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Effect of Vagus Nerve Integrity on Short and Long Term Efficacy of Antireflux Surgery
Selwyn Van Rijn*1, 2, Nicolaas Fedde Rinsma1, Jan Ringers3, Roeland Veenendaal4, José M. Conchillo1, Nicole D. Bouvy2, Ad Masclee1
1Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, Netherlands; 2General Surgery, Maastricht University Medical Center, Maastricht, Netherlands; 3General Surgery, Leiden University Medical Center, Leiden, Netherlands; 4Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
Background: Vagal nerve injury is a feared complication of antireflux surgery that may negatively affect reflux control and is associated with delayed gastric emptying and symptoms as diarrhoea, nausea and vomiting. The aim of the present prospective study was to evaluate the short term and long term impact of vagal nerve injury, evaluated by PP (pancreatic polypeptide) response to insulin hypoglycemia, on short and long term antireflux control and quality of life after antireflux surgery.
Methods: In the period 1990 until 2002, 121 patients (63 women and 58 men) with gastroesophageal reflux disease (GERD) underwent antireflux surgery at a single institution in whom vagus nerve integrity was evaluated. Of these patients, prior to and 6 months after surgery vagus nerve integrity test (PP response to insulin-induced hypoglycemia), 24-h pH-monitoring and gastric emptying were performed and reflux-associated symptoms were evaluated. In 2014, 12 to 24 years after surgery, 106 patients eligible for follow-up were contacted again for evaluation of long term symptomatic outcome using two validated questionnaires (GRSR and GERD-HRQL).
Results: Short term follow up : vagus nerve injury (PP peak <47pmol/L) was observed in 25 patients (21%) 6 months after fundoplication. In patients with and without vagal nerve injury a comparable decrease of reflux parameters and reflux symptoms was observed at 6 months of follow-up (acid exposure time; resp. from 9.7% (5.8-13.4%) to 1.8% (0.5-5.0%) and from 8.0% (5.2-14.4%) to 1.1% (0.3-3.4%), p=ns). Gastric emptying increased in patients without vagal nerve damage (half emptying time (min): 97 (75-114) vs 69 (58-88), p<0.001), while it was unaffected by fundoplication in patients with vagal nerve injury (half emptying time (min): 84 (75-142) vs 92 (71-138), p=ns).
Long term follow up: total of seventy-one (59%) patients completed both questionnaires for evaluation of long term reflux control. Patients in the vagal nerve injury group (n=15) showed a significantly worse symptomatic outcome (GERD-HRQL: 12 (3-22) vs 3 (0-9), p<0.05) and a higher re-operation rate when compared to patient without vagal nerve injury (53% vs 13%, p<0.001).
Conclusions: Reflux control 6 months after surgery was not affected by vagal nerve injury, however long term follow up showed an adverse effect on symptomatic outcome and was associated with a higher re-operation rate in patients with vagal nerve injury. We therefore believe that identifying the anterior and posterior branch of the vagal nerve is of high importance for the assurance of vagal nerve integrity and maintenance of reflux control after fundoplication.
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