A case series of “Candy Cane Syndrome”: An underappreciated cause of abdominal pain and nausea after Roux-en-Y Gastric Bypass Surgery

Amir H Aryaie, MD, Mojtaba Fayezizadeh, MD, Mujjahid Abbas, Leena Khaitan, MD. University Hospitals Case Medical Center

Introduction: “Candy Cane syndrome” (a blind afferent Roux limb at the gastro-jejunostomy [GJ]) has been implicated as a cause of abdominal pain, nausea, and emesis after Roux-en-Y gastric bypass procedure (RYGB), but remains poorly described.  This case series demonstrates that “candy cane” syndrome is real and can be treated effectively with revisional bariatric surgery.

Methods: A prospective database was used to identify all patients who underwent revisional bariatric surgery for “candy cane” between January, 2011, and July, 2015.  All had pre-operative work up including upper gastro-intestinal series (UGI), upper endoscopy, and detailed history. Demographic data, peri-operative symptoms, data regarding the hospitalization and post-operative weight loss were assessed through retrospective chart review.  All those noted to have a combination of abdominal pain, emesis and/or nausea in the setting of an elongated afferent limb identified on endoscopy and UGI were taken for revision of the “candy cane”. Proper dietary habits were confirmed prior to revision. Data maintained in excel database and analyzed using student’s T-test.

Results: Nineteen patients had resection of the “candy cane” (95% female, mean age 50 ±11), within 3-11 years after initial RYGB.  Presenting symptoms were epigastric abdominal pain (68%) and nausea/vomiting (42%), particularly with fibrous foods and meats. On UGI, the afferent limb appeared to fill first before “spilling” into the roux limb.  On endoscopy, the afferent limb was the most direct outlet from the gastro-jejunostomy. Eighteen (94.7%) cases were completed laparoscopically (mean operative time 106 minutes (range 54-206).  All patients had intra-operative endoscopy to ensure patency of the gastro-jejunostomy whilst removing the “candy cane”.  Length of candy cane ranged from 3-22 cm (mean=7.6). Median length of stay was 1 day (range 1-16). After resection, 18 (94.7%) patients had complete resolution of their symptoms (p <0.001).  Mean BMI decreased from 33.9 (range 26-45) pre-operatively to 31.7 (range 25-42), at 6 months (17.4% EWL), and 30.5 (range 22-41) at 1 year (25.7% EWL). There were no complications or readmissions.

Conclusion: “Candy Cane” syndrome is a real phenomenon that resolves after resection of the blind afferent limb. A thorough diagnostic work up is paramount to proper identification of this syndrome. This syndrome can be managed safely with excellent outcomes with revisional surgery and removal of the afferent limb. Based on these data, surgeons should consider minimizing the size of the blind afferent loop left at the time of initial RYGB.