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Chapter16

Vagotomy:Truncaland HighlySelective



MaryT.HawnGeorgeA.SarosiJr. AshleyAugspurgerDavis

DEFINITION

■ Truncalvagotomyisdefinedasthedivisionoftheanteriorandposteriorvagus nerves,whichinnervatethestomachandremainderofthegastrointestinal (GI)tract,atthelevelofthedistalesophagus.Vagotomyeliminates cholinergicstimulationtogastricparietalcellsanddecreasesparietalcell responsetogastrinandhistamine,therebyreducinggastricacidsecretion.By transectingattheentrancepointintotheabdomen,allinnervationtotheliver, gallbladder,pancreas,andsmallintestineisalsodivided.Truncalvagotomy requiresadrainageprocedureduetothedisruptionofantralandpyloric muscularinnervation.

■ Formanyyears,vagotomywasoneofthecornerstonesofsurgicaltreatment ofulcers.However,withfurtherunderstandingoftheroleofHelicobacter pyloriinulcerpathogenesisandadvancementinpharmacologic managementincludingprotonpumpinhibitors(PPIs)andhistamine blockers,theroleofsurgeryhaschanged.Oftheclassicindicationsfor ulcer,surgery,bleeding,perforation,obstruction,andintractability, vagotomyisonlycommonlyusedinthosepatientswhorequiresurgical controlofulcerbleeding.

■ Leveloneevidencesuggeststhatitisnotnecessaryinthetreatmentof

duodenalperforationinpatientswhoareH.pyloripositive,1andthe numberofpatientsrequiringoperationforgastricoutletobstructionand intractabilityhasdeclineddramaticallywiththeadventofimproved pharmacologicandendoscopictherapyofpepticulcerdisease(PUD).The incidenceofdefinitiveacidreductionsurgerydecreasedbymorethan50% from1993to2006.

■ Highlyselectivevagotomy(HSV)isdefinedasthedivisionofthegastric branchesofthenervesofLatarjet.ThenervesofLatarjet,celiacdivisionof posteriorvagus,andhepaticdivisionofanteriorvagusarepreserved. Therefore,cholinergicstimulationisselectivelyeliminatedtoreduceacid secretionbyparietalcellsinthebodyandfundus,andtheinnervationofthe antrumandpylorus,biliarytract,andsmallandlargeintestinesareuntouched. AdrainageprocedureisnotrequiredwithHSV.Thisisalsoknownas “parietalcellvagotomy”or“proximalgastricvagotomy.”

■ Theoperationwasdevelopedtoavoidtheneedforagastricdrainage procedure,whichisrequiredwithtruncalvagotomy,asuptoone-thirdof patientswilldevelopdelayedgastricemptyingfollowingthisprocedure. Despitetheeleganceofparietalcellvagotomy,itisatechnically demandingoperationwithahigherulcerrecurrencerateandmuchlonger learningcurvethantruncalvagotomy.Inanerawhenfewvagotomiesare performed,ithaslargelyfallenoutoffavor.

■ Ofhistoricalnote,aselectivevagotomysectionstheanteriorvagusjustdistalto thepointwherethebranchtothegallbladderandliverandtheposteriorvagus justdistaltothebranchtothepancreasandsmallintestines.Althoughin theorythismightreducethesideeffectsofvagotomy,itisunclearinpractice thatthishadanyeffectonoutcomes.

DIFFERENTIALDIAGNOSIS

■ InapatientwithacutesevereupperGIbleeding,thedifferentialdiagnosis

includesableedingpepticulcer,bleedingesophagealorgastricvarices secondarytoportalhypertension,esophagealmucosaldiseasessuchassevere esophagitisandMallory-Weisstears,gastricarteriovenousmalformationsand Dieulafoy’slesion,andrarely,ulceratedtumorsorhemobilia.

■ Inapatientwithacuteabdominalpainandfreeair,thedifferentialdiagnosis shouldincludeaperforatedpepticulcer,perforateddiverticulitis,perforated appendicitis,andsmallbowelperforation.

■ Inthepatientwithgastricoutletobstruction,thedifferentialdiagnosisincludes PUD,gastriccancer,duodenalweb,functionaldelayingastricemptying,and chroniculcerdiseaserelatedtononsteroidalantiinflammatorydrug(NSAID) oraspirinuse.

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Chapter17).

■ 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.

TECHNIQUES

TRUNCALVAGOTOMY—OPEN

SkinIncisionandRetractorPositioning

■ Useastandarduppermidlineincision,fromjustbelowxiphoidprocesstolevel oftheumbilicus.

■ Abodywallretractorbladeisplacedoneithersideoftheupperhalfofthe incisiontofacilitateexposure.

■ Dependingonthesizeoftheleftlateralsegmentoftheliver,itmaybenecessary todividetheavascularportionofthelefttriangularligamenttoallowtheleft lateralsegmenttoberetractedinordertofacilitatevisualizationofthe abdominalesophagus(FIG1).

ExposureoftheEsophagus

■ Theparsflaccidaandthephrenoesophagealligamentaredividedtoexposethe rightcrusandanterioresophagealwall.Takecautiontorecognizeand preserveanaccessorylefthepaticarterywhendividingtheparsflaccida.The positionoftheesophaguscanbeverifiedbypalpationofthenasogastrictube withinthelumenoftheesophagus.

■ Identifytherightcrusofthediaphragm;gentlydissecttoexposetheanterior surfaceoftheesophagus.Thisperitonealincisionshouldbecarriedacrossthe anteriorsurfaceoftheesophagusandontotheleftcrusofthediaphragmto exposetheanteriorsurfaceoftheesophagus(FIG2A).Byapplying downwardandrightwardtractiononthestomach,thesurgeoncanplacethe esophagusontensiontoenhanceexposure(FIG2B).

■ Continuetodevelopaplanebetweenrightcrusandtheesophagus;extend posteriorlytocreatearetroesophagealwindow.

■ Theesophagusisthendissectedcircumferentiallyandthis,again,canbe facilitatedbypalpatingthenasogastrictubeinthelumenoftheesophagus.

■ APenrosedrainisplacedaroundtheGEjunctiontoassistwithdownward tractionontheGEjunction.

IdentificationandDivisionoftheAnterior(Left)VagusNerve

■ Thevagusnervesrotatecounterclockwiseattheleveloftheesophagealhiatus

withtherightvagusnervecoursingmoreposteriorandtheleftvagusnerve anteriorwithrespecttotheesophagus.

■ Theleft(anterior)vagusnerveistypicallyanteriorandjustrightofmidlineat the1o’clockto2o’clockposition.Itisoftenalmostwithinthelongitudinal musclelayer(FIG3).

■ DownwardtractionoftheGEjunctionviathePenrosedraincanhelptense thenervelikeaguitarstringtohelpwithpalpation.

■ Dissectthenerveofftheanteriorsurfaceofesophagususingarightangle withsharpdissection,minimalcautery.

■ Anyadditionalanteriorvagusnerveshouldbedissectedfreeofesophagusif present.Inabout10%ofcases,twoorrarelymoreanteriorvagalbranches maybefound.

■ Amediumclipisthenplacedonthenerve(s)atthelevelofthediaphragmanda secondclipisplacedonthenerve3to4cmdistaltothefirst.Thesegmentof nerve(s)betweentheclipsisexcisedandsentforpathologytoverifynervous tissuewasexcised(FIG4).

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