S6273 Gastrointestinal Symptoms as a Result of Sympathetic Denervation During Retroperitoneal Surgery

Introduction: The extrinsic sympathetic and parasympathetic nerves influence function of the enteric nervous system. Sympathetic innervation of the abdominal organs synapses in the prevertebral ganglia and functions as the “brake” of bowel motility. Previous studies in dogs documented celiac1 or mesenteric ganglionectomy2 are associated with persistent diarrhea. Sympathetic adrenergic denervation (e.g. in diabetic animals) also results in small intestinal secretion.3 We aimed to describe patients presenting with abdominal pain, diarrhea, and nausea following surgical disruption to prevertebral ganglia, and to document the prescribed treatments and outcomes based upon clinical follow-up. Case Description/Methods: We included 4 patients who developed diarrhea after undergoing surgery in the region of the prevertebral ganglia and diagnostic testing (including scintigraphic measurement of gut transit, as well as fecal pancreatic elastase). All underwent gastric and small bowel transit (measured using 99mTc-egg meal [320 kcal, 30% fat]), and, in 2, colonic transit was measured using 111In-charcoal particles delivered to the colon. All patients developed diarrhea and abdominal pain after surgery, 3 experienced nausea, 2 had rapid colonic transit (shown by the geometric center [GC] at 24 h and the difference between GC at 24 h and 48 h), and 3 had fast gastric emptying at 1 h. The first patient did not respond to rifaximin (for presumed small intestinal bacterial overgrowth) and pancreatic enzyme supplementation. The second patient also lacked improvement on a combination of loperamide, darifenacin, and a bile acid sequestrant. After starting these first 3 patients on α2-adrenergic agonist clonidine (patch) or somatostatin analog, octreotide, they reported resolution of diarrhea and relief of associated symptoms upon follow-up. Patient 4 was treated with cyclical antibiotics with short-term improvement. Discussion: The clinical features and rapid gastrointestinal and colonic transit following retroperitoneal surgery conceivably damaged sympathetic innervation to the gut. The positive response to treatment with clonidine and octreotide suggests also a component of secretory diarrhea in these patients. References 1. Annu Rev Physiol 1981;43:53-68 2. Am J Physiol 1979;237:E432-43 3. J Clin Invest 1985;75:1666-70