Published online Jul 16, 2023. doi: 10.4253/wjge.v15.i7.510
Peer-review started: April 11, 2023
First decision: May 19, 2023
Revised: May 30, 2023
Accepted: June 9, 2023
Article in press: June 9, 2023
Published online: July 16, 2023
Processing time: 91 Days and 11.8 Hours
Candy cane syndrome (CCS) is a particular case of the blind pouch syndrome after gastrectomy or gastric bypass, so named in a 2007 paper describing a small series of patients with gastrointestinal symptoms associated with a long blind loop proximal to the gastro-jejunostomy after gastric bypass and creation of an end-to-side anastomosis to a jejunal loop. The pathophysiology of CCS appears to be predominantly mechanical, as an excessive long or mispositioned blind loop proximal to the anastomosis may preferably direct food and increase luminal pressure, causing dilatation, early satiety, fullness, pain, reflux, regurgitation, post-prandial vomiting, weight loss, and, ultimately, inability to eat and cachexia.
CCS remains underrecognized and misdiagnosed due to the lack of knowledge about this condition, however, its manifestations have been described as common after gastrectomy. Since gastroenterologists are often the first clinicians to come into contact with patients with CCS, it is important that this clinical condition be part of the list of differential diagnoses for patients with digestive symptoms after gastrectomy or gastric bypass. To our knowledge, there is no published review on this subject.
The objective of this work was to systematically gather all the published evidence on CCS, in order to make this clinical condition known and to systematize the diagnostic and therapeutic approach.
A literature search was conducted using PubMed and Google Scholar, and by searching in addition to electronic links to related articles, from May 1, 2007, through March 31, 2023. Search terms included candy cane syndrome, blind pouch syndrome, blind loop syndrome, afferent loop syndrome, Roux limb syndrome, post-gastrectomy syndromes, complications of gastrectomy, side-to-side intestinal anastomosis, end-to-side intestinal anastomosis, and symptoms (pain, reflux, regurgitation, vomiting, and/or weight loss) after gastrectomy. The bibliographies of the retrieved articles were manually searched for additional relevant articles.
We found 20 articles on CCS, most case reports or case series in which the treatment was surgical, usually resection of the blind loop. In seven articles the treatment was endoscopic, using lumen-apposing metal stents to divert the passage of the luminal contents (two case reports), suture devices to close the blind loop (two case reports), or by cutting the septum between the blind loop and the efferent loop, promoting the marsupialization of the blind loop (one clinical case and the only prospective study available). In one case, balloon dilatation was performed, without clinical success. In general, treatment results are good, but the surgical approach is associated with complications in a significant number of patients.
CCS remains an under-recognized clinical condition and since gastroenterologists are usually the first clinicians to come into contact with these patients it is important to make it more familiar. As the number of bariatric surgeries increases, it is likely that the number of patients with CCS will increase as well. CCS patients are usually frail, with comorbidities, and it is important to establish the best diagnostic and therapeutic approach. Surgical treatment is effective but is associated with complications and there is still no optimal and reproducible endoscopic treatment.
We believe that, in the same way that the treatment of Zenker's diverticulum has changed from surgery to the endoscopic section of the diverticular septum, in a simple, fast, effective and reproducible procedure, marsupialization of the septum between the blind loop and the efferent loop can become the ideal treatment for CCS.