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Candy Cane Roux Syndrome: an Under Recognized Complication of an Excessive Roux Limb After Roux-EN-Y Gastric Bypass Surgery
Abdul Rehman*1, Siegfried W. Yu1, Muhammed Sherid1, Neal Patel1, Brian F. Lane2, Sean M. Lee2, Sherman Chamberlain1
1Internal Medicine Gastroenterology, Georgia Regents University, Augusta, GA; 2Surgery, Georgia Regents University, Augusta, GA
Introduction: An increasing number of patients are undergoing weight loss surgery due to the obesity epidemic. Roux-en-Y gastric bypass surgery (RYGB) is the most common bariatric surgery and is associated with a wide range of complications such as nutritional deficiencies, strictures, marginal ulcers, leaks and fistula formations. "Candy Cane" Roux Syndrome (CCRS) is an under recognized syndrome in patients with RYGB in which an excessive length of Roux limb proximal to the gastrojejunostomy can cause symptoms including nausea, vomiting, abdominal pain and diarrhea. We present a series of 2 patients with CCRS.
Cases: Two post-op RYGB patients were evaluated between January, 2012, and July, 2014, for various severe GI symptoms, after having undergone prior unremarkable work up for their complaints. A 57 year-old female patient presented with a 4 month history of nausea, vomiting, abdominal pain, and GERD, occurring 9 years after an uneventful RYGB. She underwent an EGD which showed an 8 cm long blind Roux limb. CCRS was suspected, and this led to laparoscopic resection of the Roux limb, and complete resolution of her GI symptoms. A 42 year-old female presented with persistent watery diarrhea along with epigastric pain which started after 2 months of RYGB surgery. An upper endoscopy revealed 15 cm Roux limb. She underwent surgical resection of the Roux limb which resulted in complete resolution of her abdominal pain and diarrhea.
Discussion: CCRS is a rarely reported complication of RYGB, with only four prior cases described in the literature, and is probably under recognized. It occurs when the excessive length, longer than 2-4cm, of the Roux limb proximal to the gastrojejunostomy results in various gastrointestinal symptoms including nausea, vomiting, abdominal pain and diarrhea. The symptoms of CCRS may result from small intestinal bacterial overgrowth due to poor drainage. Clinical suspicion of CCRS and endoscopic recognition by measurement of the Roux limb in our 2 cases led to the appropriate surgical resection of the excessive Roux limb, and subsequent resolution of a wide spectrum of GI symptoms.
Conclusion: Minimizing redundancy in the Roux limb during the primary RYGB procedure and/or subsequent surgical shortening of these excessive limbs can prevent and minimize CCRS. Surgeons and gastroenterologists who evaluate GI symptoms in post-RYGB patients should be aware of CCRS to appropriately evaluate these patients, which should include a formal measurement of the blind Roux limb during endoscopy. We propose that blind limbs longer than 4 cm should prompt referral for consideration of surgical correction once other causes of upper GI symptoms in post-RYGB patients have been excluded. Further studies are needed to better characterize CCRS, and to establish guidelines for surgeons and gastroenterologists who evaluate post-RYGB patients.
Table-1 Patient's clinical findings and response to treatment
| Patient | Sex | Age | Surgery | Symptoms | Post-surgery Symptom onset | Roux length (endoscopic) | Roux length (surgical) | Correctional surgery | Symptom improvement | | 1 | Female | 57 | RYGB | Nausea, vomiting, abdominal pain, GERD | 9 years | 8 cm | 10-12 cm | Laparoscopic Roux limb shortening | 100% | | 2 | Female | 42 | RYGB | Diarrhea, abdominal pain, bloating | 2 months | 15cm | 10cm | Open Roux limb shortening | 100% |
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