“Candy cane syndrome:” an underappreciated cause of abdominal pain and nausea after Roux-en-Y gastric bypass surgery



      “Candy cane” syndrome (a blind afferent Roux limb at the gastrojejunostomy) has been implicated as a cause of abdominal pain, nausea, and emesis after Roux-n-Y gastric bypass (RYGB) but remains poorly described.


      To report that “candy cane” syndrome is real and can be treated effectively with revisional bariatric surgery


      All patients underwent “candy cane” resection at University Hospitals of Cleveland.


      All patients who underwent resection of the “candy cane” between January 2011 and July 2015 were included. All had preoperative workup to identify “candy cane” syndrome. Demographic data; pre-, peri-, and postoperative symptoms; data regarding hospitalization; and postoperative weight loss were assessed through retrospective chart review. Data were analyzed using Student’s t test and χ2 analysis where appropriate.


      Nineteen patients had resection of the “candy cane” (94% female, mean age 50±11 yr), within 3 to 11 years after initial RYGB. Primary presenting symptoms were epigastric abdominal pain (68%) and nausea/vomiting (32%), particularly with fibrous foods and meats. On upper gastrointestinal study and endoscopy, the afferent blind limb was the most direct outlet from the gastrojejunostomy. Only patients with these preoperative findings were deemed to have “candy cane” syndrome. Eighteen (94%) cases were completed laparoscopically. Length of the “candy cane” ranged from 3 to 22 cm. Median length of stay was 1 day. After resection, 18 (94%) patients had complete resolution of their symptoms (P<.001). Mean body mass index decreased from 33.9±6.1 kg/m2 preoperatively to 31.7±5.6 kg/m2 at 6 months (17.4% excess weight loss) and 30.5±6.9 kg/m2 at 1 year (25.7% excess weight loss). The average length of latest follow-up was 20.7 months.


      “Candy cane” syndrome is a real phenomenon that can be managed safely with excellent outcomes with resection of the blind afferent limb. A thorough diagnostic workup is paramount to proper identification of this syndrome. Surgeons should minimize the size of the blind afferent loop left at the time of initial RYGB.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery for Obesity and Related Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Decker G.A.
        • DiBaise J.K.
        • Leighton J.A.
        • et al.
        Nausea, bloating and abdominal pain in the Roux-en-Y gastric bypass patient: more questions than answers.
        Obes Surg. 2007; 17: 1529-1533
        • Greenstein A.J.
        • O׳Rourke R.W.
        Abdominal pain after gastric bypass: suspects and solutions.
        Am J Surg. 2011; 201: 819-827
        • Dallal R.M.
        • Cottam D.
        “Candy cane” Roux syndrome—a possible complication after gastric bypass surgery.
        Surg Obes Relat Dis. 2007; 3: 408-410
        • Romero-Mejía C.
        • Camacho-Aguilera J.F.
        • Paipilla-Monroy O.
        [“Candy cane” Roux syndrome in laparoscopic gastric by-pass].
        Cirugia y cirujanos. 2009; 78: 347-351
        • Schippers E.
        • Schumpelick V.
        [Motility disorders in the blind loop after Roux-en-y reconstruction. Electromyography studies in the animal experiment].
        Langenbecks Arch Chir. 1994; 379: 99-104
        • Lakhani S.V.
        • Shah H.N.
        • Alexander K.
        • Finelli F.C.
        • Kirkpatrick J.R.
        • Koch T.R.
        Small intestinal bacterial overgrowth and thiamine deficiency after Roux-en-Y gastric bypass surgery in obese patients.
        Nutr Res. 2008; 28: 293-298
        • Roberts K.
        • Duffy A.
        • Kaufman J.
        • Burrell M.
        • Dziura J.
        • Bell R.
        Size matters: gastric pouch size correlates with weight loss after laparoscopic Roux-en-Y gastric bypass.
        Surg Endosc. 2007; 21: 1397-1402
        • Edholm D.
        • Ottosson J.
        • Sundbom M.
        Importance of pouch size in laparoscopic Roux-en-Y gastric bypass: a cohort study of 14,168 patients.
        Surg Endosc. 2015; 30: 1-5
        • Flanagan Jr, L.
        Measurement of functional pouch volume following the gastric bypass procedure.
        Obes Surg. 1996; 6: 38-43
        • Coakley B.A.
        • Deveney C.W.
        • Spight D.H.
        • et al.
        Revisional bariatric surgery for failed restrictive procedures.
        Surg Obes Relat Dis. 2008; 4: 581-586
        • Abdelgawad M.
        • De Angelis F.
        • Iossa A.
        • Rizzello M.
        • Cavallaro G.
        • Silecchia G.
        Management of complications and outcomes after revisional bariatric surgery: 3-year experience at a bariatric center of excellence.
        Obes Surg. 2016; 26: 1-6
        • Patel S.
        • Szomstein S.
        • Rosenthal R.J.
        Reasons and outcomes of reoperative bariatric surgery for failed and complicated procedures (excluding adjustable gastric banding).
        Obes Surg. 2011; 21: 1209-1219
        • Behrns K.E.
        • Smith C.D.
        • Kelly K.A.
        • Sarr M.G.
        Reoperative bariatric surgery. Lessons learned to improve patient selection and results.
        Ann Surg. 1993; 218: 646
        • Nguyen D.
        • et al.
        Outcomes of revisional treatment modalities in non-complicated Roux-en-Y gastric bypass patients with weight regain.
        Obes Surg. 2015; 25: 928-934
        • Leena K.
        • Sickle K.V.
        • Rodrigo G.
        • et al.
        Laparoscopic revision of bariatric procedures: is it feasible?.
        Am Surgeon. 2005; 71: 6-12
        • Saber A.A.
        • Scharf K.R.
        • Turk A.Z.
        • Elgamal M.H.
        • Martinez R.L.
        Early experience with intraluminal reinforcement of stapled gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass.
        Obes Surg. 2008; 18: 525-529
        • Masoomi H.
        • Nguyen N.T.
        • Stamos M.J.
        • et al.
        Overview of outcomes of laparoscopic and open Roux-en-Y gastric bypass in the United States.
        Surg Technol Int. 2012; 22: 72-76