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Observational Study
. 2021 Sep 29;21(1):234.
doi: 10.1186/s12871-021-01449-9.

Predominant role of gut-vagus-brain neuronal pathway in postoperative nausea and vomiting: evidence from an observational cohort study

Nana Li #  1 , Lu Liu #  2 , Menghan Sun #  3 , Ruiliang Wang  1 , Wenjie Jin  1 , Cunming Liu  1 , Youli Hu  4
Affiliations
Observational Study

Predominant role of gut-vagus-brain neuronal pathway in postoperative nausea and vomiting: evidence from an observational cohort study

Nana Li et al. BMC Anesthesiol. .

Abstract

Background: Postoperative nausea and vomiting (PONV) as a clinically most common postoperative complication requires multimodal antiemetic medications targeting at a wide range of neurotransmitter pathways. Lacking of neurobiological mechanism makes this 'big little problem' still unresolved. We aim to investigate whether gut-vagus-brain reflex generally considered as one of four typical emetic neuronal pathways might be the primary mediator of PONV.

Methods: Three thousand two hundred twenty-three patients who underwent vagus nerve trunk resection (esophagectomy and gastrectomy) and non-vagotomy surgery (hepatectomy, pulmonary lobectomy and colorectomy) from December 2016 to January 2019 were enrolled. Thirty cases of gastrectomy with selective resection on the gastric branch of vagus nerve were also recruited. Nausea and intensity of vomiting was recorded within 24 h after the operation.

Results: PONV occurred in 11.9% of 1187 patients who underwent vagus nerve trunk resection and 28.7% of 2036 non-vagotomy patients respectively. Propensity score matching showed that vagotomy surgeries accounted for 19.9% of the whole PONV incidence, much less than that observed in the non-PONV group (35.1%, P < 0.01). Multivariate logistic regression result revealed that vagotomy was one of underlying factor that significantly involved in PONV (OR = 0.302, 95% CI, 0.237-0.386). Nausea was reported in 5.9% ~ 8.6% vagotomy and 12 ~ 17% non-vagotomy patients. Most vomiting were mild, being approximately 3% in vagotomy and 8 ~ 13% in non-vagotomy patients, while sever vomiting was much less experienced. Furthermore, lower PONV occurrence (10%) was also observed in gastrectomy undergoing selective vagotomy.

Conclusion: Patients undergoing surgeries with vagotomy developed less PONV, suggesting that vagus nerve dependent gut-brain signaling might mainly contribute to PONV.

Keywords: Emetic neuronal pathway; Postoperative nausea and vomiting; Vagotomy.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
A flowchart elucidating the patients selection process and grouping methods included in this observational cohort study
Fig. 2
Fig. 2
Schematic diagram illustrating the effect of vagotomy on PONV. Four neural pathways potentially send stimulating inputs to the nucleus of the solitary tract (NTS) in the hindbrain: 1) gut vagal afferent fibers (yellow line) from the gastrointestinal tract; 2) motion-related vestibular input from the vestibular nuclei (Vnu); 3) area postrema (AP) and 4) descending pathways from the forebrain. NTS then produces the emetic reflex by activating its output pathways within local brainstem areas and causes nausea by projecting to the mid- and forebrain. However, which one of these four neuronal pathways as the primary mediator of PONV is still unknown. In this cohort study, occurrence of PONV is about 30% after non-vagotomy surgery (hepatectomy, pulmonary lobectomy and colorectomy), while PONV is reduced to approximately10% after vagotomy surgery (esophagectomy and gastrectomy) and selective vagotomy, suggesting that vagus nerve dependent gut-brain signaling mainly contributes to PONV
See this image and copyright information in PMC

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