J Sabella et al. JPGN 2023; 76: 282-287. Multidisciplinary Tiered Care Is Effective for Children and Adolescents With Rumination Syndrome

The was a retrospective single-center study (n=171). The median length of treatment was 6.5 months for outpatient care, four days for intensive outpatient care and nine days for intensive inpatient care.

Key findings:

• After treatment, 72% of OP, 95% of IOP, and 96% of IP patients reported that symptoms were better or fully resolved compared to baseline
• In a subset of 16 children, At follow-up (median 5.3 months), 86% of IOP and 66% of IP patients had symptoms that remained better or resolved.
• The authors found “an association between patient or family reluctance to accept the diagnosis of rumination syndrome and a lack of response to treatment. Prior studies have demonstrated the importance of commitment and belief in the process of treatment and/or fully commit to the behavioral treatment process as a barrier to care.”

In a commentary on this article from Pediatrics Nationwide, Dr. Peter Lu noted: “What was striking to me was how effective the intensive treatment programs are. Both of those groups included the most severe of patients, oftentimes, they’ll have a feeding tube or a central line for parenteral nutrition. Even in that selected, very severe refractory group, we had very good response rates to treatment…RS is a disorder that cannot be effectively treated by a GI doctor alone…Treatment of RS involves a GI doctor and a GI psychologist, and we oftentimes will involve one of our GI dieticians”

My take: This study shows that treatment can be very effective in treating rumination syndrome, especially if the patient/family is amenable to therapy.

Related blog posts:

• The Half Empty Glass: Rumination Outcomes
• Internet Survey: Lots of People Have Rumination
• Expert Advice for Diagnosis and Treatment of Rumination Syndrome
• Baclofen for Rumination
• Dupixent for Eosinophilic Esophagitis (1-11 yrs) and Clinical Diagnosis of Rumination from DDW Tweets

Also, good tips on managing rumination were given on a bowel sounds podcast: Desale Yacob & Ashley Kroon Van Diest – Rumination Syndrome (August 2021)

K Tazi et al. JPGN Reports 4(2):p e316, May 2023. | DOI: 10.1097/PG9.0000000000000316. Open Access: Complications of Percutaneous and Surgical Gastrostomy Placements in Children: a Single-Centre Series.

In this retrospective single-center pediatric (n=124) study, the authors analyzed complications that occurred up to 1 year after placement. Key findings:

• Fifty-nine patients (47.6%) underwent endoscopic placement, 59 (47.6%) surgical placement, and 6 (4.8%) laparoscopic-assisted percutaneous endoscopic gastrostomy. 
• 29 (14.4%) major and 173 (85.6%) minor complications were reported
• This study highlights at least 1 complication (regardless of severity) in 106 (85.5%) patients and reports a significantly lower complication rate in the PEG group (major and minor combined) compared to the surgical group (laparoscopy and laparotomy) (OR, 0.3; 95% CI, 0.07–0.9) (P = 0.001).
• In the endoscopic group, patients with concomitant neurological disease had significantly more early complications (25.8 vs. 3.6%; OR, 9.1)
• In the surgical group, patients with undernutrition had significantly more major complications (12.1% vs. 40%; OR, 4.7; 95% CI, 1.2–18; P = 0.01)

Discussion:

• The authors note that although their results found fewer complications in the PEG group, other studies have reported lower complications in surgically-placed GTs. “Baker et al (⁴)^. report, like Sanderg et al (⁹)., an advantage of the laparoscopic technique compared to the endoscopy technique in terms of major complication (OR, 0.29; 95% CI, 0.17–0.51; P = 0.0001). Several other studies (^9,20,21) show similar results.”
• “Although a single prophylactic antibiotic therapy with cefazolin is systematically administered before each procedure, the rate of infectious complications remains high: 13 cases of abdominal wall abscess or cellulitis (6.4% of total complications) and 33 cases of minor infection (16.3% of total complications) requiring local treatment.”
• The strengths of this study are an exhaustive collection of detailed data permitting a precise analysis of complications

My take: The majority of studies suggest that laparoscopic GT placement is safer, unlike this study. A more definitive answer would require a randomized prospective study with rigorously-collected data. Also, GT complications are common, ~85% in this study; thus, family education is important both before and after GT placement.

Related blog posts:

• Gastrostomy Tube Recommendations in Pediatrics
•  Is a Laparoscopic Gastrostomy Better Than a Percutaneous Endoscopic Gastrostomy?
• Updated ESPGHAN Percutaneous Endoscopic Gastrostomy Position Paper
• Helpful Position Paper: Percutaneous Endoscopic Gastrostomy in Children
• Complications with G-tube Placement (reports 2015 study with same group)
• Which kids who aspirate need a gastrostomy tube?
• Long-term Outcomes with Pediatric PEG Placement

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