Background

Gastropericardial fistula is a rarely reported complication following Roux-en-Y gastric bypass (RYGB). We present a case involving a step-wise approach of successful management of a gastropericardial fistula by first performing drainage of associated pericardial abscess and fistula exclusion then subsequent definitive management after fistula recurrence involving gastric pouch/fistula resection with esophagojejunostomy and rotational rectus flap for coverage of diaphragmatic defect. Gastropericardial fistula after gastric bypass is a rare complication that can be treated in a step-wise manner with good outcomes at a comprehensive bariatric center specialized in high-risk, complicated procedures.