Endoscopic management of candy cane syndrome with a lumen-apposing metal stent.

Background and Aims: Candy cane (CC) or "hockey stick" syndrome is an adverse event of Roux-en-Y gastric bypass (RYGB) caused by an excessively long blind afferent limb distal to the gastrojejunostomy. This anatomical anomaly leads to symptoms such as pain, regurgitation, vomiting, and weight loss. Although surgical resection is the standard treatment, it is technically challenging and associated with significant risks. Alternative endoscopic approaches have been described in limited case reports. Methods: We present a novel EUS-guided approach to managing CC syndrome. A 61-year-old man with a history of RYGB presented with abdominal pain, vomiting, and low-grade fever for 2 months. Upper GI fluoroscopy and endoscopy confirmed CC anatomy. Under EUS guidance, a 20-mm lumen-apposing metal stent was deployed to create an anastomosis between the blind limb and the Roux limb, restoring luminal continuity. Results: The patient tolerated the procedure well and was able to resume oral intake postoperatively. At 4-month follow-up, symptoms had resolved, and endoscopic evaluation confirmed stent patency. At 6 months, the patient remained asymptomatic, and the stent was successfully removed. A patent jejunojejunostomy was confirmed with free flow of contrast between the blind limb and the Roux limb. Conclusion: This case highlights a novel, minimally invasive endoscopic approach for CC syndrome. EUS-guided enteroenterostomy with lumen-apposing metal stent offers a safe and effective alternative to surgical resection, potentially reducing morbidity in patients with this under-recognized adverse event of RYGB.