Truncal and Highly Selective Vagotomy

Introduction

Vagotomy was once the “gold standard” for patients with duodenal and gastric ulcers. However, the widespread use of medical techniques to manage ulcer disease has dramatically decreased the need for elective surgical intervention. The development of effective acid suppression medications, including histamine receptor blockers and proton pump inhibitors, has helped with this evolution in treatment. Also playing an important role is the recognition, diagnosis, and treatment of Helicobacter pylori as a factor in the development of peptic ulcer disease. Now used much less often than in the past, surgical management is reserved for patients who have failed maximum medical therapy and undergone treatment and eradication of H. pylori and for those presenting with complications of peptic ulcer disease, including bleeding, perforation, and gastric outlet obstruction.

Excessive gastric acid production contributes to the formation of duodenal and gastric ulcers. When medical therapy is inadequate, surgical intervention is designed to interrupt the neural pathway responsible for this. Options include truncal vagotomy, selective vagotomy, and highly selective (or proximal gastric) vagotomy. Knowledge of the general anatomy of the upper abdomen, specifically the innervation of the stomach, as well as the pathophysiology of complications, is vital to all surgeons caring for patients with this disease process.

Acute ulcer disease presents as acute gastrointestinal hemorrhage or perforation (Fig. 7-1). Knowledge of the anatomy of the stomach and its surrounding arterial supply can help predict the complication of ulceration (Fig. 7-2). Erosion of the ulcer posteriorly into the gastroduodenal artery can lead to life-threatening hemorrhage, presenting as tachycardia, hypotension, and hematemesis. Anterior erosion can lead to perforation of the duodenal wall with an acute abdomen, including tachycardia, abdominal tenderness with guarding and rigidity, and pneumoperitoneum on upright chest radiograph. In a more chronic scenario, recurrent episodes may lead to gastric outlet obstruction from repeated scarring.

FIGURE 7–1 Complications of gastric and duodenal ulcers.

FIGURE 7–2 Arterial supply of stomach.

Less severe presentations of peptic ulcer disease often include complaints of burning epigastric abdominal pain. Definitive diagnosis and elimination of other conditions can be made by upper gastrointestinal endoscopy or upper gastrointestinal series (Fig. 7-3). Any gastric ulcerations seen on endoscopy should be biopsied at multiple sites around the border to determine if the lesion harbors a malignancy. Patients should be evaluated for the presence of H. pylori and treated if positive. They should also undergo medical treatment with acid suppression medication before surgery is considered. Patients with persistent severe disease, especially after maximal medical therapy and treatment for H. pylori, should be considered for a definitive acid-reducing procedure.