ) . 

the redundant mucosa was transacted by a linear cutter stapler ( fig .  2 ) and
figure  2:intra - operative picture of the obstructing gastric mucosal fold ( a ) being prepared for transection .
intra - operative picture of the obstructing gastric mucosal fold ( a ) being prepared for transection .
the anterior plication ( ap ) involves the plication of the anterior wall of the stomach without the mobilization of the greater curvature and the greater curvature plication ( gcp ) in which the short gastric vessels are divided and the greater curvature is folded inward . the gcp appears to be superior in weight loss comparing with ap .
the greater omentum was taken off the greater curvature of the stomach starting just proximal to the pylorus using an energy device .
a 38 french calibration tube was passed by the anaesthetist from the mouth traversing the pylorus . using about 45 interrupted 2 - 0 absorbable sutures ,
the calibration tube insured maintaining a fixed diameter lumen at the entire length of the stomach . at the end of the procedure
, methylene blue dye test was performed to rule out any leak associated with suturing .
lgcp attempts to mimic the well - documented results of laparoscopic sleeve gastrectomy . in our case ,
lgcp has the potential advantages of absence of staple line and its risk of leak .
these include perforation , obstruction , permanent nausea and vomiting , intracapsular abscess , sialoreia , gi bleeding and partial jejunal necrosis [ 8 , 9 ] .
there were no specific complaints in four follow - up visits prior to presentation to the emergency room . to our knowledge ,
we report the first case of obstructive jaundice as a long - term complication of lgcp .
an endoscopic attempt of reduction may be of value as previously reported in the literature .
. however , once the herniation was corrected surgically , the jaundice gradually resolved . in conclusion ,
the procedure remains investigational and should be performed under the research ethic review board approval .
 laparoscopic greater curvature plication ( lgcp ) is relatively a new procedure . 
 we report a novel complication of obstructive jaundice in a 24-year - old patient post lgcp . 
 this was secondary to gastric mucosa prolapse with obstruction of the ampulla of vater . 
 a literature review revealed no previous reports of similar complication . 
INTRODUCTION
CASE REPORT
DISCUSSION