"Candy cane syndrome:" an underappreciated cause of abdominal pain and nausea after Roux-en-Y gastric bypass surgery

Surgical management of candy cane syndrome after Roux-en-Y bypass

BACKGROUND

Candy cane (CC) syndrome is a complication that occurs following Roux-en-Y bypass (RYGB), implicated as a long, small-bowel blind limb at gastrojejunostomy possibly caused using circular staplers.

OBJECTIVES

We aimed to report our experience with CC resection and improving outcomes following RYGB.

SETTING

University hospital.

METHODS

We performed a retrospective analysis of patients who underwent CC resection at our institution from 2017 to 2023. Patient's charts were then reviewed to evaluate for symptoms, operative, and weight data. Only patients with an afferent blind limb in the most direct outlet from the gastroesophageal junction (GJ) visualized in upper gastrointestinal (GI) study and endoscopy were included.

RESULTS

Twenty-nine patients had presented with symptoms of and underwent surgery of resection of the CC (83% female; 50.3 ± 12.9 years) within 11 ± 6 years after initial RYGB. In addition, 58.6% underwent a concomitant procedure (10 hiatal hernia repair, 4 revision gastrojejunostomy, and 3 internal hernia reduction and defect closure). The mean length of the CC was 7.5 ± 3.9 cm. Resection of CC was performed in 62.1% as stapling only, 34.5% as stapling and oversewing, and 3.4% as oversewing only. The 30-day hospital readmission rate was 7.4% (n = 2). At 8.5-month follow-up, there was a significant reduction (P < .005) of bloating, nausea or vomiting, and dysphagia; however, abdominal pain and diarrhea slightly decreased. The estimated weight loss percentage was 29.4% ± 5.6%, and body mass index decreased from 32.1 ± 7.3 kg/m2 to 29.1 ± 4.7 kg/m2.

CONCLUSIONS

Resection of blind afferent limb can be managed safely with excellent outcomes and resolution of symptoms, even if major procedures are performed concomitantly. Surgeons should resect excess Roux limb in the initial RYGB to decrease the likelihood of this syndrome.

Candy cane syndrome with or without concomitant hiatal hernia after Roux-en-Y gastric bypass: A hidden enemy leading to postoperative symptoms

BACKGROUND

Candy cane syndrome (CCS) is a rare complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). It occurs due to redundancy in the blind loop at the gastro-jejunal anastomosis.

OBJECTIVE

To evaluate the type of symptoms, anatomic and functional findings, and outcome after treatment.

MATERIAL AND METHODS

A prospective case series study was conducted between 2010 and 2022, including symptomatic patients with CCS after LRYGB. Symptoms were correlated with anatomic and functional findings. Big gastric pouch was defined if its size was >5 cm, and a long candy cane loop was diagnosed if its length was >5 cm. Due to failure of medical treatment, revision surgery (RS) was indicated for resection of the elongated blind jejunal loop, resizing the redundant gastric pouch and repairing the hiatal hernia repair (HH) when necessary.

RESULTS

The study included 23 patients, with a mean age of 49 ± 11 years. Twenty-one patients underwent primary LRYGB, and 2 were converted to this technique after sleeve gastrectomy (SG). The mean time from LRYGB to symptom onset was 7.6 ± 4.3 years. Pain and reflux symptoms were the most frequent, with no differences between patients with or without HH (P < .05). CCS coexisted with a large gastric pouch in 56.5% and HH in 52.2% of cases. A defective lower esophageal sphincter, abnormal esophageal motility, and pathological acid reflux test were observed. After surgery, improvement was observed in 86.9%.

CONCLUSION

CCS can lead to gastrointestinal symptoms following LRYGB, regardless of the presence of HH. Complete examinations are crucial for diagnosis and to determine the surgical intervention, which is the best option for treatment.

A successful management of Candy Cane syndrome post Roux-en-Y gastric bypass: a rare case report

Introduction and importance

Candy Cane syndrome (CCS) is a rare condition in which the proximal gastrojejunal attachment's afferent blind limb is elongated. This can lead to different symptoms, including nausea and vomiting, with less commonly described reflux and regurgitation symptoms.

Case presentation

A 38-year-old female presented with a chronic complaint of postprandial pain, discomfort, and reflux lasting for about 2 years after a previous Roux-en-y gastric bypass (RYGB) surgery. Upper endoscopy was done and raised suspicion for CCS. The patient underwent an exploratory laparoscopy, which confirmed the diagnosis. Surgical resection of the afferent limb was done, and all symptoms were completely resolved at the postoperative follow-up.

Clinical discussion

CCS is considered a rarely described complication that can occur after RYGB gastric bypass surgery. Diagnosing this condition includes performing upper gastrointestinal (GI) studies and endoscopy, which reveal a redundant afferent limb. Laparoscopy serves as a dual-purpose tool, confirming the diagnosis of CCS and providing a definitive curative intervention. Surgical resection has a high success rate, with evidence supporting its efficacy in relieving symptoms.

Conclusion

As the popularity of Bariatric surgeries rises, it is crucial to consistently consider CCS, despite its rarity, as a potential complication. Although diagnosing CCS can be challenging, physicians should maintain a high index of suspicion, especially in patients presenting with upper GI symptoms following metabolic surgeries.

Candy cane syndrome: A systematic review

BACKGROUND

Candy cane syndrome (CCS) is a condition that occurs following gastrectomy or gastric bypass. CCS remains underrecognized, yet its prevalence is likely to rise due to the obesity epidemic and increased use of bariatric surgery. No previous literature review on this subject has been published.

AIM

To collate the current knowledge on CCS.

METHODS

A literature search was conducted with PubMed and Google Scholar for studies from May 2007, until March 2023. The bibliographies of the retrieved articles were manually searched for additional relevant articles.

RESULTS

Twenty-one articles were identified (135 patients). Abdominal pain, nausea/vomiting, and reflux were the most reported symptoms. Upper gastrointestinal (GI) series and endoscopy were performed for diagnosis. Surgical resection of the blind limb was performed in 13 studies with resolution of symptoms in 73%-100%. In surgical series, 9 complications were reported with no mortality. One study reported the surgical construction of a jejunal pouch with clinical success. Six studies described endoscopic approaches with 100% clinical success and no complications. In one case report, endoscopic dilation did not improve the patient’s symptoms.

CONCLUSION

CCS remains underrecognized due to lack of knowledge about this condition. The growth of the obesity epidemic worldwide and the increase in bariatric surgery are likely to increase its prevalence. CCS can be prevented if an elongated blind loop is avoided or if a jejunal pouch is constructed after total gastrectomy. Diagnosis should be based on symptoms, endoscopy, and upper GI series. Blind loop resection is curative but complex and associated with significant complications. Endoscopic management using different approaches to divert flow is effective and should be further explored.

Magnet and wire remodeling for the treatment of candy cane syndrome: first case series of a new approach (with video)

BACKGROUND AND AIMS

Candy cane syndrome (CCS) is an adverse event (AE) from gastrectomy or gastric bypass and end-to-side anastomosis to a jejunal loop. Preferential passage of food to the blind loop induces early satiety, pain, and regurgitation. An endoscopic device that combines 2 magnets and a self-retractable wire was designed to perform progressive septotomy with marsupialization. We evaluated the clinical safety and efficacy of this treatment in CCS.

METHODS

Consecutive patients presenting with symptoms associated with CCS after gastrectomy or Roux-en-Y gastric bypass were treated with the MAGUS (Magnetic Gastrointestinal Universal Septotome) system. Weight, dysphagia, pain scores, 12-item Short Form Survey quality of life physical and mental scores, GERD Health-Related Quality of Life, and Eckardt score were measured at baseline and 1 and 3 months postprocedure. Satisfaction with therapy and AEs were monitored during follow-up.

RESULTS

Fourteen consecutive patients with CCS were enrolled in the study. Thirteen MAGUS systems migrated within 28 days after achieving uneventful complete septotomy. In 1 patient the magnet had to be collected from the right-sided colon after 1 month. Treatment was completed in a single endoscopy session. Dysphagia score (2 [1-3] vs 1 [1-1], P = .02), pain score (7 [6-8] vs 1 [0-1], P = .002), Eckardt score (5 [3-8] vs 1 [0-2], P = .002), GERD Health-Related Quality of Life score (37 [29-45] vs 8 [6-23], P = .002), and quality of life physical and mental scores were all significantly improved at 3 months. No device or procedure-related serious AEs were observed. One patient died during follow-up from evolution of oncologic disease.

CONCLUSIONS

Endoluminal septotomy using a retractable wire and magnet system in CCS is feasible and safe, with rapid improvement of symptoms. (Clinical trial registration number: NCT04480216.).

Candy cane syndrome at jejunojejunostomy causing small bowel obstruction following revisional laparoscopic gastric bypass: A case report and review of literature

Introduction and importance

The literature described Candy cane syndrome (CCS) as causing various symptoms and affecting patients' quality of life. Most of the literature described this syndrome occurrence at gastrojejunostomy (GJ) anastomosis. The literature lacks data on this syndrome occurring at the jejunojejunostomy (JJ).

Case presentation

We describe a patient who underwent revision of laparoscopic gastric bypass (LGB) due to weight regain and presented three days after the procedure with small bowel obstruction (SBO). The patient was admitted as she demonstrated a picture of SBO. A complete workup and contrast study was done and showed dilated bowel loops. The patient was taken for exploratory laparoscopy, which revealed dilated 10–15 cm candy cane near the JJ, causing and obstruction. Resection of the elongated blind pouch was done, and the patient tolerated the surgery with improvement in her symptoms. Preoperative imaging, perioperative management, procedure videos, and follow-up were used to describe the case.

Clinical discussion

After reviewing the literature, eight papers reported CCS, 7 of those articles mentioned the syndrome located at the GJ. CCS located near the JJ can lead to symptoms including SBO. Management is mainly surgical, and prevention of occurrence can be achieved by limiting unnecessary elongated blind pouches.

Conclusion

CCS is a well-established condition occurring at the GJ following LGB, but it can manifest similarly if an elongated blind limb is left unresected at the JJ.

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Candy cane syndrome is an uncommon entity following laparoscopic gastric bypass.

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Most of literature mentioned this syndrome occurring at the gastrojejunostomy with vague unspecific symptoms.

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We report an unusual presentation of candy cane syndrome occurring at jejunojejunostomy causing small bowel obstruction.

Successful treatment of "candy cane" syndrome through endoscopic gastrojejunal anastomosis revision

Candy cane syndrome is an underappreciated complication reported in bariatric patients following Roux-en-Y gastric bypass. It results from an excessively long blind afferent Roux limb at the gastrojejunostomy that can lead to food accumulation. Patients often present with nausea, vomiting, food intolerance, acid reflux, and abdominal pain. Many patients remain undiagnosed due to vague gastrointestinal symptoms, delayed presentation, and physician unawareness. Here, we present the case of a 40-year-old female who presented for a third opinion on the cause of intractable acid reflux and nausea. Workup revealed her symptoms stemmed from an excessively long afferent Roux limb. Traditionally, treatment would include laparoscopic or open surgical removal of the blind limb. Although effective, surgical intervention is invasive, may not be an option in high-risk patients, and can lead to further complications. We were able to successfully address this patient's candy cane syndrome by utilizing a novel endoscopic approach to revise the gastrojejunal anastomosis, which led to full resolution of her symptoms. Endoscopic therapy of candy cane syndrome may provide a minimally invasive approach that exposes patients to decreased procedural risk while potentially producing similar treatment results as more invasive surgical approaches.

Magnets and a self-retractable wire for endoscopic septotomies: from concept to first-in-human use

BACKGROUND

A medical device that allows simple and safe performance of an endoscopic septotomy could have several applications in the gastrointestinal (GI) tract. We have developed such a device by combining two magnets and a self-retractable wire to perform a progressive septotomy by compression of the tissues. We describe here the concept, preclinical studies, and first clinical use of the device for the treatment of symptomatic epiphrenic esophageal diverticulum (EED).

METHODS

The MAGUS (MAgnetic Gastrointestinal Universal Septotome) device was designed based on previous knowledge of compression anastomosis and currently unmet needs. After initial design, the feasibility of the technique was tested on artificial septa in pigs. A clinical trial was then initiated to assess the feasibility and safety of the technique.

RESULTS

Animal studies showed that the MAGUS can perform a complete septotomy at various levels of the GI tract. In two patients with a symptomatic EED, uneventful complete septotomy was observed within 28 and 39 days after the endoscopic procedure.

CONCLUSIONS

This new system provides a way of performing endoluminal septotomy in a single procedure. It appears to be effective and safe for managing symptomatic EED. Further clinical applications where this type of remodeling of the GI tract could be beneficial are under investigation.

König's Syndrome After Roux-en-Y Gastric Bypass: Candy Cane Twist

BACKGROUND

A König's syndrome is referred to abdominal pain in relation to meals with constipation alternated with diarrhea, meteorism, and abdominal distension. A postoperative long-term complication after Roux-en-Y gastric bypass could be the appearance of chronic abdominal pain associated with vomiting, dysphagia, and nausea.

CASE REPORT

A 43-year-old female patient was submitted for a Roux-en-Y gastric bypass for morbid obesity with an initial body mass index (BMI) of 36 kg/m² (weight 100 kg, height 168 cm). At the 5-year follow-up, the patient's BMI was 22.3 kg/m² with a weight loss of 40 kg. In the last month, the patient has undergone a further weight loss of 8 kg (BMI 18.4 kg/m²) with the presence of chronic abdominal pain, dyspepsia, and dysphagia and abdominal distension. Any vasomotor problems (hot flushing, sweating, palpitations, and diarrhea) were described. The computer tomography (CT) with oral contrast shows the presence of a blind afferent Roux limb at the gastrojejunostomy, explaining a possible König's syndrome.

RESULTS

The patient was submitted for a diagnostic laparoscopy, which revealed the presence of a twisted candy cane that was identified and resected. The postoperative stages were uneventful and the patient was discharged on the second postoperative day.

CONCLUSION

Candy cane syndrome is a rare and challenging complication reported in bariatric patients following Roux-en-Y gastric bypass and is best investigated with a barium swallow or oesophago-gastro-duodenoscopy (OGD). This means that this kind of pathology could be avoided by not leaving such a long blind loop during the primary gastric bypass operation. An explorative laparoscopy could be performed in the event of abdominal pain, nausea, and vomiting at a long-term follow-up after gastric bypass. Even if there are little data regarding the efficacy of surgical treatment, if present, "candy cane" surgical revision seems to be the best treatment for the majority of the patients with long-term symptomatic relief.

Intussusception, a Plausible Cause of the Candy Cane Syndrome (Roux Syndrome): Known for a Century-Still a Frequently Missed Cause of Pain After Roux-en-Y Gastric Bypass

BACKGROUND

Candy cane syndrome (CCS), which is also called Roux syndrome, is a rarely reported and neglected complication of proximal Roux-en-Y gastric bypass (RYGB) surgery.

METHODS

Forty-seven cases of CCS that underwent candy cane (CC) resection were analyzed retrospectively for pain remission to determine whether intussusception is a possible underlying mechanism.

RESULTS

Forty-three patients (89.6%) benefited from laparoscopic CC resection (p < 0.001). The highly sensitive diagnostic tests were upper gastrointestinal series (91%) and gastroscopy (96%). Intussusception of the CC into the gastric pouch was demonstrated in most cases and was postulated as the trigger for CCS. In some cases, retroperistaltic intussusception led to nonspecific upper gastrointestinal bleeding.

CONCLUSION

A vast majority of CCS cases benefited significantly from CC resection. The long-described retroperistaltic intussusception of the CC was suggested as an important underlying mechanism of the symptoms. Although CC resection remains a stopgap, evidence on its clinical significance has been shown for a century. Building on this wealth of experience and the already vast storage of practical knowledge, awareness of this underestimated complication after RYGB should be raised.

Vague abdominal pain after Roux-en-Y gastric bypass: not always an internal herniation: case report and literature review

Background: Roux-en-Y gastric bypass is a frequently carried out bariatric procedure, proven to be effective in the management of obesity and its accompanying health issues. Following its popularity, admission to the emergency department for abdominal pain is often seen with known early and late onset causes. We present a case of a young woman with vague abdominal pain years after her gastric bypass, who eventually underwent a resection of a 'candy cane' like biliopancreatic blind loop.Methods: A healthy 23-year-old woman has been suffering of vague abdominal complaints after a gastric bypass procedure 4 years earlier. Postprandial pain, diarrhoea and abdominal distension were present at a daily to weekly basis. Several investigations and management options were administered by surgeons, gastroenterologists as well as endocrinologists. On a performed explorative laparoscopy, a large blind loop at the entero-enteric anastomosis was seen and resected.Results: At current follow-up of 15 months the resection of the candy cane like blind end of the biliopancreatic loop resulted in a complete withdrawal of our patient's symptoms. A tentative diagnosis of bacterial overgrowth in the blind loop was made.Conclusions: Abdominal pain after gastric bypass is a frequent cause of admission to the emergency department. Besides the more serious complications, internal hernia is often withheld as possible diagnosis in the differential diagnosis of late onset, postprandial epigastric pain. This case report highlights another possibility. At initial surgery, a candy cane shaped blind loop should be avoided both at the gastro-jejunal as well as the entero-enteric anastomosis.

Candy cane revision after Roux-en-Y gastric bypass

Background

An excessively long-blind end of the alimentary limb following a Roux-en-Y gastric bypass (RYGB), known as a ‘candy cane’ (CC), may cause symptoms including abdominal pain, regurgitation and vomiting. Very few studies have examined the efficacy of surgical resection of the CC.

Objectives

The aim of this study was to assess sensitivity of preoperative diagnostic tools for CC, as well as perioperative outcomes and symptom resolution after CC revision surgery.

Setting

High volume bariatric centre of excellence, United Kingdom.

Methods

Observational study of CC revisions from 2010 to 2017.

Results

Twenty-eight CC revision cases were identified (mean age 45 ± 9 years, female preponderance 9:1). Presenting symptoms were abdominal pain (86%), regurgitation/vomiting (43%), suboptimal weight loss (36%) and acid reflux (21%). Preoperative tests provided correct diagnosis in 63% of barium contrast swallows, 50% of upper gastrointestinal endoscopies and 29% computed tomographies. Patients presenting with pain had significantly higher CC size as compared with pain-free group (4.2 vs. 2 cm, p = 0.001). Perioperative complications occurred in 25% of cases. Complete or partial symptom resolution was documented in 73% of patients undergoing CC revision. Highest success rates were recorded in the regurgitation/vomiting group (67%).

Conclusion

Surgical revision of CC is associated with good symptom resolution in the majority of patients, especially those presenting with regurgitation/vomiting. However, it carries certain risk of complications. CC diagnosis may frequently be missed; hence more than one diagnostic tool should be considered when investigating symptomatic patients after RYGB.

A Case series of candy cane limb syndrome after laparoscopic Roux-en-Y gastric bypass

Candy cane syndrome is a rare complication reported in bariatric patients following Roux-en-Y gastric bypass. It occurs when there is an excessive length of roux limb proximal to gastrojejunostomy, creating the possibility for food particles to lodge and remain in the blind redundant limb. Patients present with non-specific symptoms such as abdominal pain associated with nausea and vomiting. Most remain undiagnosed as the disease process is poorly described. We report three cases of candy cane syndrome treated successfully at our institution.

Laparoscopic revisional surgery for an unusual complication of Roux-en-Y gastric bypass

With the worldwide epidemic of obesity, there has been an increase in the numbers of primary and revisional procedures of bariatric surgery such as the Roux-en-Y gastric bypass (RYGBP). Nevertheless, this type of surgery is not exempt from complications. An excessive length of non-functional Roux limb proximal to the jejunojejunostomy can cause abnormal upper gastrointestinal symptoms after laparoscopic RYGBP. We present the case of a female patient who presented these unspecific abdominal symptoms after laparoscopic RYGBP who underwent laparoscopic resection in order to reduce the length of the dilated blind loop responsible for the symptoms.

Abdominal Pain After Roux-En-Y Gastric Bypass for Morbid Obesity

Background and Aims:

Roux-en-Y gastric bypass is widely used as treatment of morbid obesity. Weight loss, effects on obesity-related co-morbidities and quality of life are well documented post Roux-en-Y gastric bypass. Other outcome measures are less well studied. This review explores aspects of prevalence, diagnostic evaluations, etiology, and treatment of abdominal pain specific to Roux-en-Y gastric bypass.

Methods:

The review is based on PubMed searches and clinical experience with Roux-en-Y gastric bypass. Symptoms in the early postoperative phase (<30 days) were not included.

Results:

Based on limited evidence, up to about 30% of the patients may perceive recurrent abdominal pain post Roux-en-Y gastric bypass in the long term. A substantial subset of patients will need health-care evaluation for acute abdominal pain and hospital admission. The etiology of abdominal pain is heterogeneous and includes gallstone-related disease, intestinal obstruction, anastomotic ulcerations and strictures, intestinal dysmotility, dysfunctional eating, and food intolerance. Surgical treatment and guidance on diet and eating habits may allow symptom relief. The cause of pain remains undefined for a subset of patients. Impact of abdominal pain post Roux-en-Y gastric bypass on the perception of well-being, quality of life, and patient satisfaction with the procedure needs to be further evaluated and may be influenced by complex interactions between new symptoms post Roux-en-Y gastric bypass and relief of pre-existing symptoms.

Conclusion:

Abdominal pain should be part of follow-up consultations post Roux-en-Y gastric bypass. Future studies should focus on combined evaluations before and after surgery to enlighten potential casual relationships between abdominal pain and Roux-en-Y gastric bypass.