A 70-year-old man presented with a 10-year history of heartburn, acid brash, and hoarseness. He was placed on oral pantoprazole 40 mg twice daily and oral ranitidine 150 mg at bedtime with some improvement of symptoms. In addition, he had been experiencing episodes of chest pain for 1 year that were attributed to acid reflux. His barium esophagram demonstrated esophageal dysmotility and a moderate hiatal hernia with evidence of gastroesophageal reflux. This was verified with a 24-hour multichannel intraluminal impedance-pH study performed while the patient was taking oral pantoprazole 40 mg twice daily and oral ranitidine 150 mg at bedtime, demonstrating increased esophageal acid and non-acid exposure (16 acidic episodes, 132 weakly acidic) and a Johnson-DeMeester score of 35.6 (normal <14.7). HREMI revealed a decreased lower esophageal sphincter pressure of 7.5 mm Hg (normal 13-43 mm Hg) with evidence of a hiatal hernia. Esophagogastroduodenoscopy showed a 4-cm hiatal hernia and esophagitis without evidence of Barrett's esophagus on distal esophageal biopsy. The patient underwent a robotic-assisted hiatal hernia repair with Toupet fundoplication without major complications. During his second postoperative visit, approximately 4 weeks after his surgery, he noted 3 episodes of sudden-onset lightheadedness, hunger, tachycardia, perspiration, and diarrhea shortly after eating. Due to his history of diabetes mellitus type 2, he was able to check his blood glucose and found himself to be hypoglycemic after these episodes. He was given recommendations to eat small, frequent meals with complex carbohydrates (e.g., oatmeal, brown rice) and to avoid sugar and caffeine. Stool studies were also negative. Despite keeping a strict log of his diet, he continued to experience his previously described episodes. He was prescribed oral dicyclomine 20 mg 3 times daily with mild improvement of his diarrhea; however, he continued to have similar postprandial episodes. After a few weeks, his diarrhea returned, and he discontinued the dicyclomine. He was started on oral acarbose 25 mg 3 times daily before meals with significant improvement in his symptoms. At 1 year postsurgery, his symptoms remain controlled.