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. 2025 Feb 5:13:a25097573.
doi: 10.1055/a-2509-7573. eCollection 2025.

Endoscopic blind limb reduction with septotomy for the treatment of candy cane syndrome after Roux-en-Y gastric bypass: Pilot feasibility study

Kambiz Kadkhodayan  1 , Zubair Khan  2 , Shayan Irani  3 , Artur Viana  1 , Saurabh Chandan  1 , Sagar Pathak  1 , Abdullah Abassi  1 , Mustafa A Arain  1 , Maham Hayat  4 , Deepanshu Jain  1 , Dennis Yang  1 , Muhammad Khalid Hasan  4 , Gustavo Bello Vincentelli  5
Affiliations

Endoscopic blind limb reduction with septotomy for the treatment of candy cane syndrome after Roux-en-Y gastric bypass: Pilot feasibility study

Kambiz Kadkhodayan et al. Endosc Int 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.

Keywords: Endoscopy Small Bowel; GI surgery; Small bowel endoscopy.

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Conflict of interest statement

Conflict of Interest Shayan Irani, MD is a consultant for Boston Scientific, Gore, and Conmed. Dennis Yang, MD is a consultant for Microtech, Medtronic, Olympus, FujiFlim, and Apollo Endosurgery. Mustafa Arain is a consultant for Cook, Boston Scientific, and Olympus. Muhammad Hasan, MD is a consultant for Boston Scientific and Olympus. Bello Vincentelli Gustavo, MD is a consultant for Teleflex Medical Device Company. The remaining authors have no conflict of interest to declare.

Figures

Fig. 1
Fig. 1
a Illustration depicting the EBLR procedure. Using a single suture at one end of the IJS (I), multiple passes or bites are taken using the following technique. After every throw of the needle, constant outward tension is applied (1). This results in tightening of the IJS between bites (2) and progressive shortening of the blind limb (3) until a desired blind limb length is achieved (4). Following this, a cinch is applied. Using the same technique, a separate suture is applied at the other end of the inter-jejunal septum (II). b Illustration depicting a septotomy. A scissor type electrosurgical knife is used to dissect the inter-jejunal septum along a horizontal plane (dotted line) that is equidistant from the previously placed sutures. c Illustration of typical candy cane post-RYGB anatomy. d Illustration depicting post-EBLR anatomy. Note that the IJS and BARL are replaced by a large common channel that empties directly into the afferent limb. (Courtesy Kadkhodayan.et al 4 )
Fig. 2
Fig. 2
Endoscopic images demonstrating different steps of Endoscopic Blind Limb Reduction (EBLR). a Long, blind afferent roux limb (BARL) is seen prior to endoscopic reduction (arrow). b Endoscopic suturing of both ends (arrows) of the Inter Jejunal Septum (IJS). c Shortening of the BARL and IJS (arrow) after application of sutures. d Follow-up endoscopy revealing significant shortening of the BARL and IJS, resulting in remodeling and formation of a common chamber beyond the GJ-anastomosis that leads directly into the afferent limb.
Fig. 3
Fig. 3
Endoscopic images demonstrating a septotomy procedure (EBLR-S). a After application of sutures at either end of IJS, a scissor type knife is used to dissect the IJS along a place that is equidistant from both the sutures. b Dissection is completed when the base of the BARL is reached. c Follow-up endoscopy revealing a healed septotomy site and complete reduction of the IJS and BARL. d Fluoroscopic image of the BARL and IJS before EBLR-S. e Fluoroscopic image of the common chamber emptying into the BARL after the EBLR-S procedure.
See this image and copyright information in PMC

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