J Gastric Cancer.  2019 Mar;19(1):49-61. 10.5230/jgc.2019.19.e2.

Intraoperative Neurophysiologic Testing of the Perigastric Vagus Nerve Branches to Evaluate Viability and Signals along Nerve Pathways during Gastrectomy

• Kong SH
• Kim SM
• Kim DG
• Park KH
• Suh YS
• Kim TH
• Kim IJ
• Seo JH
• Lim YJ
• Lee HJ
• Yang HK

• KMID: 2458817
• DOI: http://doi.org/10.5230/jgc.2019.19.e2

Abstract

PURPOSE
The perigastric vagus nerve may play an important role in preserving function after gastrectomy, and intraoperative neurophysiologic tests might represent a feasible method of evaluating the vagus nerve. The purpose of this study is to assess the feasibility of neurophysiologic evaluations of the function and viability of perigastric vagus nerve branches during gastrectomy.
MATERIALS AND METHODS
Thirteen patients (1 open total gastrectomy, 1 laparoscopic total gastrectomy, and 11 laparoscopic distal gastrectomy) were prospectively enrolled. The hepatic and celiac branches of the vagus nerve were exposed, and grabbing type stimulation electrodes were applied as follows: 10-30 mA intensity, 4 trains, 1,000 µs/train, and 5× frequency. Visible myocontractile movement and electrical signals were monitored via needle probes before and after gastrectomy. Gastrointestinal symptoms were evaluated preoperatively and postoperatively at 3 weeks and 3 months, respectively.
RESULTS
Responses were observed after stimulating the celiac branch in 10, 9, 10, and 6 patients in the antrum, pylorus, duodenum, and proximal jejunum, respectively. Ten patients responded to hepatic branch stimulation at the duodenum. After vagus-preserving distal gastrectomy, 2 patients lost responses to the celiac branch at the duodenum and jejunum (1 each), and 1 patient lost response to the hepatic branch at the duodenum. Significant procedure-related complications and meaningful postoperative diarrhea were not observed.
CONCLUSIONS
Intraoperative neurophysiologic testing seems to be a feasible methodology for monitoring the perigastric vagus nerves. Innervation of the duodenum via the celiac branch and postoperative preservation of the function of the vagus nerves were confirmed in most patients. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0000823

Keyword

Vagus nerve; Gastrectomy; Intraoperative neurophysiological monitoring

MeSH Terms

Diarrhea
Duodenum
Electrodes
Gastrectomy*
Humans
Information Services
Intraoperative Neurophysiological Monitoring
Jejunum
Methods
Needles
Prospective Studies
Pylorus
Vagus Nerve*

Figure

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  Fig. 1 Port sites and introduction of electrodes. (A) Two stimulating electrodes (yellow arrowhead) and 2 recording electrodes (yellow arrow) were introduced in the peritoneal space through 12-mm sized trocars. Two electrodes were placed under the skin in the left upper abdominal wall for grounding and reference (orange arrow). (B) Stimulating electrode. (C) Recording electrode.

• 

  Fig. 2 Placement of electrodes. (A) Hepatic and celiac branches of the vagus nerves were dissected and exposed through the lesser sac. (B) Stimulating electrodes were placed at the hepatic branch (arrow) and the celiac branch (arrowhead). (C) Intramuscular placement of recording electrodes at the first portion of the duodenum. (D) Proximal jejunum.

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  Fig. 3 Electrophysiologic measurement of the myocontractile response. (A) Measurement of the latency and the peak amplitude. A representative wave of response to the stimulation of the (B) hepatic branch and (C) celiac branch is presented.

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  Fig. 4 Predicted pathway of the vagus nerve. Large arrows indicate the region of stimulation. The linkage from the celiac branch to the pylorus (*) and the jejunum (†), which were observed preoperatively, was disconnected postoperatively in cases 3 and 7, respectively. *Possible route of connection between celiac branch and duodenum.

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  Fig. 5 Survey of gastrointestinal symptoms and Sigstad score taken Pre-op., POP 3w, and POP 3 m. Pre-op. = preoperatively; POP 3 w = postoperatively in the 3rd week; POP 3 m = postoperatively in the 3rd month.

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