Vagotomy: Truncal and Highly Selective



Vagotomy: Truncal and Highly Selective


Mary T. Hawn

George A. Sarosi Jr.

Ashley Augspurger Davis







PATIENT HISTORY AND PHYSICAL FINDINGS



  • The majority of operations for PUD performed now are urgent or emergent operations for complicated ulcer disease.


  • A thorough history and physical should be obtained with key focus on the duration of symptoms, previous ulcer therapy, NSAID or aspirin use, and smoking history. Consider investigation into hypersecretory and malignant etiologies in patients with refractory ulcer disease.


  • Patients should be specifically questioned regarding H. pylori status and prior H. pylori treatment including a history of eradication. In patients unable to stop antiinflammatory drug use or those with H. pylori-negative ulcer disease, it may be reasonable to consider performing an acid-reducing procedure at the time of ulcer repair.


  • Bleeding can occur in 15% to 20% of patients with PUD and is the most common ulcer-related complication.4 The majority will resolve with conservative or endoscopic treatment. In patients undergoing operation for a bleeding duodenal ulcer, the best available evidence suggests that vagotomy should be combined with oversewing of a duodenal ulcer.5 As such, the patient’s H. pylori status, history of prior NSAID use, or prior ulcer disease will not affect the use of vagotomy in the management of their bleeding duodenal ulcer


  • Perforations occur in up to 10% of ulcer complications.4 Patients that will most likely to benefit from acid-reducing surgical intervention during repair of a perforation include those that have contraindications to PPI, perforation on PPI, or prior eradication of H. pylori.


  • Obstruction is the least common complication of ulcer disease at 5% to 8% and occurs as a result of scarring of the pylorus.4 Endoscopy often delineates location and degree of the obstruction and also allows for therapeutic balloon dilation of the pylorus. Surgery is reserved for failure of less invasive treatments.



  • Intractable disease encompasses failure of medical management to heal the ulcer, relapse of disease while on current therapy, or multiple courses of medical therapy. Medical management includes acid suppression, H. pylori eradication, and NSAID cessation. Symptoms should be substantiated with endoscopic visualization of a persistent or recurring ulcer.


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • In a patient with sudden onset acute abdominal pain and physical exam findings of peritonitis, an upright chest radiograph confirming the finding of free intraperitoneal air is a sufficient workup prior to proceeding to the operating room (OR) for a presumed perforated ulcer.


  • In patients with a history and physical consistent with a perforated ulcer, but without free air on radiograph, a computed tomography (CT) scan or upper GI contrast study using water-soluble contrast can help to make the diagnosis.


  • Testing for H. pylori is used to confirm presence of or gauge the eradication of disease. Antibody testing assesses overall exposure but is not specific for active disease. Urease breath test and stool antigen test can be used to confirm eradication. Full treatment of H. pylori should be attempted before definitive acid reduction surgery is considered.



    • Stool antigen testing for H. pylori should be performed prior to operation for PUD, as knowledge of H. pylori status may help determine the need for vagotomy. As mentioned earlier, it may not be necessary to perform vagotomy for H. pylori positive disease, but may be considered in treatment of H. pylori-negative ulcer disease.


  • Serum gastrin levels should be tested to rule out hypergastrinemic syndromes.


  • Endoscopy is part of standard investigation of ulcer disease when symptoms persist despite medical therapy. Endoscopy is also used to assess ulcer healing and perform biopsies to evaluate malignancy, gastritis, and H. pylori infection.


  • In patients with a bleeding peptic ulcer, the surgeon should be present at the time of upper endoscopy to gain an accurate anatomic understanding of the location of the ulcer. Patients with gastric ulcers not caused by acid, such as ulcers along the lesser curvature proximal to the incisura or near the gastroesophageal (GE) junction, will not require a vagotomy. Patients with duodenal or prepyloric ulcer should undergo vagotomy at the time of their operation for bleeding control.


SURGICAL MANAGEMENT


Preoperative Planning



  • Patients undergoing emergency surgery for peptic ulcer bleeding will have a stomach full of blood and are at significant risk of aspiration. A nasogastric tube should be placed prior to induction for all vagotomy procedures, and rapid sequence induction should be used if possible.


  • When performing an emergency operation for bleeding, the surgeon should ensure that blood is cross-matched and available.


  • For laparoscopic procedures, having the ability to perform intraoperative esophagogastroduodenoscopy (EGD) can facilitate the identification of the ulcer in difficult cases.


  • With truncal vagotomy, the gastric antrum and pylorus are denervated and concomitant drainage procedure must be performed.



    • Options include pyloroplasty, gastrojejunostomy, or gastric resection with reconstruction (see Part 2, Chapter 9).


  • HSV preserves antral muscular function and the pylorus mechanism. It is not necessary to perform a drainage procedure.


  • Transthoracic vagotomy requires double lumen intubation tube and separate lung ventilation; for sufficient exposure to distal esophagus, the left lung must be collapsed.


  • Perioperative antibiotics should be administered; cefazolin is standard, clindamycin plus a fluoroquinolone or aminoglycoside for penicillin allergy.


Positioning—Open



  • Open approach: Patient is supine with the arms tucked or extended.



    • Space is left on the patient’s left side to attach a Bookwalter or Omni retractor to the bed rail.


  • Reverse Trendelenburg position of the table will help with exposure of the hiatus.


Positioning—Laparoscopic



  • Laparoscopic approach: Patient is supine with right arm tucked. Surgeon stands on patient’s right and assistant stands on patient’s left.


  • Reverse Trendelenburg position of the table will help with exposure of the hiatus.


Positioning—Transthoracic



  • Patient is placed in right lateral decubitus position.

Jul 24, 2016 | Posted by in GENERAL SURGERY | Comments Off on Vagotomy: Truncal and Highly Selective
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