Journal of Surgical Case Reports, 2018;10, 1–3

doi: 10.1093/jscr/rjy244
Case Report

CASE REPORT

Downloaded from https://academic.oup.com/jscr/article-abstract/2018/10/rjy244/5116006 by guest on 07 November 2018

A Case series of candy cane limb syndrome after
laparoscopic Roux-en-Y gastric bypass
Khuram Khan*, Ricardo Rodriguez, Saqib Saeed, Amrita Persaud,
and Leaque Ahmed
Department of Surgery, Harlem Hospital Center, Columbia University, New York, NY, USA
*Correspondence address. Department of Surgery, Harlem Hospital Center, Columbia University, 506 Lenox Avenue, New York 10037, USA.
Tel: +1-718-865-6252; Fax: +1-212-939-1698; E-mail: [email protected]

Abstract
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 asso-
ciated 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.

BACKGROUND right side of her abdomen and epigastric area. All the labs find-
ings were unremarkable. Prior to this visit patient had an eso-
Laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery is the
phagogastroduodenoscopy (EGD) which was also negative. CT
most common surgery performed in USA for weight loss. Even
scan of abdomen shows hepato-splenomegaly with periappen-
though, it is considered one of the safest surgical procedure,
diceal fat stranding and dilated appendix. Patient was taken to
rare complication such as candy cane syndrome can occur,
the operating room for diagnostic laparoscopy and appendec-
leading to debilitating symptoms which are difficult to diag-
tomy in April 2017 and was found to have candy cane syn-
nose and manage [1]. Pathophysiology in candy cane syndrome
drome. We resected excessive redundant (4 cm length) of the
is related to redundant roux length at the time of creation of
long blind jejunal loop of gastrojejunostomy anastomosis using
gastrojejunosotmy which serves as a blind pouch for the food
Endo GIA Tri-Stapler device. Post-operative patient had upper GI
to stay. Treatment is centered on minimizing the redundancy
which was normal (Figs 1 and 2). Post-operative course was
and shorting the excessive length of roux limb proximal to
uneventful. The patient was discharged to home on post-
gastrojejunosotmy.
operative Day 2 and returned to clinic 2 weeks for follow up and
tolerating diet and completely pain free.
CASE SERIES PRESENTATION Second patient is a 35-year-old female with BMI 32.3 of with
A 44-year-old female with BMI 25.5 with history of hepatic cir- history of diabetes mellitus, hyperlipidemia who underwent
rhosis, upper GI bleed, GERD underwent LRYGB in March 2016, LRYGB in June 2014, laparoscopic cholecystectomy 2014 was seen
ventral hernia repair 2016. She presented to the clinic 1 year in the clinic for 1 year follow up. After having lost 54 pounds with
post 81 pounds weight lost since surgery with chronic colicky right sided abdominal pain associated with nausea and vomiting.
abdominal pain associated with nausea and vomiting. Vital Patient had an upper GI which was negative and subsequently
signs were stable. On physical exam, she had tenderness in the still continue to have the abdominal pain and undergone an EGD

Received: June 14, 2018. Accepted: September 18, 2018

Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
For commercial re-use, please contact [email protected]

1
 2 | K. Khan et al.

Downloaded from https://academic.oup.com/jscr/article-abstract/2018/10/rjy244/5116006 by guest on 07 November 2018

Figure 1: Post-op upper GI, was normal.

Figure 3: Patient post-op upper GI was normal after resection.

Figure 2: Post-op upper GI after resection of redundant limb.

which was normal as well. At that point patient was lost to follow Figure 4: Patient post-op upper GI after resection.
up for over a year as she moved to Florida and states while in
Florida had CT scan of abdomen which showed questionable
internal hernia at the anastomosis. Patient was seen and evalu- Three weeks post laparoscopy patient had upper GI which was
ated in our emergency room with complaints of right sided found to be normal (Figs 3 and 4).
abdominal pain with nausea and vomiting. Vital signs were Third patient is a 26-year-old female with BMI 25.1 of with
stable. On physical exam, tenderness in the epigastric area. All history of morbid obesity who underwent LRYGB in June 2017
the labs findings were unremarkable. CT scan of abdomen did was seen in the clinic for 6 month follow-up after having lost
not show any abnormality. However, due to possibility for an 87 pounds with right upper quadrant abdominal pain asso-
internal hernia, patient was admitted and was taken to the oper- ciated with on/off nausea and vomiting. Prior to this visit,
ating room for diagnostic laparoscopy on November 2017. She patient had visited outside hospital where they did CT scan of
was found to have long candy cane limb. We resected excessive abdomen which was negative. In addition patient also had
redundant 4 cm length of the long blind jejunal loop of gastrojeju- abdomen US, showed acalculus cholecystitis with gallbladder
nostomy anastomosis using Endo GIA Tri-Stapler device, Intra-op wall edema. Patient was taken to the operating room for diag-
EGD was performed showing 4 cm gastric pouch. Post-operative nostic laparoscopy and cholecystectomy February 2018 with
course was uneventful. The patient was discharged to home on Intra-op EGD showing long candy cane limb. We resected
post-operative Day 4 and returned to clinic 1 week for follow up excessive 5 cm length of the long blind jejunal loop of gastroje-
and tolerating diet and completely asymptomatic and pain free. junostomy anastomosis using Endo GIA Tri-Stapler device and
 Candy cane limb syndrome after gastric bypass | 3

cholecystectomy with Intra-op EGD show no ulcers and smaller suspicion is required to diagnose a candy cane syndrome.
stomach pouch. Post-operative course was uneventful. The Keeping the redundancy afferent limb shorter in primary
patient was discharged to home on post-operative Day 3 and LRYGB can prevent candy cane syndrome. Prompt diagnosis
returned to clinic 1 week for follow up and tolerating diet and and laparoscopic resection of afferent blind limb can lead to
without symptoms. favorable outcome to treat ‘Candy Cane’ syndrome and can
provide symptomatic relief for the patient [2]. Having excessive
DISCUSSION length >4 cm of afferent limb should undergo surgical
resection.
Since the first laparoscopic gastric bypass in 1993 several stud-
ies have proven the safety of this procedure. Candy Cane limb
syndrome is a difficult diagnosis to make after a patient under-
goes LRYGB surgery. With good history and physical exam
CONFLICT OF INTEREST STATEMENT

Downloaded from https://academic.oup.com/jscr/article-abstract/2018/10/rjy244/5116006 by guest on 07 November 2018

along with diagnostic work up is preponderant to treating this None declared.
syndrome upper gastrointestinal study and endoscopy (EGD)
are the diagnostic studies used to diagnose this syndrome. The
symptoms that could be suspicious for candy cane syndrome REFERENCES
are reported from as early as 3 months to up to 11 years [2, 3].
All of our patients presented with chronic abdominal pain, the 1. Lee M, Lyass S. ‘Candy Cane’ Redundant Roux Syndrome
cause of which was negative on routine imaging studies. A After Gastric Bypass. UT Southwestern Medical Center,
high level of suspicion is required to diagnose a candy cane Dallas, Cedars Sinai Medical Center. SAGES.
syndrome. The length of the blind loop is reported to be 2. Aryale AH, Fayezizadeh M, Wen Y, Alshehri M, Abbas M,
between 3 and 22 cm [4]. Re-operations after bariatric surgery Khaitan L. Candy cane syndrome. An underappreciated
are usually necessary due to failure of weight loss, weight cause of abdominal pain and nausea after Roux en Y gastric
regain or secondary to complications. LRYGB fails in between bypass surgery. Surg Obes Relat Dis 2017;13:1501–5. doi:10.
15 and 33% of the cases [1, 4]. Of the failures only up to 20% will 1016/j.soard.2017.04.006.
require second operation [5]. In order to avoid occurrence of 3. Dallal RM, Cottam D. ‘Candy cane’ Roux syndrome—a pos-
candy cane syndrome, bariatric surgeons should decrease the sible complication after gastric bypass surgery. Surg Obes
length of the blind loop and reposition by directing towards Relat Dis 2007;3:408–10.
right side by allowing gravitational drainage and obviate the 4. Kellogg TA. Revisional bariatric surgery. Surg Clin North Am
problems in the jejunojejunal anastomosis which cause back- 2011;91:1353–71.
ward enlargement of the Roux-en-Y limb [6]. 5. Edholm D, Svensson F, Näslund I, Karlsson FA, Rask E,
Sundbom M. Long term results 11 years after primary gastric
bypass in 384 patients. Surg Obes Rel Dis, 2013; 9: 708–13.
CONCLUSION 6. Romero-Mejía C, Camacho-Aguilera JF, Paipilla-Monroy O.
Candy cane or afferent limb syndrome is an under-reported ‘Candy cane’ Roux syndrome in laparoscopic gastric by-pass.
complication of Roux-en-Y gastric bypass. A high level of Cir Cir 2010;78:347–51. Spanish.