Kamthorn Yolsuriyanwong, MD, Eric Marcotte, MD, Mukund Venu, Bipan Chand, MD. Loyola University Chicago, Stritch School of Medicine
Background: Thoracic and gastric operations can cause vagal nerve injury, either accidentally or intended. The most common procedure, which can lead to such an injury, includes fundoplication, lung or heart transplantation and esophageal or gastric surgery. Patients may present with minimal symptoms or some degree of gastroparesis. Gastroparetic symptoms of include nausea, vomiting, early satiety, bloating and abdominal pain. If these symptoms occur and persist, the clinician should have a high suspicion of a possible vagal injury. Investigative studies include endoscopy, esophageal motility, contrast imaging and often nuclear medicine gastric emptying studies (GES). However, GES in the post-surgical patient have limited sensitivity and specificity. If a vagal nerve injury is encountered, subsequent secondary operations must be planned accordingly.
Methods: From January 2014 to August 2017, patients who had a previous surgical history of a foregut operation, with the potential risk of a vagal nerve injury, had vagal nerve integrity (VNI) test results reviewed. VNI test was measured indirectly by the response of plasma pancreatic polypeptide to sham feeding. The data collected and analyzed included age, gender, previous surgical procedures, clinical presentation, results of VNI testing and the secondary procedure planned or performed. VNI testing was compared to other testing modalities to determine if outcomes would have changed.
Results: Eight patients (5 females) were included. The age ranged from 37 to 73 years. Two patients had prior lung transplantation and six patients had prior hiatal hernia repair with fundoplication. Seven patients presented with reflux and delayed gastric emptying symptoms. One lung transplantation patient had no symptoms but his lung biopsy pathology showed chronic micro-aspiration with rejection. The VNI testing results were compatible with vagal nerve injury in 6 patients. According to these abnormal results, the plans for Nissen fundoplication in 2 patients were modified by an additional pyloroplasty and the plans for redo-Nissen fundoplication in 4 patients were changed to redo-Nissen fundoplication plus pyloroplasty in 1 patient and partial gastrectomy with Roux-en-Y reconstruction in 3 patients. The operative plans in 2 patients with a normal VNI test were not altered. All patients that had secondary surgery had improvement in symptoms and or improvement in objective tests (ie signs of rejection).
Conclusion: The addition of VNI testing in patients with previous potential risks of vagal nerve injury may help the surgeon select the appropriate secondary procedure.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87210
Program Number: P450
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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