Systematic Reviews
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jul 16, 2023; 15(7): 510-517
Published online Jul 16, 2023. doi: 10.4253/wjge.v15.i7.510
Candy cane syndrome: A systematic review
Ricardo Rio-Tinto, Jorge Canena, Jacques Devière
Ricardo Rio-Tinto, Jacques Devière, 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
Jorge Canena, Serviço de Gastrenterologia, Hospital Amadora-Sintra, Amadora 1600, Lisbon, Portugal
Jorge Canena, Serviço de Gastrenterologia, Hospital de Santo António dos Capuchos - CHLC, Lisbon 1600, Lisbon, Portugal
Jorge Canena, Cintesis - Center for Health Technology and Services Research, Universidade do Minho, Braga 1600, Braga, Portugal
Jacques Devière, Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital - Université Libre de Bruxelles, Brussels 1050, Brussels, Belgium
Author contributions: Rio-Tinto R reviewed the literature and wrote the manuscript; All authors critically reviewed the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ricardo Rio-Tinto, MD, Consultant Physician-Scientist, Digestive Oncology Unit, Champalimaud Foundation, Avenida Brasília, Lisbon 1600, Lisbon, Portugal. ricardo.riotinto@fundacaochampalimaud.pt
Received: April 11, 2023
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
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.

Keywords: Candy cane syndrome; Blind pouch syndrome; Post-gastrectomy syndromes; Side-to-side enteral anastomosis; End-to-side enteral anastomosis

Core Tip: Enteral resections with side-to-side or end-to-end anastomosis, if a long blind end is left in place and dilates, can cause symptoms that may appear many years later. The classic designation for this clinical condition is blind pouch syndrome, although it is possible to find references under other designations, causing confusion. Candy cane syndrome (CCS) is a particular case of the blind pouch syndrome following gastrectomy or gastric bypass. CCS was first reported in a 2007 paper describing a 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. With unknown prevalence, few reports and case series have described the condition. Yet, with the increasing prevalence of obesity and number of operations being performed worldwide, surgical complications such as CCS are expected to become more frequent. Knowledge of candy cane syndrome is important to avoid delays in diagnosis and inadequate treatments. Thus, the goal of this study was to collate evidence on CCS symptoms, diagnosis, treatments, and outcomes. To the best of our knowledge, no previous literature review on this topic has been published.