Candy Cane Deformity in Post Roux-en-Y Gastric Bypass

October 15, 2018

Candy Cane Deformity

I was sitting in my office, the other day, when suddenly I hear a patient in our lobby coughing continuously.  I thought to myself, I bet she has the Candy Cane deformity.

Sure enough, she was my next patient, a patient of my fathers’ who had an open Roux-en-Y gastric bypass back in early 2000. We sat down and she began telling me her story, that is, her story between coughs; At 74 years old, she is delightful and quick-witted, informing me that she still secretly has a crush on my father “after all of these years!”.  Although she has maintained weight loss to date of 86 pounds, she was discouraged because of her weight regain of 70 pounds. She admitted that she had wavered from the recommendations of eating protein forward meals and was eating more processed and easy to digest foods because that is all she could eat.

As our visit continued she voiced other concerns including reflux, nausea with occasional vomiting, and stomach pain experienced when eating. Her biggest concern was her cough. “It’s changed my voice,” she said. “Just listen to me.”

She’s had this cough for years, having seen specialists throughout different healthcare systems including an extensive work up through the specialized Mayo Clinic. To her disappointment, despite numerous office visits and tests, there never was a reason found or treatment plan developed.

The specialists just said; “They didn’t know. Can you believe that?” She was prescribed a prescription acid reducer with the thought that she might have reflux. The treatment plan did not add up to me - the Roux-en-Y gastric bypass should be a fix for acid reflux, not a cause. I knew she had the Candy Cane deformity.

Identifying the Candy Cane Deformity

The candy cane deformity is a possible complication from the Roux-en-Y procedure. Candy Cane describes the non-functioning or blind end of the Roux limb where it connects to the new small pouch in the gastric bypass operation.

This might be an original problem following surgery or more likely develop over time. With the pressure of eating, this blind limb becomes a catch area, extending, lengthening and curving like the tip of a candy cane. Food and liquid will begin to become lodged or trapped in this area causing the symptoms of this deformity.

Symptoms Include:

1. Weight Gain
2. Pain With Eating
3. Pain Relieved to Vomiting
4. Nausea
5. Regurgitation
6. Epigastric Fullness

As a now “seasoned” bariatric surgeon, I am often tasked with getting to the bottom of medical issues for many patients – some are quite easy to figure out while others more challenging. To quote a famous Farmer’s Insurance Ad, “We know a thing or two because we’ve seen a thing or two.”  So what was it that I was to see, the four symptoms stood out with my father’s patient.

1. A chronic cough without a diagnosis, this because she was refluxing trapped food and liquid into her lungs, irritating her lungs when she would lie down to sleep.
2. Epigastric pain, this because foods and liquids start collecting in this collection area/ this blind limb causing painful distension with nowhere to go.
3. Weight regain, this because solid foods cause more distension with more discomfort then softer, slippery foods so patients begin to eat foods higher in carbohydrates and fats.
4. Nausea and vomiting this because the blind limb would fill up, overextend, then decompress with the food often running back up the esophagus.

I was confident that I had a diagnosis but now I needed a diagnostic confirmation.

Testing for the Candy Cane Deformity:

1. A UGI small bowel follow through (UGISBFT): A note to my colleagues - these films should be critically reviewed. In my experience, 40% of the positive studies visualized the deformity but the issue was not commented on in the radiologist’s note.
2. An upper endoscopy (EGD). Ideally, your surgeon will observe or perform this test with this deformity in mind to critically identify the deformity.

These two tests confirmed that my father’s patient did indeed have the Candy Cane deformity.

Treatment for the Candy Cane Deformity

The good news for patients with this problem, there is a solution. The solution requires surgery and in simple terms, the blind limb of the Roux-en-Y gastric bypass is surgically removed returning the bypass anatomy back to normal size in a normal position, termed a “surgical revision.”

Over the course of my 19 years in practice, I have only seen a couple of patients with the candy cane deformity. These patients walk into my office complaining of weight regain, pain, reflux, some with a cough and/or vomiting and this, always following the Roux-en-Y gastric bypass operation. The best part, following surgery to correct this problem, their quality of life immediately improves.

As is the case with my father’s patient, immediately following her revision, her symptoms resolved. Her voice returned and she is back to being her quick-witted and insightful self.

ABOUT THE AUTHOR Dr. Jeffrey Baker is a board-certified physician specializing in bariatric surgery at Riverside Medical Center. He has performed over 2,500 weight loss surgeries since specializing in bariatrics in 2003. He sits on the review boards of two international state-of-the-art medical device companies developing new technologies for bariatric innovations. Read more articles by Dr. Baker!

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