Vagal-sparing esophagectomy: a more physiologic alternative.
OBJECTIVE
To evaluate the function of the vagal nerves and the gastric reservoir after vagal-sparing esophagectomy.


BACKGROUND
Esophagectomy as currently performed includes division of the vagal nerves and surgical alteration of the stomach, with attendant postoperative dumping, diarrhea, reduced meal capacity, and weight loss. Vagal-sparing esophagectomy has been introduced as a technique for removal of the esophagus while preserving the vagal nerves and gastric reservoir. The procedure is touted as having a low morbidity and is applicable to patients with end-stage benign or early malignant disease.


METHODS
A random sample of 15 patients at a median of 20 months after a vagal-sparing esophagectomy was compared to 23 asymptomatic normal subjects; 10 randomly selected patients, 29 months after esophagogastrectomy with colon interposition; and 10 randomly selected patients, 47 months after standard esophagectomy with gastric pull-up. Gastric mucosal acidification was tested with Congo red staining. Vagal secretory function was measured by gastric acid output and pancreatic polypeptide response to sham feeding. Vagal motor function was assessed by a technetium gastric emptying scan and a questionnaire to evaluate dumping and diarrhea. Gastric reservoir function was evaluated by measuring meal capacity and postoperative changes in body mass index.


RESULTS
Vagal-sparing esophagectomy preserved the function of the vagi, as evident by an increase in gastric acid output, a rise in serum pancreatic polypeptide following sham feeding, and preservation of normal postoperative gastric emptying in 70% of the patients. After vagal-sparing esophagectomy, patients were free of dumping and diarrhea and were analogous to normal subjects in meal capacity but had a slight reduction in the speed of eating.


CONCLUSIONS
Vagal-sparing esophagectomy preserves gastric secretory, motor, and reservoir function. Postoperatively, patients have normal alimentation, bowel regulation, and no weight loss. It is an ideal procedure for patients with end-stage benign disease, Barrett's esophagus with high-grade dysplasia, or esophageal carcinoma limited to the lamina propria.
Department of Surgery, University of Southern California, Los Angeles, California 90033, USA.
Farzaneh
F
Banki
Rodney J
RJ
Mason
Steven R
SR
DeMeester
Jeffrey A
JA
Hagen
Nagammapudur S
NS
Balaji
Peter F
PF
Crookes
Cedric G
CG
Bremner
Jeffrey H
JH
Peters
Tom R
TR
DeMeester
D000328:Adult; D001471:Barrett Esophagus / Q000601:surgery*; D002277:Carcinoma / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005744:Gastric Acid / Q000378:metabolism; D005746:Gastric Emptying; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D014630:Vagus Nerve / Q000502:physiology*