Post written by Anne Kimberly Lim-Fernandez, MD, from the Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.

Candy cane syndrome is an uncommon but clinically significant adverse event after gastric bypass or total gastrectomy. It arises when the long blind pouch at the anastomosis preferentially fills with ingested food. This can lead to symptoms of dysphagia, regurgitation, abdominal pain, and nutritional compromise.

Surgical resection of the blind pouch has traditionally been the standard treatment, but this option carries higher risk in patients with altered anatomy or significant comorbidities. Endoscopic approaches have emerged as minimally invasive alternatives, particularly with the use of lumen-apposing metal stents (LAMSs).

Our patient presented more than a decade after total gastrectomy with dysphagia, regurgitation, and significant weight loss. Imaging demonstrated candy cane syndrome with an enlarged blind jejunal pouch and the esophagojejunostomy displaced into the thorax. Given the patient’s surgical history, a minimally invasive solution was preferred over reoperation.

Instead of traditional surgical resection, we performed an EUS-guided retrograde LAMS insertion between the efferent limb and blind pouch. A tandem approach using an ultraslim gastroscope (GIF-XP180N; Olympus, Tokyo, Japan) and echoendoscope (GF-UCT180; Olympus) enabled safe deployment, with saline instilled into the blind pouch to optimize visualization and target stability.

Under EUS guidance, a LAMS was deployed to create a direct bypass between the efferent limb and blind pouch. This approach allowed us to maintain an optimal axis and stability for stent placement.

Postprocedure, the patient gained 9 kg over 4 months, tolerating a normal diet. At 10 to 12 months, LAMS removal was planned to allow longer indwelling time and greater rate of patency.    

This minimally invasive technique demonstrates the adaptability of EUS-guided interventions to complex postsurgical adverse events. In addition, this technique avoids the morbidity of repeat surgery in altered anatomy.     

We felt that the retrograde approach provides a stable target and favorable axis for LAMS deployment when antegrade access is not ideal. This case underscores the evolving role of advanced endoscopy in offering effective, less-invasive alternatives to reoperation.    

I extend my deepest appreciation to my collaborators and coauthors whose expertise and support made this case possible.    

Fluoroscopic images of LAMS deployment. A, Gastroscope position was confirmed with intraluminal contrast instilled into the blind pouch. The echoendoscope was alongside a nasojejunal tube in the efferent limb. B, A single puncture was created using an electrocautery-enhanced delivery system from the efferent limb into the blind pouch. C, Deployment of LAMS. LAMS, Lumen-apposing metal stent.

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