Vagotomy

INTRODUCTION — The vagus nerves play a central role in regulating gastric acid production. Therefore, the disruption of vagal innervation has long been exploited as an antisecretory measure. The surgical technique of vagotomy has a rich history dating back nearly a century [1]. At its peak application, vagotomy performed in conjunction with either pyloroplasty or antrectomy was once the gold standard for the treatment of peptic ulcer disease. The following decades saw the development of histamine H2-receptor antagonists and proton pump inhibitors, along with the discovery of the role Helicobacter pylori plays in peptic ulcer disease [2]. The success of these modern nonsurgical therapies reduced the incidence of ulcer-related complications requiring surgical interventions. When surgical interventions are required, technological advances have allowed vagotomy to be performed with minimally invasive techniques with fewer procedure-related complications [3].

The use of vagotomy in treating complicated peptic ulcer disease and the technical aspects of performing vagotomy will be reviewed here. Other considerations of peptic ulcer disease management are discussed elsewhere. (See "Surgical management of peptic ulcer disease" and "Peptic ulcer disease: Treatment and secondary prevention".)

INDICATIONS — Vagotomy is indicated for patients who develop acute complications from peptic ulcer disease (ie, bleeding, perforation, obstruction) or chronic intractable symptoms such as pain, despite being on maximally tolerated medical therapies. Vagotomy is rarely performed as a "stand-alone" procedure except for treatment of chronic duodenal ulcers. It is generally performed in conjunction with a stomach drainage, resection, or diversion procedure to treat complicated peptic ulcer disease [4].

While the primary procedure is chosen to treat the complication, vagotomy is typically added to prevent ulcer recurrence, especially in patients who are refractory to or intolerant of maximal medical therapy. An increasingly popular view is that the primary goal is for surgery to treat the complication while causing as little trauma as possible. Medical treatment is then instituted to treat the underlying cause of the peptic ulcer disease.

The efficacy of vagotomy is difficult to measure separately from the primary procedure, and the outcomes of patients undergoing peptic ulcer disease surgery depend mostly on the success of the primary procedures. (See "Surgical management of peptic ulcer disease".)

Bleeding ulcers — Bleeding is the most common complication of peptic ulcer disease requiring surgery. Although there has been a significant decrease in the number of acute bleeding ulcers over the years, the percentage of bleeding ulcers that need operation and the percentage of patients undergoing vagotomy each year remained relatively stable [5]. For patients with gastroduodenal ulcers who either fail endoscopic or angiographic control of their bleeding or cannot tolerate these interventions due to instability, surgical management is warranted. (See "Overview of the treatment of bleeding peptic ulcers".)

Duodenal — The initial surgical intervention for a bleeding duodenal ulcer is to expose and oversew the ulcer via a longitudinal gastroduodenostomy. Once the bleeder is ligated, a pyloroplasty is then completed in the transverse fashion. If the patient has tolerated the procedure well thus far and is known to have failed maximal medical therapy, a truncal vagotomy may be added to reduce the risk of recurrent bleeding. (See 'Open truncal vagotomy' below.)

For bleeding ulcers, vagotomy combined with a drainage procedure, such as a pyloroplasty, has been associated with a significantly lower postoperative mortality rate than local ulcer oversewing alone [6], possibly because these patients are less prone to major postoperative rebleeding. A highly selective vagotomy may be chosen for the hemodynamically stable patient, but the benefits of highly selective vagotomy are less clear if a gastroduodenostomy has already been performed [7,8]. (See 'Highly selective vagotomy' below.)

Alternatively, in a patient who may not tolerate a prolonged procedure, the vagotomy may be deferred to a later date. Vagotomy should be performed by an expert under optimal conditions, when possible via a minimally invasive surgical approach. Attempting a vagotomy when unfamiliar with the technique may disturb the natural anatomic plane, which makes any subsequent interventions challenging and increases patient morbidity.

Occasionally, a more aggressive resection is required to remove the area of bleeding (eg, distal gastrectomy). However, in two studies, compared with vagotomy and drainage, vagotomy with resection resulted in no improvement in short-term outcomes and significantly prolonged hospital stay and decreased long-term survival [6,9].

Gastric — In the case of a gastric bleeding ulcer, the ulcer area should be excised for pathologic evaluation to rule out underlying malignancy. After temporary hemostasis is achieved by oversewing, efficient definitive resection (distal gastrectomy or wedge resection for more proximal lesion) is then accomplished with a stapling device (see "Surgical management of peptic ulcer disease", section on 'Gastric ulcer'). Gastric ulcer patients usually have low acid production. Therefore, vagotomy is rarely indicated.

Perforated ulcers — For patients with perforated duodenal ulcer, open or laparoscopic lavage with omental patch closure of the perforation is the procedure of choice. Two retrospective studies showed that adding a drainage or resection procedure did not provide any identifiable benefit over simple closure in terms of early postoperative outcomes; adding a resection procedure actually increased the rates of postoperative complications such as intra-abdominal abscesses and shock [10,11].

However, for ulcers close to the pylorus, repair of the perforation may be incorporated into a pyloroplasty. In such cases, truncal vagotomy may be added to provide additional antisecretory benefit, particularly in patients who have already failed maximal medical therapy.

Vagotomy has a limited role in the management of perforated gastroduodenal ulcer in modern practice, especially in the presence of significant intra-abdominal contamination from the perforation. In the past, there had been a recommendation for select patients with minimal contamination to undergo single-stage highly selective vagotomy in addition to the omental patch, if they were already on maximal medical therapy [12] (see 'Highly selective vagotomy' below). The decline in ulcer surgery in general, however, has served to reduce the opportunities for young surgeons to learn techniques such as highly selective vagotomy [13]. Even without the addition of highly selective vagotomy, the ulcer recurrence rate remains low due to the wide use of proton pump inhibitors and H. pylori eradication.

However, in a series from the United States, 77 patients who underwent emergency omental patching for perforated foregut ulcers had a 23 percent recurrence of ulceration, hemorrhage, perforation, or repeat surgical intervention despite proton pump inhibitors. None of the 17 patients who underwent emergency vagotomy and either pyloroplasty or antrectomy in this series developed recurrent ulceration or required repeat intervention [14].

Similarly, in a long-term cohort study from Asia that excluded patients with H. pylori infections, patients undergoing truncal vagotomy and pyloroplasty had a decreased risk (hazard ratio [HR] 0.33, 95% CI 0.29-0.38) and cumulative incidence (6.23 versus 15.07 percent) of repeated ulcer-associated surgery compared with simple ulcer closure [15].

For patients with perforated gastric ulcer, ulcer excision or partial gastric resection and careful histopathologic examination are necessary to exclude malignancy. (See "Surgical management of peptic ulcer disease", section on 'Perforated gastric ulcer'.)

Gastric outlet obstruction — Severe peptic ulcer disease can cause scarring or distortion of the antral-pyloric area, leading to gastric outlet obstruction. In patients with gastric outlet obstruction caused by peptic ulcer disease who have failed both medical management and endoscopic dilatation, surgery is indicated to relieve obstruction and reestablish gastrointestinal continuity. (See "Gastric outlet obstruction in adults".)

For young patients, especially those who either smoke or use aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), the combination of a vagotomy and antrectomy is preferred to relieve the gastric outlet obstruction. The truncal vagotomy serves to prevent ulcer recurrence (see 'Open truncal vagotomy' below). In those scenarios where a complete resection of the ulcerated region (antrectomy) is not safe or a subsequent narrowing or obstruction of the gastric outlet is present, a vagotomy and drainage procedure such as gastrojejunostomy or gastroduodenostomy is appropriate [16].

For older patients with gastric outlet obstruction, gastrojejunostomy is sufficient to relieve the obstruction. Vagotomy is not performed in the absence of active ulcer disease in this group of patients, as it may exacerbate gastroparesis in a chronically obstructed stomach.

Refractory ulcers — Patients with chronic symptoms, such as intractable pain despite maximal medical therapy, are particularly challenging to manage. These patients invariably abuse cigarettes and NSAIDs and therefore are at very high risk of ulcer recurrence. Alternatively, patients may develop chronic marginal ulcers following bariatric surgery, specifically Roux-en-Y gastric bypass (RYGB). (See "Approach to refractory peptic ulcer disease".)

Duodenal — The goal of surgery for patients with chronic duodenal ulcer disease who fail medical therapies is to reduce acid secretion. The optimal technique should reduce the risk of recurrent ulceration and minimize the risk of postoperative complications and long-term sequelae. Among the available options, two laparoscopic approaches, highly selective anterior vagotomy combined with posterior truncal vagotomy or anterior seromyotomy combined with posterior truncal vagotomy, offer the best combination of acid reduction and preservation of pyloric function. If laparoscopic expertise is not available, we suggest referral to a facility with surgeons who have training and experience with these procedures.

Based upon retrospective reviews and small randomized trials, these two procedures, each derived from an open procedure, are preferred over truncal vagotomy for the elective management of chronic duodenal ulcer disease. With these procedures, pyloric function is preserved, and thus a drainage procedure, with its inherent risk of bile reflux, is not needed. The side effects are similar to those of highly selective vagotomy [17].

●The Taylor procedure is a combination of a posterior truncal vagotomy and anterior serosal myotomy [17-19]. In one trial, 146 patients with chronic duodenal ulcers were randomly assigned to the open Taylor procedure or truncal vagotomy and pyloroplasty [17]. After a mean follow-up of 4.5 years, a similar proportion of patients in the two groups developed recurrent duodenal ulcer (6 and 3 percent, respectively). Adverse effects, including dumping symptoms and diarrhea, were significantly less common after the Taylor procedure (10 versus 45 percent) [17].

In the laparoscopic version of the Taylor procedure, the serosal myotomy is performed as a stapled anterior linear gastrotomy. In retrospective series of patients with chronic duodenal ulcers, the laparoscopic Taylor procedure was effective for reducing acid secretion as evidenced by ulcer healing in the majority of patients [20,21].

●The Hill-Barker procedure is a combination of posterior truncal vagotomy and anterior highly selective vagotomy. In observational studies, results for this procedure are similar to those of the modified Taylor procedure [22-24].

In the past, partial gastrectomy, either as an antrectomy and truncal vagotomy or subtotal gastrectomy, was commonly used in the surgical management of duodenal ulcer disease [25]. However, removal of the pylorus with these procedures leads to rapid emptying of liquids and solids from the stomach and, potentially, to reflux of intestinal contents into the stomach. Given the high incidence of postgastrectomy complications, these procedures are no longer needed for the management of duodenal ulcer disease refractory to medical management. (See "Partial gastrectomy and gastrointestinal reconstruction" and "Postgastrectomy complications".)

Gastric — Patients with chronic refractory gastric ulcer should have the ulcer excised to exclude malignancy. Specific procedures used in excising gastric ulcer are discussed elsewhere. (See "Surgical management of peptic ulcer disease", section on 'Elective surgery for gastric ulcer'.)

Although some gastric ulcer patients have low acid production (eg, types I and IV), they are not achlorhydric. Therefore, some experts still add truncal vagotomy to selected gastric resection procedures used to treat gastric ulcers. Vagotomy may be particularly helpful in treating types II and III gastric ulcers in patients who have the same secretory profiles as duodenal ulcer patients.

For patients with medically refractory ulcer disease, every possible maneuver should be employed at the time of their surgery to reduce postoperative acid production and the risk of ulcer recurrence. If they have failed multiple procedures in the past, a subtotal or total gastrectomy may have to be used as the definitive surgical treatment.

Marginal — Marginal ulceration is a well-known complication of RYGB performed to treat severe obesity. (See "Laparoscopic Roux-en-Y gastric bypass", section on 'Marginal ulcers'.)

This ulceration presents itself on the jejunal side of a gastrojejunostomy and is usually managed successfully with proton pump inhibitor therapy [26]. The surgical management of marginal ulcers refractory to medical therapy includes revision of the anastomosis to remove the ulcer and truncal vagotomy to allow for long-term healing of the ulcer, which can be performed through a variety of techniques and approaches [27-32].

SURGICAL TECHNIQUES — Vagotomy is a procedure that transects or removes a portion of the vagus nerves or branches of the vagus nerves to decrease gastric acid secretion (figure 1). Vagotomy eliminates direct cholinergic stimulation of acid secretion and renders the acid-producing parietal cells less responsive to histamine and gastrin. Vagotomy also abolishes the vagal stimulus for release of antral gastrin. Vagotomy can be performed by sectioning the vagal trunks (ie, truncal vagotomy), sectioning distal nerve fibers (referred to as highly selective vagotomy, parietal cell vagotomy, or proximal gastric vagotomy), or a combination of techniques. It can be performed in an open, laparoscopic, or thoracoscopic fashion.

Truncal vagotomy is the simplest procedure to perform. Basal and stimulated acid secretions are reduced by 80 and 50 percent, respectively [25]. However, truncal vagotomy sacrifices innervation to the pancreas, small intestine, proximal colon, and hepatobiliary tree and alters gastric physiology, requiring some form of gastric emptying procedure (pyloroplasty or gastroenterostomy). Highly selective vagotomy reduces basal and stimulated acid secretion by more than 75 and 50 percent, respectively, while minimizing the effects of vagotomy on gastric emptying [25]. However, surgeons-in-training have less exposure to the more technically demanding procedures, like highly selective vagotomy (parietal cell vagotomy), because of the decrease in the hospitalization rate for peptic ulcer disease [33,34].

Open truncal vagotomy — To perform an open truncal vagotomy, the left lobe of the liver is retracted toward the patient's right to expose the pars flaccida. This structure is incised, and the dissection is followed toward the right diaphragmatic crura. The esophagogastric junction is identified and bluntly encircled with a Penrose drain. With this exposure, the right crura is followed down toward the juncture with the left crura. The right vagus is identified crossing over this juncture. It will feel bow-like when the esophagogastric junction is being retracted laterally with the Penrose drain. The vagus nerve is encircled and clipped above and below a 1 cm segment, which is removed and sent to pathology for frozen section to confirm the presence of the nerve.

Dissection is continued toward the lesser gastric curve, and the narrow fibers of the left vagus nerve are traced cephalad as they form the main trunk of the left nerve, usually identified embedded within the musculature of the distal esophagus. The more proximal the exposure, the easier it will be to identify as fewer bifurcations have occurred and the diameter is larger.

Laparoscopic truncal vagotomy — To perform a laparoscopic truncal vagotomy, the liver is retracted to the patient's right, and the lesser curve of the stomach is mobilized to the patient's left to expose the right crura. The pars flaccida is incised, and the edge of the right crura is identified and dissected toward its base and juncture with the left crura. In doing this maneuver, the right vagus will be encountered as the single structure crossing over the crura and away from the posterior surface of the esophagus. The nerve is dissected circumferentially, clips are placed proximally and distally, and the intervening segment is excised and sent to pathology for an intraoperative frozen section confirmation.

The left vagus usually divides into smaller branches by the time it is in the abdomen, so it is more challenging to identify. The aid of magnification and illumination of the laparoscope is advantageous in this regard. One can also trace smaller branches of the vagus found distally all the way back up into the thorax where they will meet into a larger, more substantial segment. The left vagus is typically embedded into the anterior surface of the esophagus and will require some careful dissection to remove a segment in a similar fashion as described above for the right vagus.

Thoracoscopic truncal vagotomy — Patients are placed in a right lateral decubitus position to expose the left chest with selective single lung ventilation. Access is provided via ports in the intercostal spaces, and the inferior pulmonary ligament is transected to allow for circumferential dissection of the esophagus. Short segments of the anterior and posterior vagus nerves are resected from the surface of the esophagus [35].

Highly selective vagotomy — Highly selective vagotomy eliminates the vagal stimulation to only the acid-secreting portion of the stomach without interrupting motor innervation to the antrum and pylorus.

The operation involves severing the terminal branches of the vagus nerve that innervate the corpus and fundus of the stomach along the lesser curvature. Because nerve branches are bundled with their blood supply, cutting the nerve branches will devascularize the lesser curvature of the stomach from just above the gastroesophageal junction to the "crow's foot" on the antrum. By preserving the main vagal nerve branches leading to the pylorus, this procedure preserves gastric emptying postoperatively and avoids the need for a drainage procedure such as pyloroplasty or additional anastomosis (gastrojejunostomy) in an acutely inflamed and contaminated field.

Laparoscopic versions of highly selective vagotomy such as the Taylor procedure and the Hill-Barker procedure have been reported [17-24]. (See 'Duodenal' above.)

COMPLICATIONS — Intraoperative complications include bleeding and serosal injury to the esophagus or stomach, both associated with the dissection, transection, and ligation of the vagus nerves. Esophageal perforation, splenic tear, and necrosis of the lesser curvature or fundus of the stomach can also occur but are rare.

Postoperative complications of vagotomy include ulcer recurrence due to missed or incomplete vagotomy as well as delayed gastric emptying. Although procedures such as highly selective vagotomy were designed to prevent delayed gastric emptying while circumventing the need for a drainage procedure, 0.5 percent of patients who undergo highly selective vagotomy will develop gastric retention and require the addition of a drainage procedure several months after the initial operation [36].

Symptomatic patients with delayed gastric emptying that is refractory to medical management have been managed with a variety of therapies with varying degrees of success. Endoscopic options include Botox injection, pneumatic dilation, and gastric peroral pyloromyotomy [37]. Surgical options include venting gastrostomy, gastric electrical stimulation, pyloroplasty, and gastrojejunostomy [38].

Two other long-term complications of vagotomy and drainage procedures are dumping syndrome and postvagotomy diarrhea. Dumping syndrome comprises a constellation of symptoms that occur within 30 minutes of a meal, including fullness, pain, nausea, cramps, and diarrhea. Some patients describe vasomotor signs and symptoms such as diaphoresis, lightheadedness, hypotension, tachycardia, flushing, and headache. The etiology of this syndrome is thought to relate to rapid gastric emptying that may follow vagotomy and a drainage procedure, both of which allow "dumping" of hyperosmolar gastric contents into the small bowel. This triggers an influx of water into the lumen in order to maintain isotonicity, resulting in acute contraction of plasma volume and the vasomotor signs and symptoms noted above. Simultaneous release of vasoactive compounds such as serotonin and bradykinin may augment the vasomotor symptoms. Rapid gastric emptying may be demonstrated by a radionuclide gastric emptying scan in some patients with dumping syndrome and can confirm the clinical impression [39]. Management of dumping after vagotomy and gastric drainage procedure is aimed at lowering the sugar content of the meal, reducing the volume of liquids ingested with meals, and increasing the frequency of feeding. Reclining after a meal may help minimize the effect of gravity on rapid gastric emptying. Medications aimed at delaying gastric emptying, such as anticholinergics and sedatives, are not very useful but may be tried in cases refractory to dietary management. Surgical reconstruction of the pylorus is reserved for patients with intractable dumping and/or diarrhea, in an attempt to delay gastric emptying [40]. (See "Bariatric operations: Late complications with subacute presentations", section on 'Dumping syndrome'.)

Postvagotomy diarrhea has been described in up to 30 percent of patients after peptic ulcer surgery, bariatric surgery, fundoplication, and esophageal resection, during which intentional or unintentional truncal vagotomy can occur. Selective vagotomy of the stomach seems to protect against diarrhea. Many patients have transient watery diarrhea for three to six months postvagotomy. In an unfortunate few, the diarrhea can be severe, chronic, and disabling. The mainstay of therapy for postvagotomy diarrhea is cholestyramine, suggesting that excess bile acids in the intestine are stimulating colonic secretion [41]. For those few patients who do not respond to cholestyramine, reconstruction of the pylorus or interposition of a reversed jejunal segment 70 to 90 cm from the ligament of Treitz may provide relief of disabling diarrhea [42].

SUMMARY AND RECOMMENDATIONS

●Indications of vagotomy – Vagotomy is a classical surgical technique indicated for patients who develop acute complications from peptic ulcer disease (PUD; ie, bleeding, perforation, obstruction) or chronic symptoms such as intractable pain despite being on maximally tolerated medical therapies. Vagotomy is rarely performed as a "stand-alone" procedure except for treatment of chronic duodenal ulcers. It is generally performed in conjunction with a drainage, resection, or diversion procedure to treat complicated PUD. (See 'Indications' above.)

●Surgery for bleeding duodenal ulcer – The initial surgical intervention for a bleeding duodenal ulcer is to oversew the bleeder. For stable patients with bleeding duodenal peptic ulcer who have failed maximal medical therapy, a truncal vagotomy with a pyloroplasty can be added as an acid-reducing procedure to reduce the rebleeding rate. (See 'Duodenal' above.)

For patients who may not tolerate a prolonged procedure, a vagotomy may be deferred to a later date to be performed by an expert under optimal conditions.

●Surgery for bleeding gastric ulcer – For patients with bleeding gastric ulcers, partial gastrectomy with reconstruction is generally indicated because of the risk for malignancy. However, for patients with medical comorbidities, ulcer excision combined with truncal vagotomy and pyloroplasty is an option. (See 'Gastric' above.)

●Surgery for perforated gastric or duodenal ulcer – Vagotomy has very little role in the management of perforated gastroduodenal ulcer, especially in the presence of significant intra-abdominal contamination from the perforation. However, for ulcers close to the pylorus, repair of the perforation may be incorporated into a pyloroplasty. In such cases, truncal vagotomy may be added to provide additional antisecretory benefit, particularly in patients who have already failed maximal medical therapy. (See 'Perforated ulcers' above.)

●Surgery for obstructing gastric or duodenal ulcer – For young patients with obstructing ulcer disease who are at high risk of ulcer recurrence, we perform a truncal vagotomy and antrectomy. For older patients with obstructing ulcer disease, we perform a drainage procedure, such as gastrojejunostomy without vagotomy. Vagotomy is not performed in the absence of active ulcer disease in this group of patients, as it may exacerbate gastroparesis in a chronically obstructed stomach. (See 'Gastric outlet obstruction' above.)

●Surgery for chronic duodenal ulcer – For patients with intractable symptoms from chronic duodenal ulcer disease, we suggest highly selective vagotomy over truncal vagotomy or other acid-reducing procedures (Grade 2B). We further suggest a laparoscopic or thoracoscopic rather than an open approach to vagotomy (Grade 2C). Among the available options, two laparoscopic approaches, highly selective anterior vagotomy combined with posterior truncal vagotomy or anterior seromyotomy combined with posterior truncal vagotomy, offer the best combination of acid reduction and preservation of pyloric function. (See 'Duodenal' above.)

●Surgery for chronic gastric ulcer – Patients with a chronic refractory gastric ulcer should have the ulcer excised to exclude malignancy. Truncal vagotomy can be used in conjunction with the chosen primary procedure to augment acid reduction. Specific procedures used in excising gastric ulcers are discussed elsewhere. (See 'Gastric' above and "Surgical management of peptic ulcer disease", section on 'Elective surgery for gastric ulcer'.)