Perioperative management of vagotomy for treatment of frequent syncope

A 66-year-old man was admitted to our hospital because of frequent chest pain and loss of consciousness. He had a 6-year history of angina and has taken nitroglycerin. He had received total laryngo-pharyngoectomy with the graft by jejunum for pharyngeal cancer seven months ago. The tumor, however, recurred at the neck lymphnodes. Against the increased episodes of severe bradycardia and loss of consciousness, he was scheduled to undergo subemergent vagotomy at proximal and distal side of the cancer since the cancer surrounded the nutrition vessels of the graft. Atropine 0.25mg i.m. and 0.25mg i.v. were administered to treat bradycardia and hypotension in the morning of operation. As a premedication atropine 0.5mg p.o. was given. Anesthesia was induced with midazolam 3mg, sevoflurane 5%, nitrous oxide 8 l · min^-1 in oxygen 4 l · min^-1. Intubation through tracheostomy was facilitated with fentanyl 100 μg. When the operator touched the neck, heart rate and blood pressure decreased suddenly to 35 beats · min^-1 and 62 mmHg/20 mmHg, respectively. Atropine l mg i.v. and ephedrine 8 mg i.v. were effective. This was the only episode during surgery. After surgery all bradycardiac episodes have gone away without atropine or any other treatment. His frequent attack of bradycardia and hypotension with syncope was due to vagal reflex by the recurrent tumor.