LAUSR

Candy cane syndrome refers to an excessive blind jejunal limb length in gastroor esophago-jejunostomy. This conformation favors its preferential filling and progressive dilation across time, which pushes against the efferent limb and impedes its outlet [1]. We report the case of an 80-year-old man who presented, 40 years after gastrectomy for a cardia adenocarcinoma, with progressive oral intolerance, regurgitation, vomiting, pyrosis and malnutrition. At the barium contrast swallow and endoscopy, the afferent loop was dilated with significant stasis (▶Fig. 1, ▶Fig. 2). As the patient had undergone numerous previous abdominal interventions (gastrectomy, appendicectomy, cholecystectomy, anastomosis revision, and previous occlusion episode because adherences), endoscopic management was proposed with placement of a lumen-apposing metal stent (LAMS) by endoscopic ultrasonography (EUS). Using a therapeutic echoendoscope (EG3870UTK, 4mm; Pentax, Tokyo, Japan) the efferent loop was punctured from the afferent loop using a 20× 10mm electrocautery-enhanced LAMS (Hot Axios; Boston Scientific, Marlborough, Massachusetts, USA), with pure current cut, followed by guidewire insertion (▶Video 1). Contrast injection confirmed good position and distal patency. A computed tomography scan also showed good stent position (▶Fig. 3). The patient was able to eat at postoperative Day 1 and was discharged on Day 3. Symptom resolution was immediately noted and was persistent at the endoscopic follow-up performed 6 weeks later. The LAMSwas still in place and completely patent, and it was possible to pass through the stent to the distal jejunal limb (▶Fig. 4). Contrast injection demonstrated stent patency with distal media passage (▶Fig. 5). Video 1 Endoscopic treatment for candy cane syndrome. ▶ Fig. 1 Esophago-jejunal anastomosis with dilated afferent loop (left side) and efferent loop (right side). ▶ Fig. 2 Dilated afferent loop.