A 44-year-old woman was referred to the gastroenterology practice for evaluation of long-standing heartburn refractory to proton pump inhibitor (PPI) therapy. Her 24-hour multichannel intraluminal impedance-pH study on dexlansoprazole 60 mg daily revealed increased esophageal acid exposure (5.7% total time spent with esophageal pH <4) and a total of 15 impedance reflux episodes (10 acidic, 5 weakly acidic). High-resolution esophageal manometry with impedance (HREMI) showed normal esophageal function with 100% bolus clearance. HREMI revealed a sliding hiatal hernia of approximately 2 cm, which was confirmed on endoscopy. Biopsies were negative for eosinophilic esophagitis. Due to her persistent symptoms and high daily dosage of antacids, she underwent robotic-assisted laparoscopic hiatal hernia repair and Nissen fundoplication, during which the anterior and posterior vagal nerves were identified and preserved. Her postprocedure recovery was unremarkable, and she was discharged on the second day after the procedure. She was readmitted on 7 days later due to dehydration with symptoms of nausea, vomiting, and coughing. During this admission, she was hydrated and her symptoms improved. However, she gradually developed postprandial weakness and was eventually admitted 5 months postsurgery with diaphoresis, dyspnea, and palpitations occurring 2 hours after meals. Upper endoscopy demonstrated an intact wrap (Figure 1). A barium swallow revealed a normal post-fundoplication appearance. Interestingly, gastric emptying scintigraphy revealed rapid gastric emptying (Figure 2) with only 7% solid meal left in the stomach after 1 hour, 3% after 2 hours, and 1% after 4 hours (<30% after 1 hour is considered abnormal). Small bowel transit was normal, with 60-70% accumulation of the radiotracer bolus in the ileocecal region at 6 hours. As a result of her symptoms and objective rapid gastric emptying, the patient was diagnosed with dumping syndrome. Dietary modification with a low-carbohydrate diet and separating solids from liquid ingestion was instituted. The patient reported improvement of symptoms with these dietary modifications during her next follow up clinic visit 2 months later.