This syndrome is believed to be the cause of abdominal pain, nausea, and vomiting after Roux-en-Y gastric bypass surgery, but its description is still poor. This case series shows that the Candy Cane syndrome is real and can be effectively treated with bariatric surgery.
Candy cane syndrome is a real phenomenon that disappears after removal of the blind afferent limb. Thorough diagnosis is essential to correctly identify this syndrome. This syndrome can be treated with revision surgery and removal of afferent limbs.
Candy Cane Syndrome in patients undergoing Roux-en-Y gastric bypass surgery refers to the presence of excessively long blind passages into Roux’s limbs during gastrojejunostomy, resulting in postprandial pain, which is usually relieved by vomiting.
Blind afferent limbs (“candy canes”) are believed to act as a blocked ring when filled with food (usually preferred), and the expansion of the ring can cause pain until the food spills into Roux’s limb or vomits.
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Candy Cane Syndrome after Gastric Bypass
One finding after gastric bypass is Candy Cane gastric bypass. Nausea, vomiting, and epigastric pain are common complaints in patients undergoing RNY gastric bypass surgery. In addition, the incidence of patients with complications of weight rebound or dumping syndrome is high.
The symptoms of nausea, vomiting, and epigastric pain in patients with a history of gastric bypass surgery are often evaluated by the primary care center and referred to a gastroenterologist.
The recommended “routine” examination is an abdominal X-ray examination, possibly a contrast examination and of course upper gastrointestinal endoscopy. A common and unreported problem may be Candy Cane’s discovery.
The “blind” end of the small intestine anastomosis is too long, causing food to settle on the candy cane hook. Symptoms of nausea, vomiting, and epigastric pain may be due to residual food and fluid not being drained from the area.
How to treat candy cane syndrome?
The most common bariatric surgery is Roux-en-Y gastric bypass (RYGB) and is associated with early and late complications. These complications are usually diagnosed and treated by endoscopy, including anastomotic stenosis, marginal ulcers, leaks and fistulas.
We describe a patient with little-known complications after RYGB. A 57-year-old woman accepted RYBB in 2003 without accident. She had a history of nausea and vomiting for 4 to 5 months after 9 years. He also reported pain in the upper abdomen and upper left abdomen, as well as symptoms of GERD.
His weight before the operation was 315 pounds, which was reduced to about 219 pounds a year. Now he is back at 263 pounds and has a BMI of 42.5. Before her visit, she had received a simple EGD from an external gastroenterologist. Studies of the upper gastrointestinal tract showed no evidence of leakage or obstruction.
Repeat EGD at our institution showed 2 cm hiatus hernia, grade A LA esophagitis, 7 cm gastric pouch and gastrojejunostomy, as well as the Roux cercal tip extending approximately 8 cm proximal to the gastrojejunostomy (“candy cane”).
Subsequently, the patient underwent laparoscopic surgery, repaired two accidental mesenteric hernias, and removed the Roux big blind branch of the jejunum 10-12 cm in length. The patient’s nausea and vomiting disappeared immediately.
During the one-month follow-up, her stomach pouch worked well, she lost 18 pounds, and her symptoms did not recur. Roux Candy Cane syndrome was described as a complication of RYGB in 2007, in which the proximal non-functional Roux limb of the gastrojejunostomy was too long.
Only 4 cases are described in the literature. With the increase in gastric bypass surgery, this syndrome may be more common than previously established.
Since the gastroenterologist may be the first referral provider to evaluate symptomatic patients after gastric bypass, when performing upper gastrointestinal endoscopy, one should recognize this complication and explore Roux’s blind limb, especially this is when there is no abnormality in the imaging examination. In addition, gastric pouch inflation is also very important for diagnosis.
References:
https://journals.lww.com/ajg/fulltext/2012/10001/candy_cane_roux_syndrome__a_not_so_sweet.719.aspx
