Postoperative dysphagia following laparoscopic gastric bypass due to isolated unilateral hypoglossal nerve palsy

M. Naef, A. Metzger, C. Hansen, A. Glättli, R. Steffen

Objective

Hypoglossal nerve palsy is a recognized but rare complication of oropharyngeal manipulation such as orotracheal intubation, laryngeal mask airway, bronchoscopy or carotid endarterectomy. The symptoms include tongue discomfort, dysarthria and dysphagia.

Methods

We present an unusual case of postoperative dysphagia of a 37-year-old patient undergoing laparoscopic gastric bypass surgery for morbid obesity.

Results

The female patient with morbid obesity (BMI 42.8 kg/m2) underwent laparoscopic proximal gastric bypass Roux-Y in March 2013. Personal history showed a condition after pulmonary embolism due to factor V Leiden mutation, gastro-esophageal reflux disease and cigarette smoking (>10 pack years). Preoperatively oral anticoagulation was stopped and low molecular weight heparin administered. Orotracheal intubation with a 7.0 mm endotracheal tube with prior muscle relaxation and the administration of general anesthesia proceeded without any difficulties and the operation (laparoscopic proximal gastric bypass Roux-Y with antecolic alimentary limb) was performed without incidents. The operation time was 100 minutes and after the patient awoke from anesthesia, extubation was performed without any difficulties. The next day after surgery, the patient reported discomfort while moving her tongue and slight difficulty with articulation. After beginning a semi-liquid diet at day 3, the patient suffered from severe dysphagia. An otorhinolaryngology consultation showed a deviation of the tongue to the left side, a slight swelling on the left and impairment of sensibility on the left side, suggesting a loss of the left hypoglossal nerve function. The symptoms, especially dysphagia, improved gradually in the following 4 weeks without any pharmacological treatment. The patient made a full recovery within 2 months.

Conclusion

Possible mechanisms of injury to the hypoglossal nerve in the present case include indirect trauma from positioning/stretching of the neck and direct trauma from continuous pressure of the endotracheal tube cuff, resulting in a transient isolated unilateral hypoglossal nerve palsy due to neuropraxia, which is a rare cause for postoperative dysphagia after gastric bypass, otherwise a common finding following this type of surgery.