Vagotomy is a surgical procedure used to treat peptic ulcers of the upper gastrointestinal tract. The goal of vagotomy is to reduce stomach acid production by severing certain branches of the vagus nerve. This allows the stomach lining to heal more effectively and reduces the risk of further ulcers. Historically, vagotomy played an important role, particularly in the treatment of gastric ulcers and duodenal ulcers.
Over time, various forms of vagotomy have been developed, including truncal vagotomy, selective vagotomy, and selective proximal vagotomy. Today, treatment is more commonly carried out with proton pump inhibitors and, in cases of Helicobacter pylori infection, with antibiotic therapy. Nevertheless, vagotomy remains important for treatment-resistant cases and specific surgical indications.
Definition: Vagotomy
A vagotomy is a surgical procedure used to treat stomach and duodenal ulcers. A vagotomy involves severing the two main branches of the vagus nerve (truncular vagotomy) or their branches. These nerves are responsible, among other things, for acid production in the stomach. Acid is produced by parietal cells in the fundus and body of the stomach. Acid secretion is stimulated by the nerve fibers of the vagus nerve.
The goal of the various vagotomy procedures is to suppress acid production. To do this, the surgeon cuts the nerve fibers that extend to the stomach and duodenum at various points along the stomach.
In addition to vagotomy, the following procedure is also available:
- Partial removal of the stomach
- Partial removal of the stomach, including the ulcer (distal gastrectomy)
- A combination of both procedures
Vagotomy for Stomach and Duodenal Ulcers
Stomach or duodenal ulcers are caused by increased acid production in the stomach or by an imbalance. They are deep defects in the mucous membrane that can progress to a perforated stomach.
The causes of gastric or duodenal ulcers vary:
- Chronic gastritis caused by bacteria (Helicobacter pylori)
- Long-term use of NSAIDs (e.g., aspirin, diclofenac, etc.)
- Tobacco use
- Alcohol
- Rarely: parathyroid adenomas, vascular anomalies (Dieulafoy’s ulcer)
Gastritis is very painful and is common among older adults @ New Africa /AdobeStock
The first-line treatment is acid-suppressing medication. These drugs inhibit acid production in the stomach (so-called proton pump inhibitors). As a result, the number of vagotomies performed has decreased significantly over the past two decades. However, drug therapy is not always sufficient or possible. If the condition is a duodenal ulcer, a vagotomy is therefore indicated.
Adequate medication and antibiotic therapy may provide initial relief. If the patient subsequently develops another duodenal ulcer, vagotomy is not advisable: acid suppression following vagotomy will not be significantly better than that achieved with medication.
Anatomical Course of the Vagus Nerve
The vagus nerve is the tenth cranial nerve. From the point where it enters the thoracic cavity, it functions as a purely parasympathetic nerve. It passes through the diaphragm (esophageal hiatus) into the abdominal cavity. Its distribution extends from the stomach through the small intestine down to the large intestine. The nerve terminates at the so-called Cannon-Böhme point, which is located in the region of the left colonic flexure.
The vagus nerve innervates all organs that are parasympathetically innervated, from the neck region to the left colonic flexure. It is the only cranial nerve that innervates beyond the head and neck region.
In the digestive tract, it is responsible for:
- an increase in peristalsis of the smooth muscle
- increased secretion from the glands in that area, and
- a change in the chemical composition of digestive juices
As it passes from the thoracic cavity into the abdominal cavity, the vagus nerve divides into two trunks:
- Truncus vagalis anterior (anterior trunk), running to the right of the esophagus
- posterior vagal trunk (posterior branch), running to the right of the esophagus
- Ramus criminalis, running to the left of the esophagus.
Anatomical course of the vagus nerve @ pikovit /AdobeStock
Procedure for a vagotomy
There are three vagotomy procedures:
- Selective proximal vagotomy (SPV)
- Selective gastric vagotomy (SGV)
- Truncular vagotomy (TV)
Selective proximal vagotomy (SPV)
In a selective proximal vagotomy, doctors sever all anterior and posterior vagus nerve branches that extend to the fundus and corpus. The motor branches responsible for gastric motility are preserved. Thus, only the secretory vagus branches are severed. The nerve supply to the antrum and pylorus is preserved. This helps prevent gastric emptying disorders.
During a selective proximal vagotomy, doctors must not overlook the ramus criminalis. This nerve branch contains fibers that run to the fundus ventriculi. They thus stimulate acid production in the upper portion of the stomach. Doctors must locate and ligate this branch. Selective proximal vagotomy is completed by ligating the ramus gastroepiploicus in the region of the greater curvature of the stomach.
Selective Gastric Vagotomy (SGV)
In selective gastric vagotomy, all branches of the vagus nerve that run to the stomach are transected. This includes the nerve fibers to the pylorus. Only the branches to the liver and the celiac ganglion are spared. This procedure results in impaired gastric emptying. Therefore, a drainage procedure (pyloroplasty or pyloromyotomy) is always necessary.
Truncular vagotomy (TV)
In a truncal vagotomy, both trunks of the vagus nerve are severed near the diaphragm. This leads to complete denervation of the entire innervated area in the abdominal cavity. Here, too, a drainage procedure is mandatory. Due to the significant complications, this procedure is no longer used today.
Complications of a Vagotomy
The most common complication following a vagotomy is delayed gastric emptying, which occurs in approximately 20 percent of cases. It occurs particularly after a truncal vagotomy (TV). This is the result of insufficient relaxation of the muscles in the area of the gastric outlet (pylorospasm). As a result, a second operation is usually necessary.
The second most common complication following a vagotomy, occurring in about 6 to 10 percent of cases, is the recurrence of an ulcer. This is caused by an inadequately performed vagotomy. Injuries to the spleen and esophagus are observed in 1 to 2 percent of cases. Diarrhea or bloating occur less frequently (approximately 1 percent).
Once full recovery has been achieved, no significant limitations in daily life are generally expected following a vagotomy.
Conclusion on Vagotomy
When surgical treatment of a gastric or duodenal ulcer is necessary, gastric resection is superior to the various vagotomy procedures.
Vagotomy is now used only in the rarest of cases. It has been virtually replaced by the use of medication to suppress stomach acid.
FAQ
What is a vagotomy?
A vagotomy is a surgical procedure in which nerve fibers of the vagus nerve are severed. The goal of this procedure is to reduce stomach acid production and promote the healing of peptic ulcers. The term encompasses various techniques that differ in terms of which branches of the vagus nerve are affected.
What types of vagotomy are there?
The most important types of vagotomy include truncal vagotomy, selective vagotomy, and selective proximal vagotomy (SPV). While truncal vagotomy involves severing the main trunks of the cranial nerve, selective vagotomy more specifically spares certain structures. Selective proximal vagotomy focuses on the acid-producing areas of the stomach.
When is a vagotomy appropriate?
Traditionally, vagotomy was indicated for patients with gastric or duodenal ulcers, particularly when conservative treatments had failed. Today, the procedure is primarily considered for treatment-resistant or complicated cases. Modern alternatives include proton pump inhibitors and treatment for Helicobacter pylori infection.
What role do pyloroplasty and other procedures play?
Pyloroplasty is often combined with a truncal vagotomy to improve gastric emptying. This surgical procedure prevents the reduced gastric motility resulting from the nerve transection from causing symptoms. This combination was studied in detail in older studies by Dragstedt, Goligher, and other authors.
What complications and side effects can occur?
Like any surgery, vagotomy may be associated with complications or side effects. Possible complications include changes in gastric function, digestive disorders, or symptoms in the pylorus and intestine. The surgeon assesses the exact risks on an individual basis as part of the preoperative planning.
