Swallow Syncope as a Late Complication of Sleeve Gastrectomy

Swallow syncope, also known as swallow-induced syncope, or deglutition syncope, is a type of situational reflex syncope associated with swallowing. It is believed to be due to exaggerated vagal parasympathetic stimulation leading to inhibition of heart rate during swallowing. Swallow syncope has been documented in cases of gastroesophageal structural pathologies, such as achalasia and esophageal stricture, and has even been shown to resolve following surgical correction. To date, there are 118 reported cases of swallow syncope published in medical literature, which includes 14 reports of swallow syncope with associated hiatal hernia, and only one of which reports swallow syncope following sleeve gastrectomy. We present a case of swallow syncope as a late complication of laparoscopic sleeve gastrectomy associated with gradually worsening hiatal hernia. Our patient is a 54-year-old female who presented with a chief complaint of acute-onset episodic presyncope and syncope that occurs when swallowing food or liquids. Pertinent past medical history includes morbid obesity, obstructive sleep apnea, and a remote history of neurocardiogenic syncope during childhood. Approximately six weeks prior to presentation, the patient underwent laparoscopic sleeve gastrectomy complicated by surgical infection which had since resolved. Asystolic pauses lasting three to four seconds, occurring exclusively during deglutition, and sinus bradycardia with heart rates as low as 20 beats per minute were noted on telemetry monitoring over the course of her hospital admission. Following evaluation by electrophysiology consult, shared decision was made to proceed with dual-chamber pacemaker placement. During a follow-up visit seven months post pacemaker placement, the patient reported no pre-syncopal or syncopal episodes. At that time, a review of the patient's multiple prior imaging studies incidentally revealed a hiatal hernia, which first appeared on a CT image taken eight days after her bariatric procedure. Review of the most recent imaging studies available at that time showed a progressive increase in size of the herniation since its initial appearance.  Our case of swallow syncope, a rare disorder in itself, is made even more anomalous by the underlying etiology of iatrogenic hiatal hernia following sleeve gastrectomy, the patient's family history of swallow syncope secondary to Roux-en-Y procedure, and the decision to treat with dual-chamber pacing. The patient's history of surgical infection also raises the question of whether post-infectious changes are wholly, or partly, responsible for her symptoms. Guideline treatment options such as lifestyle modification and medical management were not attempted due to concern for possible treatment failure and the need for definitive and immediate resolution of the patient's symptoms since quality of life was significantly impacted. Correction of underlying pathology was not considered prior to pacemaker placement due to failure to identify the hiatal hernia as a potential inciting factor in time. Our case highlights the variety of possible etiologies leading to situational syncope, the possibility of a hereditary component, and successful resolution of symptoms following the unconventional decision to treat with pacemaker placement.