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Kadkhodayan K, Khan Z, Irani S, Viana A, Chandan S, Pathak S, Abassi A, Arain MA, Hayat M, Jain D, Yang D, Hasan MK, Bello Vincentelli G. Endoscopic blind limb reduction with septotomy for the treatment of candy cane syndrome after Roux-en-Y gastric bypass: Pilot feasibility study. Endosc Int Open 2025; 13:a25097573. [PMID: 40007657 PMCID: PMC11855250 DOI: 10.1055/a-2509-7573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2024] [Accepted: 12/19/2024] [Indexed: 02/27/2025] Open
Abstract
Background and study aims Candy cane syndrome (CCS) refers to patients with a long and symptomatic blind afferent roux limb (BARL) after Roux-en-Y gastric bypass (RYGB). Revisional surgery is efficacious but can be cost prohibitive. Patients and methods We describe endoscopic blind limb reduction (EBLR), that converts the BARL into a "common channel" and eliminates food pooling, thereby improving symptoms. Patients that did not have a complete symptomatic response underwent a repeat EBLR or EBLR with septotomy (EBLR-S) based on residual BARL length. Results Five patients with CCS underwent the EBLR procedure. Mean age was 60.4 years, average BARL length 5.8 cm, and median Charlson comorbidity index was 3. Technical success was achieved in all five patients (100%). Symptom resolution was achieved in all five patients (100%). Two patients required a second procedure. Conclusions EBLR may be a potentially safe, efficacious, and cost-effective alternative to surgery in patients with CCS. Further prospective studies are needed.
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Affiliation(s)
- Kambiz Kadkhodayan
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Zubair Khan
- Gastroenterology, Mercy Clinic Gastroenterology - Mercy Hospital, St. Louis, United States
| | - Shayan Irani
- Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, United States
| | - Artur Viana
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Saurabh Chandan
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Sagar Pathak
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Abdullah Abassi
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Mustafa A Arain
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Maham Hayat
- Center for Interventional Endoscopy, AdventHealth Central Florida, Orlando, United States
| | - Deepanshu Jain
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Muhammad Khalid Hasan
- Center for Interventional Endoscopy, AdventHealth Central Florida, Orlando, United States
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Kadkhodayan K, Viana A, Singh S, Smith D, Irani S, Yang D, Arain M, Hasan MK. Endoscopic blind limb reduction with septotomy: a novel endoscopic approach to candy cane syndrome after Roux-en-Y gastric bypass. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:454-458. [PMID: 38026711 PMCID: PMC10665152 DOI: 10.1016/j.vgie.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Video 1The endoscopic blind limb reduction with septotomy procedure.
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Affiliation(s)
| | - Artur Viana
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
| | - Sanmeet Singh
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
| | | | - Shayan Irani
- Virginia Mason Franciscan Health, Orlando, Washington
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Florida
| | - Mustafa Arain
- Center for Interventional Endoscopy, AdventHealth, Florida
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Rio-Tinto R, Canena J, Devière J. Candy cane syndrome: A systematic review. World J Gastrointest Endosc 2023; 15:510-517. [PMID: 37547243 PMCID: PMC10401408 DOI: 10.4253/wjge.v15.i7.510] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/30/2023] [Accepted: 06/09/2023] [Indexed: 07/12/2023] Open
Abstract
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.
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Affiliation(s)
- Ricardo Rio-Tinto
- Digestive Oncology Unit, Champalimaud Foundation, Lisbon 1600, Lisbon, Portugal
| | - Jorge Canena
- Centro de Gastrenterologia, Hospital CUF Tejo - Nova Medical School/Faculdade de Ciências Médicas da UNL, Lisbon 1600, Lisbon, Portugal
- Serviço de Gastrenterologia, Hospital Amadora-Sintra, Amadora 1600, Lisbon, Portugal
- Serviço de Gastrenterologia, Hospital de Santo António dos Capuchos - CHLC, Lisbon 1600, Lisbon, Portugal
- Cintesis - Center for Health Technology and Services Research, Universidade do Minho, Braga 1600, Braga, Portugal
| | - Jacques Devière
- Digestive Oncology Unit, Champalimaud Foundation, Lisbon 1600, Lisbon, Portugal
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital - Université Libre de Bruxelles, Brussels 1050, Brussels, Belgium
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Del Gobbo GD, Kroh M. Reflux After Gastric Bypass: Roux en-Y and One-Anastomosis Gastric Bypass. THE SAGES MANUAL OF PHYSIOLOGIC EVALUATION OF FOREGUT DISEASES 2023:573-590. [DOI: 10.1007/978-3-031-39199-6_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Rio-Tinto R, de Campos ST, Marques S, Bispo M, Fidalgo P, Devière J. Endoscopic marsupialization for severe candy cane syndrome: long-term follow-up. Endosc Int Open 2022; 10:E1159-E1162. [PMID: 36238533 PMCID: PMC9552788 DOI: 10.1055/a-1869-2680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/30/2022] [Indexed: 10/25/2022] Open
Affiliation(s)
| | | | - Susana Marques
- Digestive Diseases Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Miguel Bispo
- Digestive Diseases Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Paulo Fidalgo
- Digestive Diseases Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Jacques Devière
- Digestive Diseases Unit, Champalimaud Foundation, Lisbon, Portugal,Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Jaruvongvanich V, Law R. Endoscopic management of candy cane syndrome: A sweet and attractive solution? Gastrointest Endosc 2022; 95:1254-1255. [PMID: 35410730 DOI: 10.1016/j.gie.2022.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/20/2022] [Indexed: 12/11/2022]
Affiliation(s)
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Rio-Tinto R, Huberland F, Van Ouytsel P, Delattre C, Dugardeyn S, Cauche N, Delchambre A, Devière J, Blero D. Magnet and wire remodeling for the treatment of candy cane syndrome: first case series of a new approach (with video). Gastrointest Endosc 2022; 95:1247-1253. [PMID: 34979115 DOI: 10.1016/j.gie.2021.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/25/2021] [Indexed: 02/08/2023]
Abstract
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.).
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Affiliation(s)
| | - François Huberland
- Bio, Electro and Mechanical Systems Department, Université Libre de Bruxelles, Brussels, Belgium
| | - Pauline Van Ouytsel
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Sonia Dugardeyn
- Digestive Diseases Unit, Champalimaud Foundation, Lisbon, Portugal; Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Alain Delchambre
- Bio, Electro and Mechanical Systems Department, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devière
- Digestive Diseases Unit, Champalimaud Foundation, Lisbon, Portugal; Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Successful treatment of "candy cane" syndrome through endoscopic gastrojejunal anastomosis revision. Clin J Gastroenterol 2021; 14:1622-1625. [PMID: 34476757 DOI: 10.1007/s12328-021-01511-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
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.
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Commentary: Repairing the candy cane. JTCVS Tech 2020; 2:156-157. [PMID: 34317788 PMCID: PMC8298841 DOI: 10.1016/j.xjtc.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 01/25/2020] [Accepted: 02/02/2020] [Indexed: 11/20/2022] Open
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Jin D, Peng L, Zhang G. Promoting physiological closure of the fistula, not just full-thickness suturing, is critical to heal a refractory gastric stump-cutaneous fistula after esophagectomy. Dig Endosc 2020; 32:e19-e21. [PMID: 31733077 DOI: 10.1111/den.13557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Duochen Jin
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,First Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Lei Peng
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,First Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Guoxin Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,First Clinical Medical College of Nanjing Medical University, Nanjing, China
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