Vagotomy

Overview

A vagotomy is a surgical procedure that involves cutting specific branches of the vagus nerve, which connects the digestive system to the brain. This procedure is primarily done to reduce stomach acid secretion in severe cases of peptic ulcer disease. The vagus nerve plays a crucial role in digestive processes by signaling organs like the stomach, liver, gallbladder, and pancreas to perform their functions, including secreting acid and enzymes. By cutting certain branches of this nerve, the procedure aims to address excessive acid production.

There are two main types of vagotomies, each targeting different parts of the vagus nerve. A truncal vagotomy cuts the nerve at the gastroesophageal junction, affecting not just the stomach but also other organs like the liver and pancreas, reducing their enzyme and bile production. This broader intervention can result in side effects like impaired digestion and slower movement of food through the digestive system. Despite these challenges, treatments are available to alleviate these issues.

On the other hand, a highly selective vagotomy is a more precise operation that only targets the branch of the vagus nerve responsible for triggering acid release in the stomach’s parietal cells. While this method effectively reduces stomach acid with fewer side effects, it is more technically demanding, and not all surgeons are trained in this technique. It may also be more challenging in individuals with inflamed or scarred tissues from ulcers or previous surgeries.

Reasons for undergoing the procedure

Most stomach ulcers can be effectively treated with medications, but some difficult cases may not respond to these treatments. These are called “refractory” ulcers, meaning they persist or do not heal. If long-lasting or refractory ulcers cause persistent pain or complications, surgery may be required. In such cases, your healthcare provider might recommend a vagotomy to help prevent the ulcers from recurring.

Examples of complications that may require surgery:

• Bleeding ulcers: If healthcare providers are unable to control the bleeding through other means, surgical repair may be necessary.
• Perforated ulcers: When an ulcer creates a hole in the stomach wall, it requires emergency repair. Leakage through this hole can lead to a serious abdominal infection.
• Gastric outlet obstructions: Chronic ulcers can cause scar tissue to form, which may block the outlet from the stomach to the small intestine. Surgery may be required to remove the scar tissue.

Vagotomy: A complementary procedure

Due to the complexity of these cases, a vagotomy is usually performed alongside another procedure to repair complications from peptic ulcer disease. Two frequent combinations include:

• Vagotomy with gastrectomy: In severe cases of peptic ulcer disease, a gastrectomy may be required, with the most common type being an antrectomy, which involves removing the lower third of the stomach. This part is affected by gastric outlet obstruction and secretes gastrin, a hormone that stimulates acid production. By removing the antrum, stomach acid secretion is reduced, and to further prevent ulcer recurrence, a vagotomy is often performed alongside the gastrectomy. A truncal vagotomy, which involves cutting the vagus nerve, can also help reduce the risk of bleeding from both ulcers and surgery, as ulcers treated surgically tend to recur if the vagus nerve remains intact.
• Vagotomy with pyloroplasty: If a truncal vagotomy is performed to reduce stomach acid but a gastrectomy isn’t necessary, a pyloroplasty will also be needed. This operation involves the pylorus, the muscular valve at the bottom of the stomach that allows food to pass into the small intestine. A truncal vagotomy disrupts the nerve signals that control the pylorus, so pyloroplasty is performed to keep the gastric outlet open, allowing food to pass through.

Risks

Among the complications that could arise from the procedure are:

• Bleeding.
• Infection.
• Blood clots.
• Damage to blood vessels, nerves, or organs in the vicinity.

Following a vagotomy, some side effects may include:

Diarrhea

A truncal vagotomy impacts the nerve supply to your gallbladder, leading to reduced contractions of the gallbladder. As a result, excess bile accumulates in the gallbladder. When it becomes too full, the gallbladder releases the surplus bile into the small intestine. If the small intestine cannot absorb all of the bile salts, they move into the large intestine, causing diarrhea. This is the most common complication after a truncal vagotomy and is typically temporary, though it may persist for some individuals. Your doctor can prescribe medication to help manage this issue.

Dumping syndrome

This complication is not a direct result of the vagotomy but rather stems from the pyloroplasty conducted alongside a truncal vagotomy. Pyloroplasty aims to prevent food from lingering in the stomach for extended periods; however, it can occasionally trigger rapid gastric emptying, a condition known as dumping syndrome. This syndrome may result in nausea, abdominal discomfort, and diarrhea following meals. Additionally, it can cause a sudden drop in blood sugar several hours after eating, leading to feelings of faintness. Typically, dumping syndrome is temporary and can be managed through dietary modifications.

Gallstones

Gallstones can be a potential side effect of truncal vagotomy, impacting the gallbladder. When bile builds up in the gallbladder and bile ducts, it can lead to the formation of gallstones. These stones may cause complications if they block a bile duct. To help prevent gallstone formation, your doctor may prescribe medication.

Before the procedure

To optimize your health before surgery, nonsurgical treatments may be necessary based on your specific circumstances. For instance, if you have been vomiting, you may need IV fluids; if you have a bleeding ulcer, a blood transfusion might be required. Additionally, your healthcare team will provide medications to prevent blood clots and antibiotics to reduce the risk of infection. General anesthesia will be administered to ensure you are asleep during the procedure.

During the procedure

Approach

Your surgeon may opt to perform a vagotomy using either open or laparoscopic surgery. This decision is influenced by your surgeon’s expertise, the specifics of your condition, and any additional procedures you may require alongside the vagotomy. Laparoscopic surgery is a minimally invasive approach that employs small instruments and a camera inserted through tiny incisions. In contrast, open surgery involves a larger incision to access the abdominal cavity, which can facilitate easier access in emergency situations.

Vagotomy

Your surgeon will first identify the gastroesophageal junction, the area where your stomach and esophagus connect, and then cut through the tissue lining your organs (peritoneum). At this junction, the vagus nerve has two main branches extending into the digestive system. In a truncal vagotomy, the surgeon will remove a section of both branches. In a highly selective (or parietal cell) vagotomy, the surgeon will keep the main branches intact and only cut the specific nerve branches that stimulate the acid-producing parietal cells in your stomach.

Follow-up

When a truncal vagotomy is performed by severing the nerve supply to the pylorus, a pyloroplasty is necessary to widen the pylorus. The approach taken will depend on the specifics of your condition. In complex cases where the pylorus is severely damaged or has been removed, pyloroplasty may involve bypassing and reconstructing the pylorus, necessitating additional surgical procedures. However, with a highly selective vagotomy, the pylorus remains intact and continues to function normally, along with your other digestive organs.

After the procedure

You might need to stay in the hospital for a few days, depending on the complexity of your surgery. Your doctor will keep an eye on your condition, ensuring you are stable and can move around comfortably before you are discharged.

Outcome

The recovery time depends on the specifics of your previous surgeries and whether you had laparoscopic or open surgery. Laparoscopic surgery generally involves fewer incisions, leading to a quicker recovery. It may take a few weeks before you can return to your normal diet. Initially, you will begin with a liquid diet and gradually progress to more solid foods.