Rumination syndrome after esophagectomy

  • Daniele Bernardi
  • Emanuele Asti
  • Lavinia Barbieri
  • Luigi BonavinaEmail author
short communication



Gastric conduit dysfunction after esophagectomy is a disabling condition that may require revisional surgery. Rumination syndrome is an uncommon and poorly recognized functional foregut disorder of unknown etiology characterized by effortless oral regurgitation of recently ingested food. Rumination is associated with increased intragastric pressure generated by an unconscious mechanism eliciting contraction of the abdominal wall and relaxation of the diaphragm. Rumination syndrome after esophagectomy has not been previously reported in the literature.


Two female patients were referred for inability to eat and weight loss due to severe food regurgitation following esophagectomy and gastric conduit replacement. Their previous medical and psychiatric history was apparently unremarkable. Symptoms occurred within the first postoperative year and progressively worsened. High-dose proton pump inhibitors, erythromycin, metoclopramide, antidepressant medications, pneumatic pyloric dilatation, and laparoscopic pyloromyotomy failed to relieve symptoms, and both patients eventually required permanent tube jejunostomy for nutritional support. Subsequently, thoracoscopic implant of a neurostimulator and a laparoscopic Roux-en-Y gastrojejunostomy were performed and failed in both patients.


All medical and surgical attempts to relieve symptoms were clinically unsuccessful in these patients in whom radiological and endoscopic investigations did not demonstrate trans-diaphragmatic hernia or mechanical obstruction of the gastric conduit. Eventually, the diagnosis of rumination syndrome was made based on the Rome IV criteria.


In the absence of anatomical or other functional abnormalities of the gastric conduit, revisional surgery is contraindicated; rather, the diagnosis of rumination syndrome should be considered. The role of behavioral therapy integrated with diaphragmatic breathing training and biofeedback should be investigated in these patients.


Esophagectomy Rumination syndrome Diaphragmatic breathing Functional dyspepsia Revisional surgery 



Supported by AIRES (Associazione Italiana Ricerca Esofago).

Compliance with ethical guidelines

Conflict of interest

D. Bernardi, E. Asti, L. Barbieri, and L. Bonavina declare that they have no competing interests.

Ethical standards

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975 (in its most recently amended version). Informed consent was obtained from all patients included in the study.


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San DonatoUniversity of Milan Medical SchoolSan Donato Milanese (Milano)Italy

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