Recipient pneumonectomy and the necessity for meticulous hemostasis in heart-lung transplantation can result in injury to the vagus nerves as they course through the posterior mediastinum, with consequent delay in gastric emptying. This has been reported to lead to chronic aspiration and associated pulmonary sequelae. To study the association between delayed gastric emptying, bronchiectasis, and bronchiolitis obliterans after heart-lung transplantation, we performed esophageal manometry, 24-hour pH monitoring, and radioisotopic gastric emptying in 10 patients who underwent heart-lung transplantation. Three patients had grossly delayed liquid and solid emptying that was compatible with complete vagotomy. Six other patients had delayed liquid but normal solid emptying--an unexplained finding that is the reverse of what one would expect from vagal injury. Two of these 9 patients had esophageal dysmotility, but none demonstrated gastroesophageal reflux. One remaining patient had faster than normal gastric emptying for both solids and liquids. Of the 10, 2 patients have radiologic changes of bronchiectasis and 3 have biopsy evidence of obliterative bronchiolitis. There is no relationship between these sequelae and the occurrence of esophageal dysmotility, gastroesophageal reflux, or vagotomy. We conclude that gastric emptying abnormalities can occur after heart-lung transplantation, but such abnormalities are not associated with gastroesophageal reflux and the development of pulmonary sequelae, as previously reported.