Advertisement

Magnet and wire remodeling for the treatment of candy cane syndrome: first case series of a new approach (with video)

Published:December 31, 2021DOI:https://doi.org/10.1016/j.gie.2021.12.027

      Background and Aims

      Candy cane syndrome (CCS) is an adverse event (AE) from gastrectomy or gastric bypass and end-to-side anastomosis to a jejunal loop. Preferential passage of food to the blind loop induces early satiety, pain, and regurgitation. An endoscopic device that combines 2 magnets and a self-retractable wire was designed to perform progressive septotomy with marsupialization. We evaluated the clinical safety and efficacy of this treatment in CCS.

      Methods

      Consecutive patients presenting with symptoms associated with CCS after gastrectomy or Roux-en-Y gastric bypass were treated with the MAGUS (Magnetic Gastrointestinal Universal Septotome) system. Weight, dysphagia, pain scores, 12-item Short Form Survey quality of life physical and mental scores, GERD Health-Related Quality of Life, and Eckardt score were measured at baseline and 1 and 3 months postprocedure. Satisfaction with therapy and AEs were monitored during follow-up.

      Results

      Fourteen consecutive patients with CCS were enrolled in the study. Thirteen MAGUS systems migrated within 28 days after achieving uneventful complete septotomy. In 1 patient the magnet had to be collected from the right-sided colon after 1 month. Treatment was completed in a single endoscopy session. Dysphagia score (2 [1-3] vs 1 [1-1], P = .02), pain score (7 [6-8] vs 1 [0-1], P = .002), Eckardt score (5 [3-8] vs 1 [0-2], P = .002), GERD Health-Related Quality of Life score (37 [29-45] vs 8 [6-23], P = .002), and quality of life physical and mental scores were all significantly improved at 3 months. No device or procedure-related serious AEs were observed. One patient died during follow-up from evolution of oncologic disease.

      Conclusions

      Endoluminal septotomy using a retractable wire and magnet system in CCS is feasible and safe, with rapid improvement of symptoms. (Clinical trial registration number: NCT04480216.)

      Abbreviations:

      AE (adverse event), CCS (candy cane syndrome), MAGUS (MAgnetic Gastrointestinal Universal Septotome)
      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:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Botsford T.W.
        • Gazzaniga A.B.
        Blind pouch syndrome. A complication of side-to-side intestinal anastomosis.
        Am J Surg. 1967; 113: 486-490
        • Stier C.
        • Koschker A.K.
        • Isaev Y.
        • et al.
        Intussusception, a plausible cause of the candy cane syndrome (Roux syndrome): known for a century—still a frequently missed cause of pain after Roux-en-Y gastric bypass.
        Obes Surg. 2020; 30: 1753-1760
        • Dallal R.M.
        • Cottam D.
        "Candy cane" Roux syndrome—a possible complication after gastric bypass surgery.
        Surg Obes Relat Dis. 2007; 3: 408-410
        • Granata A.
        • Cicchese N.
        • Amata M.
        • et al.
        "Candy cane" syndrome: a report of a mini-invasive endoscopic treatment using OverStitch, a novel endoluminal suturing system.
        Endoscopy. 2019; 51: E16-E17
        • Borao F.J.
        • Binenbaum S.J.
        • Matharoo G.S.
        Revisional foregut surgery.
        Cham, Switzerland: Springer, 2020: 88-90
        • Coursier K.
        • Verswijvel G.
        Candy cane sign.
        Abdom Radiol. 2020; 45: 885-886
        • Aryaie A.H.
        • Fayezizadeh M.
        • Wen Y.
        • et al.
        "Candy cane syndrome:" an underappreciated cause of abdominal pain and nausea after Roux-en-Y gastric bypass surgery.
        Surg Obes Relat Dis. 2017; 13: 1501-1505
        • Khan K.
        • Rodriguez R.
        • Saeed S.
        • et al.
        A case series of candy cane limb syndrome after laparoscopic Roux-en-Y gastric bypass.
        J Surg Case Rep. 2018; 2018: rjy244
        • Kamocka A.
        • McGlone E.R.
        • Pérez-Pevida B.
        • et al.
        Candy cane revision after Roux-en-Y gastric bypass.
        Surg Endosc. 2020; 34: 2076-2081
        • Razjouyan H.
        • Tilara A.
        • Chokhavatia S.
        Dysphagia after total gastrectomy.
        Am J Gastroenterol. 2015; 110: S262-S263
        • Takiguchi S.
        • Yano H.
        • Sekimoto M.
        • et al.
        Laparoscopic surgery for blind pouch syndrome following Roux-en Y gastrojejunostomy: report of a case.
        Surg Today. 1999; 29: 553-556
        • Kellogg T.A.
        Revisional bariatric surgery.
        Surg Clin North Am. 2011; 91: 1353-1371
        • Romero-Mejía C.
        • Camacho-Aguilera J.F.
        • Paipilla-Monroy O.
        "Candy cane" Roux syndrome in laparoscopic gastric by-pass [Spanish].
        Cir Cir. 2010; 78: 347-351
        • Cobb T.
        • Banki F.
        Thoracoscopic revision of a herniated Roux-en-Y esophagojejunostomy for treatment of "candy cane" syndrome.
        JTCVS Tech. 2020; 2: 153-155
        • Wundsam H.V.
        • Kertesz V.
        • Bräuer F.
        • et al.
        Lumen-apposing metal stent creating jejuno-jejunostomy for blind pouch syndrome in patients with esophago-jejunostomy after gastrectomy: a novel technique.
        Endoscopy. 2020; 52: E35-E36
        • Greenberg I.
        • Braun D.
        • Eke C.
        • et al.
        Successful treatment of "candy cane" syndrome through endoscopic gastrojejunal anastomosis revision.
        Clin J Gastroenterol. 2021; 14: 1622-1625
        • Cantillon-Murphy P.
        • Cundy T.P.
        • Patel N.K.
        • et al.
        Magnets for therapy in the GI tract: a systematic review.
        Gastrointest Endosc. 2015; 82: 237-245
        • Bouchard S.
        • Huberty V.
        • Blero D.
        • et al.
        Magnetic compression for treatment of large oesophageal diverticula: a new endoscopic approach for a risky surgical disease?.
        Gut. 2015; 64: 1678-1679
        • Huberland F.
        • Rio Tinto R.
        • Dugardeyn S.
        • et al.
        Magnets and self-retractable wire for endoscopic septotomies: from concept to first-in-human use.
        Endoscopy. Epub 2021 Jul 19;

      Linked Article

      • Endoscopic management of candy cane syndrome: A sweet and attractive solution?
        Gastrointestinal EndoscopyVol. 95Issue 6
        • Preview
          Candy cane syndrome is a postoperative adverse event after the creation of an end-to-side anastomosis to a jejunal loop, with the most common surgery being Roux-en-Y gastric bypass (RYGB). This disease entity has been poorly described in the literature but is thought to be rare, with an unclear prevalence. Diagnosis requires a high index of suspicion, given the nonspecific presentation, potentially including postprandial symptoms such as abdominal pain, nausea, vomiting, and gastroesophageal reflux.
        • Full-Text
        • PDF