S5297 Vagal Nerve Injury as a Complication of Transoral Incisionless Fundoplication

Introduction: Gastroesophageal reflux disease (GERD) is one of the most common presenting complaints in gastroenterology. Surgical management is commonly reserved for refractory GERD. Transoral incisionless fundoplication (TIF), a new technique rising in frequency as an endoscopic intervention for refractory cases. Vagal nerve injury is a known complication of intra-abdominal surgeries, including Nissen Fundoplication. Here we present a case concerning for vagal nerve injury due to TIF. Case Description: A 70-year-old man patient with a history of TIF performed 3 months ago and remote cholecystectomy presented to the hospital for diarrhea and intermittent epigastric pain. His bowel movements had been normal prior to the TIF procedure. His last colonoscopy in 2023 only showed 1 large polyp. The laboratory parameters demonstrated a TSH of 5.97, a pancreatic elastase of 369 and unremarkable tissue transglutaminase antibody, IgA and transglutaminase IgAs. He has reportedly tried antacids, proton pump inhibitors (PPIs), antibiotics, antiemetics, cholestyramine, loperamide and bulking agents without relief. He underwent esophagogastroduodenoscopy with biopsy which demonstrated evidence of the prior TIF procedure, a prolapsed hiatal hernia and erythema of the gastric antrum. The gastric biopsies demonstrated reactive gastropathy with focal intestinal metaplasia. The duodenal biopsies showed focal foveolar metaplasia. Stool PCR resulted negative for infectious causes. Blood VIP, gastrin and glucagon levels were normal. An abdominal CT imaging was unremarkable. Gastric emptying studies were normal. He is currently pending glucose breath testing, and endoscopy with for aspirate culture and disaccharidase assays. He is currently taking pantoprazole 40 mg daily. Discussion: GERD remains a highly prevalent disease process in the United States. TIF is a promising intervention that often decreases symptom burden and reduces long term dependence on PPIs. Commonly reported side effects of TIF include bleeding, perforation, and pneumothorax. Our patient presented with typical symptoms of vagal nerve injury including diarrhea and epigastric pain. Considering the temporal relationship of this patient’s symptoms and the TIF, a procedural complication must be considered including injury to the vagus nerve. Vagal nerve injury should be counseled as a potential side effect of TIF due to the significant impact it can have on patient’s livelihood.