Subtotal Gastrectomy as "Last Resort" Consideration in the Management of Refractory Rumination Syndrome

Rumination syndrome is a behavioral disorder resulting in effortless regurgitation of undigested food within minutes of meal intake that is subsequently either re-swallowed or ejected. It is commonly misdiagnosed, patients often undergo extensive testing and multiple therapies, many of which are directed at suspected gastroparesis. A 25-year-old Caucasian female initially presented to our care 1 year ago with a 4-year history of nausea and vomiting occurring in the immediate postprandial period, specifically within 15 minutes from oral intake. She had an extensive history of multiple diagnostic, therapeutic and surgical procedures over the previous 4 years which included cholecystectomy, botulin toxin injection into the pyloric sphincter, pyloroplasty, placement of a gastric stimulator and jejunal feeding tube with no sustained results. On a previous admission we determined the functional status of the stomach by obtaining full thickness gastric biopsies during a diagnostic laparoscopy. This revealed an adequate population number of cells of Cajal and myenteric neurons as well as normal stomach muscle. After 1 year of attempting "breathing relaxation techniques", while being nutritionally maintained by nocturnal jejunostomy feedings, the patient presented again to our care with refractory nausea and vomiting and unable to work or function. Her weight was 90 lbs. She underwent a subtotal gastrectomy (80%) with Roux-en-Y reconstruction and continuation of jejunostomy feeding. The refractory nausea and vomiting significantly improved over the 4 weeks after discharge and breathing exercises were continued. On subsequent follow-up visits over a 6-month course, the refractory nausea and vomiting had resolved by more than 85% with and improvement in her BMI and quality of life.The recommended treatment of rumination syndrome is focused on breathing exercises and relaxation techniques to "distract" while eating. We believe our case is the first reported where a subtotal gastrectomy has been used to help overcome refractory rumination along with the usual therapy. This surgery is a "last resort" consideration to improve quality of life, returning the patient to employment and functional social status.