König's Syndrome After Roux-en-Y Gastric Bypass: Candy Cane Twist

Background: A König's syndrome is referred to abdominal pain in relation to meals with constipation alternated with diarrhea, meteorism, and abdominal distension. A postoperative long-term complication after Roux-en-Y gastric bypass could be the appearance of chronic abdominal pain associated with vomiting, dysphagia, and nausea.

Case report: A 43-year-old female patient was submitted for a Roux-en-Y gastric bypass for morbid obesity with an initial body mass index (BMI) of 36 kg/m² (weight 100 kg, height 168 cm). At the 5-year follow-up, the patient's BMI was 22.3 kg/m² with a weight loss of 40 kg. In the last month, the patient has undergone a further weight loss of 8 kg (BMI 18.4 kg/m²) with the presence of chronic abdominal pain, dyspepsia, and dysphagia and abdominal distension. Any vasomotor problems (hot flushing, sweating, palpitations, and diarrhea) were described. The computer tomography (CT) with oral contrast shows the presence of a blind afferent Roux limb at the gastrojejunostomy, explaining a possible König's syndrome.

Results: The patient was submitted for a diagnostic laparoscopy, which revealed the presence of a twisted candy cane that was identified and resected. The postoperative stages were uneventful and the patient was discharged on the second postoperative day.

Conclusion: Candy cane syndrome is a rare and challenging complication reported in bariatric patients following Roux-en-Y gastric bypass and is best investigated with a barium swallow or oesophago-gastro-duodenoscopy (OGD). This means that this kind of pathology could be avoided by not leaving such a long blind loop during the primary gastric bypass operation. An explorative laparoscopy could be performed in the event of abdominal pain, nausea, and vomiting at a long-term follow-up after gastric bypass. Even if there are little data regarding the efficacy of surgical treatment, if present, "candy cane" surgical revision seems to be the best treatment for the majority of the patients with long-term symptomatic relief.