Novel Approach to the Management of Candy Cane Syndrome, Endoscopic Closure, and Luminoposic Metal Step for Marsupialization of the Blind Limb. Candy Cane Syndrome is a rare and underreported complication of Roux-en-Y gastric bypass that occurs as a result of an elongated blind limb. The diagnosis is most commonly made clinically with a combination of supportive endoscopic and fluoroscopic imaging, such as an upper GI series. While there is no singular agreed-upon treatment for Candy Cane Syndrome, the most common treatment modality is surgical resection of the blind limb. Candy Cane Syndrome occurs as the result of a long blind limb which preferentially diverts gastric contents into its lumen, resulting in distension and eventual extrinsic compression of the roux limb. The combination of distension of the blind limb with impingement of the roux limb leads to postprandial abdominal pain, nausea, and reflux symptoms. Now we present the case of a 59-year-old female with a complex medical and surgical history, including Roux-en-Y gastric bypass six years ago, who presented with postprandial abdominal pain and vomiting. Of note, her pre-gastric bypass weight was 223 pounds, and she experienced 31% total body weight loss, weighing 155 pounds at one year post-bypass. She underwent endoscopic and radiographic evaluations for investigation of her new symptoms, and the clinical diagnosis of Candy Cane Syndrome was made. Endoscopic full-thickness suturing to close the blind limb inlet was completed, with a purse-string suture to divert contents towards the roux limb. After 18 months, her symptoms unfortunately recurred, and an upper GI series was completed which revealed brisk and preferential opacification of the Candy Cane limb, leading to impingement of the roux limb. Subsequent endoscopy demonstrated reopening of the blind limb inlet with evident suture material. She was referred for potential surgical resection of the blind limb, but was deemed high-risk for complications such as enterotomy and post-procedural leak due to the presence of dense adhesions surrounding the gastric pouch and blind limb that were seen on laparoscopy for a different issue. So, ultimately, she declined surgery. The decision was made to pursue repeat closure of the blind limb inlet, this time in combination with marsupialization of the blind limb via Lamb's jejuno-jejunostomy. This would allow for both drainage of enteral secretions from the blind limb via the lambs, and direction of gastric contents towards the roux limb. Here we see her pre-procedure endoscopy, starting in the roux limb. Then we move proximally to see the reopened blind limb inlet with suture material, followed by the long candy cane limb. Fluoroscopic imaging during the pre-procedure endoscopy revealed a more stable scope position with the endoscope within the blind limb, so a decision was made to deploy lambs from the blind limb to the roux limb. Accordingly, the nasojejunal catheter was advanced into the roux limb. Once the catheter was in position, the linear echoendoscope was advanced into the blind limb, and a mixture of saline, contrast, and methylene blue was pumped into the roux limb via the nasojejunal tube. The roux limb was identified with clockwise torque and additional fluoroscopic guidance. The roux limb was punctured with a 19-gauge FNA needle, and methylene blue colored fluid was aspirated to confirm positioning prior to stent deployment. The 15 by 10 millimeter cautery enhanced lambs was then deployed from the blind limb to the roux limb, creating the jejunojejunostomy. A satisfying rush of methylene blue colored fluid entered the blind limb following deployment of the lambs. Here we see the lambs in position, successfully connecting the blind and roux limbs. An endoscopic suturing device was mounted on a therapeutic double-channel endoscope, and a full thickness endoscopic suture closure of the blind limb inlet was completed with a single running suture. Following completion of the suture pattern, the suture was tightly cinched and the procedure was completed. Following the procedure, the patient was admitted for observation and was discharged the following day. There were no adverse events or complications. She was advanced to a liquid diet for 24 hours and then a soft diet for a week. She was scheduled for a follow-up fluoroscopic upper GI series at 3 months. This follow-up GI series demonstrated preferential flow of contrast down the roux limb and showed appropriate placement of the lambs between the roux and blind limbs. This case demonstrates the potential for additive and possibly more durable benefits when combining the blind limb closure to divert gastric contents down the roux limb along with lamb's jejuno-jejunostomy to allow for drainage of enteral secretions. This approach may be favorable in symptomatic patients who are deemed high-risk or declined surgery. In conclusion, endoscopic closure and marsupialization of the candy cane limb is a viable method for the management of candy cane syndrome. Larger case series are needed to determine which endoscopic method or combination of methods provide the most efficacy and durability in the treatment of candy cane syndrome.

Candy Cane Syndrome

Roux-en-Y gastric bypass

endoscopic suturing

jejunojejunostomy

high-risk surgery