Continuing Education Activity

Peptic ulcer disease (PUD) is a prevalent condition in the United States, affecting 2 percent of its population. The treatment of PUD has evolved in the last century. Up until the late 1940s, vagotomy was considered the gold standard treatment for PUD. Currently, PUD treatment usually involves acid-reducing medications and, when the organism is present, Helicobacter pylori eradication. Although uncommon, vagotomy may still play a role in the treatment of complicated PUD. Interprofessional teams should be familiar with the surgery and its potential complications to provide effective care to their patients. This activity reviews the indications, contraindications, and techniques involved in performing a vagotomy and highlights the interprofessional team's role in the pre-operative and post-operative care of patients undergoing this procedure.

Objectives:

• Outline the indications for a vagotomy.
• Describe the technique used to perform a vagotomy.
• Summarize the complications associated with a vagotomy.
• Explain a structured interprofessional team approach to provide effective care to and appropriate surveillance of patients undergoing vagotomy.

Introduction

Peptic ulcer disease (PUD) is a prevalent condition in the United States, affecting 2% of its population. The treatment of PUD has evolved in the last century. Surgical vagotomy has historically played a major role in PUD treatment 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.[1][2]

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.[3] To understand the clinical implications of these three 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 gastric acid physiology.

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 treat patients in the modern age effectively.

Anatomy and Physiology

Parts of the Stomach

• Fundus: Most superior portion abutting the left hemidiaphragm and the spleen
• Cardia: Just distal to the gastroesophageal junction (GEJ)
• Body: Largest component ending distally at the incisura angularis along the lesser curvature
• Antrum: Comprises the distal 25% to 30% of the stomach
• Pylorus: Connects the stomach to the first portion of the duodenum

Ligaments

• Gastrohepatic (lesser omentum): Contains vagal fibers to the liver and a replaced left hepatic artery when present (up to 10% incidence)
• Gastrocolic: Greater omentum attaching the inferior aspect of the stomach to the transverse colon
• Gastrosplenic: Contains the proximal left gastroepiploic artery and the short gastric arteries

Blood Supply

The blood is supplied from the celiac trunk and superior mesenteric artery.

Four Major Arteries

1. Left gastric artery: Arises directly from the celiac trunk, largest of the 4 arteries, gives off ascending and descending branches, when present; it is the origin of the aberrant left hepatic artery, supplies the lesser curvature.
2. Right gastric artery: Arises from the proper hepatic artery (after the takeoff of the GDA)  and forms an anastomotic arcade with the left gastric artery along the lesser curvature
3. Left gastroepiploic artery: Arises from the splenic artery; supplies the greater curvature of the stomach
4. Right gastroepiploic artery: Arises from the gastroduodenal artery, forms an anastomotic arcade with the left gastroepiploic artery along the greater curvature of the stomach

Innervation

Vagus Nerves

These are branches above the esophageal hiatus that form the left (anterior) and right (posterior) LARP vagal trunks.

• Anterior trunk: Gives rise to the branches that provide innervation to the hepatobiliary system and continue along the lesser curvature as the anterior nerve of Latarjet
• Posterior trunk: Sends branches to the celiac plexus and continues along the posterior aspect of the lesser curvature as the posterior nerve of Latarjet.
• Criminal nerve of Grassi: The first branch of the posterior trunk innervates the gastric fundus. Failure to divide this nerve during an acid-reducing surgery can lead to recurrent ulcers.
• Crow's foot: The most distal branches of the anterior and posterior trunks provide innervation to the antro-pyloric region. These branches are spared in a highly selective vagotomy (HSV)
• Parasympathetics are vagally mediated using acetylcholine as the primary neurotransmitter.

Physiology

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 parasympathetic stimulation, which travels in the fibers of the vagus nerves. Histamine is released by the enterochromaffin-like cells.[4]

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 a vagotomy. The gastric phase is stimulated by amino acids and peptides, 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

Truncal Vagotomy

A truncal vagotomy is the division of the anterior and posterior trunks 4-cm proximal to the GEJ.

• Removes the acetylcholine-mediated secretion of acid from parietal cells
• Results in the accelerated emptying of liquids due to the removal of the vagally mediated receptive relaxation of the gastric fundus
• Decreases the emptying of solid due to the removal of the vagally medially relaxation of the pylorus
• Requires a draining procedure (TV + D) to increase the emptying of solids (pyloroplasty)
• It can be combined with antrectomy to suppress acid secretion further and also serves as the drainage procedure (TV + A)

Selective Vagotomy

Selective Vagotomy is the division of the anterior and posterior branches distal to the branching of the hepatobiliary and celiac branches.

• Requires a drainage procedure (SV + D)
• Can be combined with antrectomy to suppress acid secretion further and also serve as the drainage procedure (SV + A)

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.

Indications

When comparing the different types of vagotomies, mortality, recurrence, and the incidence of long-term, post-vagotomy syndromes must be considered. In general, HSV has been 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.[5] There is a lower recurrence rate for TV when comparing truncal vagotomy to selective vagotomy (with a drainage procedure or antrectomy).[6],[3]

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). [7]

Specific Scenarios[8]

• Bleeding duodenal ulcer: In a patient who has failed medical treatment for any reason (allergy to medications, recurrence despite maximum medical therapy). The original operation consists of opening the first portion of the duodenum and the pylorus, thus creating the drainage procedure (pyloroplasty). In this setting, a truncal vagotomy should be added to the procedure to limit recurrence risk.
• Bleeding gastric ulcer: Since most gastric ulcers are not associated with high acid secretion (aside from type II and III, which are located at the pre-pyloric area), a vagotomy is very rarely indicated. Typically the ulcer should be resected. A TV may be added for type II and III ulcers, along with the distal gastrectomy.
• Perforated duodenal ulcer: Typically, a Graham patch repair is performed to seal the perforation. An HSV may be considered in a stable patient with minimal soilage, high risk for recurrence (unable to stop NSAIDs or an active smoker), failure of maximum medical therapy, and recent documentation of H. Pylori negative status.
• Perforated gastric ulcer: These will be treated as a bleeding gastric ulcer as described above.
• Gastric outlet obstruction: First-line therapy consists of endoscopic balloon dilation along with PPI medication. If there is recurrence or failure of medical treatment, truncal vagotomy and antrectomy is the procedure of choice. One may consider HSV with gastrojejunostomy without resection in a case where duodenal scarring prevents a safe antrectomy.
• Intractability: In a patient with a duodenal or type II or III gastric ulcers, an HSV should be considered. In gastric ulcers not related to acid hypersecretion, gastric resection without vagotomy is the procedure recommended.
• Recurrence despite a previous vagotomy: If the patient cannot be managed medically (50% fail), then the procedure required is a TV + A.

Contraindications

Generally, contraindications relate to the patient's clinical status and include:[9]

• Pre-operative shock
• Severe generalized peritonitis
• Intra-abdominal abscess
• Delay in the diagnosis and operative treatment (usually more than 24 hours)
• Severe concurrent medical illness precluding a safe extension of operating time

Equipment

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. 

Personnel

For the operative portion, the following personnel is required:

• Anesthesiologist
• Primary surgeon
• Scrub technician
• First assistant
• Circulating nurse
• Pathologist

Preparation

Depending on the clinical situation, preoperative preparation may vary. In the elective setting, the patient is given preoperative antibiotics 30 minutes before incision and venous thromboembolism prophylaxis. Abdominal hair is removed with clippers in the preoperative area. The patient is placed supine on the operating room table. After anesthesia induction, a Foley catheter is inserted, and a nasogastric tube is positioned within the stomach. The surgeon stands on the patient's right side.

Technique or Treatment

The surgery can be performed open or laparoscopically.[10]

Open Technique[11][12]

Entrance into the peritoneal cavity

• An upper midline incision is made just superior to the umbilicus and extends superiorly to the xiphoid process.
• The peritoneal cavity is opened and inspected.
• A self-retaining retractor is placed in the abdomen for exposure, and a liver retractor is placed to facilitate access to the lesser curvature and diaphragmatic hiatus.

Distal esophageal mobilization

• The assistant retracts the greater curvature inferiorly to expose the GEJ.
• The peritoneal covering of the GEJ is incised, and the esophagus is encircled with a Penrose drain.
• The esophagus should be mobilized for a distance of 4 to5 cm above the GEJ.
• If the left lobe of the liver is obstructing exposure, the left triangular ligament may be divided.

Identification and division of the anterior vagal trunk

• A single vagal trunk is identified, typically 2 to 4 cm superior to the GEJ.
• The nerve is mobilized for a minimum of 2 cm.
• The trunk is then clipped and divided proximally and distally with medium clips for a minimum resected specimen of 2 cm.

Identification and division of the posterior vagal trunk

• The esophagus is now more mobile, having taken the anterior vagus nerve and is retracted anteriorly and to the patient's left side.
• The posterior trunk is identified along the right edge of the esophagus.
• The nerve is mobilized for a minimum of 2 cm.
• The trunk is then clipped and divided proximally and distally with medium clips for a minimum resected specimen of 2 cm.

Pathologic confirmation via frozen section

Drainage procedure or gastric resection with intestinal reconstruction[13]

• Drainage procedures include gastroenterostomy, pyloroplasty (Heineke-Mikulicz, Finney, Jaboulay), and pyloromyotomy.
• Gastric resection can vary in location depending on the location of the ulcer but is typically distal and includes the antrum.
• Reconstruction after distal gastrectomy includes gastroduodenostomy (Billroth I), gastrojejunostomy (Billroth II), and the Roux-en-Y gastrojejunostomy.

Abdominal wall and skin closure

Complications

The major immediate and intraoperative complications specific to truncal vagotomy 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.

1. Delayed gastric emptying: The stomach loses the vagally mediated receptive relaxation. This leads to an increased intragastric pressure causing an increased emptying of liquids. The pylorus does not relax effectively, and a decrease in solid food emptying is seen. This is the reason the majority of surgeons perform a concomitant drainage procedure at the time of TV.[14]
2. Postvagotomy diarrhea: Results from unconjugated bile salts entering the colon, thus leading to osmotic diarrhea. This complication is rarely seen with HSV but is the most common undesirable sequela of TV. It is first treated with codeine/loperamide along with cholestyramine.[15] If this fails, one can consider a reversed jejunal interposition graft.[16]
3. Postvagotomy hypergastrinemia: The parietal cells are denervated, causing a decrease in stomach acid output. This leads to G-cell hyperplasia and hypergastrinemia due to the loss of negative feedback mechanisms.
4. Ulcer recurrence: TV has the lowest rate of ulcer recurrence compared to the other vagotomies. Recurrence is further prevented with the addition of an antrectomy.[7]
5. Dumping syndrome: This typically is seen only when an antrectomy or drainage procedure is done concomitantly with a TV.[17]

Clinical Significance

Although acid-reducing surgery has become an operation with few indications, it is still an important tool for a surgeon. 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 truncal vagotomy and is not without consequences.

Enhancing Healthcare Team Outcomes

There was a time when truncal vagotomy was widely done, but today it is rarely performed. The availability of the PPIs has 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 to use PPIs. Surgery is the last time and should be undertaken after a great deal of consideration. The outcomes for patients who undergo TV are fair as long as they do not develop post-procedure complications.