Peptic ulcer disease (PUD) is a prevalent condition in the United States affecting 2% of the country’s population. The treatment of PUD has evolved in the last century. Surgical vagotomy has historically played a major role in the treatment of PUD as it was considered the gold standard in the late 1940s. The treatment of PUD was drastically altered with the introduction of acid-reducing medications in the late 1970s and early 80s, and medical treatment was further supported in 2005 when Drs. Barry Marshall and Robin Warren won the Nobel Prize for their research in implicating Helicobacter pylori as the etiology of PUD. ,
There are 3 types of vagotomy described in the literature: truncal vagotomy (TV), selective vagotomy (SV), and highly-selective vagotomy (HSV). All have advantages and disadvantages. To understand the clinical implications of these 3 techniques, the healthcare provider must first understand the physiology of the stomach and its acid secretion. These techniques are further described in the following section in more detail along with a brief description of the physiology of gastric acid.
Although uncommon, surgical vagotomy may still play a role in the treatment of complicated PUD. Clinicians should be familiar with the surgery and its potential complications to effectively treat patients in the modern age.
Parts of the Stomach
The blood is supplied from the celiac trunk and superior mesenteric artery.
Four Major Arteries
These are branches above the esophageal hiatus that form the left (anterior) and right (posterior) LARP vagal trunks.
The relevant physiology revolves around the mechanisms relating to stomach acid secretion. Intraluminal gastric acid is released by the parietal cells mainly located in the body of the stomach. Parietal cells are stimulated via 3 mechanisms: gastrin, acetylcholine, and histamine. All 3 mechanisms activate the hydrogen-potassium ATPase-releasing hydrogen ion into the stomach lumen. Gastrin is secreted by the G cells that are mainly located in the stomach antrum and pylorus. Acetylcholine is released in response to a parasympathetic stimulation which travels in the fibers of the vagus nerves. Histamine is released by the enterochromaffin-like cells. 
Acid Secreting Phases
Cephalic: This phase is vagally mediated in response to smell, taste, and thought of food. It accounts for 30% of total acid production. It is the shortest of the 3 phases and is the scientific basis of the Sham diet following surgery.
Gastric: This phase begins once food enters the stomach. It is stimulated by proximal stomach distension (vagally mediated). It is absent in patients with vagotomy. The gastric phase is stimulated by amino acids and peptide leading to G cell activation. It accounts for 60% of total acid production.
Intestinal: This phase is mediated by hormonal release from small bowel mucosa in response to luminal chime. It accounts for 10% of total acid production.
Types of Vagotomy
A truncal vagotomy is the division of the anterior and posterior trunks 4-cm proximal to the GEJ.
Selective Vagotomy is the division of the anterior and posterior branches distal to the branching of the hepatobiliary and celiac branches.
Highly Selective Vagotomy (HSV, Parietal Cell Vagotomy, Proximal Vagotomy)
Division of the fibers supplying the parietal cell of the fundus and body, preserving the “crow's foot” fibers that innervate the antrum and pylorus, thus eliminating the need for a draining procedure.
When comparing the different types of vagotomies, mortality, recurrence, and the incidence of long-term, post-vagotomy syndromes must be taken into consideration. In general, HSV has shown to have the highest ulcer recurrence rate with the lowest morbidity and mortality compared to other procedures. TV or SV + antrectomy has classically been known to have the lowest recurrence rate but harbors the highest morbidity and mortality of the denervation procedures. The recurrence, morbidity, and mortality of the TV/SV + drainage procedures fall in-between the results of the 2 previously described techniques. When comparing truncal vagotomy to selective vagotomy (with a drainage procedure or antrectomy), there is a lower recurrence rate for TV. ,
The indications for vagotomy are few with the advancements of medical therapy. Generally, acid-reducing operations are reserved for complicated ulcer disease in a stable patient who has failed maximum medical therapy. The type of surgery performed depends on the type of ulcer (duodenal versus gastric), the complication of PUD (bleeding, perforation, obstruction, intractability), and the location of the ulcer (types I to V gastric ulcers as described by the Modified Johnson Classification system). 
Generally, contraindications relate to the patient's clinical status and include:
The general laparotomy/laparoscopy equipment will be required depending on the technique employed. A liver retractor is typically used. Surgical clips are used when dividing the vagal trunks.
For the operative portion, the following personnel is required:
Depending on the clinical situation preoperative preparation may vary. In the elective setting, the patient is given preoperative antibiotics 30 minutes before incision as well as venous thromboembolism prophylaxis. Abdominal hair is removed with clippers in the preoperative area. The patient is placed supine on the operating room table. After induction of anesthesia, a Foley catheter is inserted, and a nasogastric tube is positioned within the stomach. The surgeon stands on the patient's right side.
The surgery can be performed open or laparoscopically.
Entrance into the peritoneal cavity
Distal esophageal mobilization
Identification and division of the anterior vagal trunk
Identification and division of the posterior vagal trunk
Pathologic confirmation via frozen section
Drainage procedure or gastric resection with intestinal reconstruction
Abdominal wall and skin closure
The major immediate and intraoperative complications specific to TV include death, bleeding and injury to the stomach or esophagus. Other complications such as staple line leak, anastomotic leak, and internal hernia may be inherent to the specific type of intestinal reconstruction done.
The postoperative complications of truncal vagotomy are well documented. Resection of the vagal nerve trunks above the celiac and hepatic branches (differentiates TV versus SV) leads to parasympathetic denervation of the pylorus, liver, biliary tree, pancreas, and small and large intestines.
Although acid reducing surgery has become an operation with few indications, it is still an important tool for a surgeon to have. Vagotomy is generally indicated for intractability or a complication of peptic ulcer disease in a stable patient who has failed maximum medical therapy. The different techniques and post-operative consequences of acid-reducing surgeries must be thoroughly understood to perform these operations. Truncal vagotomy remains one of the more popular acid reducing operations employed today due to its relative technical ease compared to the highly selective vagotomy. Most surgeons would agree that a drainage procedure must be concomitantly performed at the time of TV and is not without consequences.
There was a time when TV was widely done but today it is rarely performed. The availability of the PPIs have made TV an obsolete procedure. While the procedure is technically relatively simple, it does have a number of serious complications. If the primary care provider or nurse practitioner comes across a patient with peptic ulcer disease, the first step is the use of PPIs. Surgery is the last time and should be undertaken aftera great deal of consideration. The outcomes for patients who undergo TV are fair as long as they do not develop post procedure complications.
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