Stomach: Vagotomy & Pyloroplasty

Effects

• Primary Goal: Diminished Cholinergic Stimulation of Parietal Cells
  • Decreased Gastric Acid Secretion
  • Compensatory Increased Serum Gastrin
• Branch Effects:
  • Distal Portions: Impaired Distal Gastric Motility & Pylorus Relaxation
    • Increased Emptying of Solids
    • Decreased Emptying of Liquids
  • Celiac Branch: Impaired Small Intestine Motility
  • Hepatic Branch: Impaired Gallbladder Motility

Truncal Vagotomy

• Divides Anterior & Posterior Vagal Trunks as They Emerge Below the Diaphragm
• Lowest Recurrence Rate but More Complications
  • Addition of Antrectomy Has the Lowest Recurrence Rate
• Procedure:
  • Incise Peritoneum of GE Junction Horizontally from Right to Left Crura
  • Bluntly Encircle the Esophagus
    • Include Vagal Nerves
    • Stay Wide to Avoid Esophageal Injury
  • Resect a 1-2 cm Segment of Each Trunk with Clips Placed at the Proximal/Distal Ends
    • Posterior Trunk Often Branches Before Entry into Abdomen
    • Mare Sure to Include the Criminal Nerve of Grassi Off the Posterior Trunk
• Requires a Concurrent Gastric Emptying Procedure (Pyloroplasty or Gastrojejunostomy)

Selective Vagotomy

• Divides Anterior & Posterior Vagal Trunks After Takeoff of the Hepatic (Anterior) & Celiac (Posterior) Branches
• Now Rarely Used – More Historical
  • Attempt Was to Prevent Postvagotomy Diarrhea & Biliary Stasis Although Studies Have Shown No Difference in Diarrhea
• Procedure:
  • Incise Peritoneum of GE Junction Horizontally from Right to Left Crura
  • Bluntly Encircle the Esophagus
    • Include Vagal Nerves
    • Stay Wide to Avoid Esophageal Injury
  • Resect a 1-2 cm Segment of Each Trunk Distal to the Celiac & Hepatic Branches
    • Place Clips at the Proximal/Distal Ends Prior to Resection
  • Consider Resection of the Criminal Nerve of Grassi After it Branches Off the Posterior Trunk
• Still Requires a Concurrent Gastric Emptying Procedure (Pyloroplasty or Gastrojejunostomy)

Highly-Selective (Proximal Gastric/Parietal Cell) Vagotomy

• Divides Individual Fibers Along the Lesser Curvature
  • Preserves: Vagal Trunks, Hepatic Branch, Celiac Branch & Distal “Crow’s Foot”
• Comparison to Truncal Vagotomy:
  • Similar Reduction in Acid Secretion
  • Highest Recurrence Rate
  • Significantly Decreased Complication Rates
    • Normal Emptying of Solids with Some Minimal Rapid Emptying of Liquids
    • Lower Incidence of Dumping Syndrome
• Procedure:
  • Start 6 cm Proximal to Pylorus on the Anterior Wall of the Stomach
  • Work Up the Anterior Lesser Curvature Dividing End Blood Vessels & Vagal Branches
  • Identify & Protect the Anterior Nerve of Larajet as it Approaches the GE Junction
  • Divide Peritoneum Over the Lower Esophagus to Identify the Anterior & Posterior Vagal Trunks
  • Identify & Divide the Posterior Branches in a Similar Fashion
  • Consider “Peritonealizing” the Lesser Curvature
    • Approximate the Anterior & Posterior Gastric Walls with Interrupted Sutures
    • Will Prevent Perforation from Necrosis of the Denuded Lesser curvature
• Variations:
  • Hill-Baker Procedure – Posterior Truncal Vagotomy & Anterior Highly-Selective Vagotomy
  • Taylor Procedure – Posterior Truncal Vagotomy & Anterior Seromyotomy of Lesser Curvature

Complications

• Recurrent Ulcers
  • Highly-Selective Vagotomy: 15%
  • Truncal Vagotomy: 10%
  • Truncal Vagotomy with Antrectomy: 2% (Lowest)
• Postvagotomy/Osmotic Diarrhea (30%)
  • Most Common Complication
  • Cause: Sustained Migrating Motor Complex (MMC) – More Bile into Colon
  • No CV Sx as Seen in Dumping Syndrome
  • Tx: Cholestyramine & Loperamide
• Dumping Syndrome
  • *See Stomach: Gastric Emptying Diseases
• Gastroparesis
  • *See Stomach: Gastric Emptying Diseases
  • If All Other Tx Options Fails May Consider Near-Total Gastrectomy & Roux-en-YGastrojejunostomy
• Dysphagia (1-3%)
  • Cause: Fibrosis & Lower Esophageal Denervation
  • Onset Weeks-Months After
  • Tx: Endoscopic Dilation
    • If Fails: Myotomy