Overview of Truncal Vagotomy
Peptic ulcer disease, also known as PUD, is a common health condition in the United States, affecting about 2% of the population. This disease involves painful sores or ulcers developing in the stomach lining. Over time, the way we treat this disease has changed significantly.
In the past, around the 1940s, the primary treatment for PUD was a surgery called vagotomy. This operation interrupts nerve signals to the stomach, reducing the production of stomach acid, which can help heal the ulcers. Interestingly, it was once seen as the best treatment for the condition.
However, by the late 1970s and early 80s, the treatment shifted towards using medication to reduce stomach acid instead. This approach got a significant boost around 2005 when Drs. Barry Marshall and Robin Warren received the Nobel Prize. They discovered that a bacteria named Helicobacter pylori was often the cause of PUD.
Regarding the vagotomy, there are three main types: truncal vagotomy (TV), selective vagotomy (SV), and highly selective vagotomy (HSV). Each type has its benefits and drawbacks. To fully comprehend these options, it’s essential to understand how the stomach and its acid production work.
Although it’s not a common option today, vagotomy surgery can still be used to treat severe or complex cases of PUD. Therefore, it’s key that doctors are familiar with the aspects of this surgery and potential complications to give the best care to their patients in today’s world.
Anatomy and Physiology of Truncal Vagotomy
The stomach is a crucial organ in the human body and it is divided into different parts.
– Fundus: This is the top part of the stomach located near the diaphragm and spleen, on the body’s left side.
– Cardia: You can find this part close to the area where the stomach and esophagus (food pipe) join.
– Body: This is the largest part of the stomach and it ends at the bend along the narrower side of the stomach.
– Antrum: This is towards the end of the stomach, making up 25% to 30% of its total size.
– Pylorus: This part of the stomach connects to the first section of the small intestine, called the duodenum.
There are ligaments which connect the stomach to other organs and parts of the body:
– Gastrohepatic ligament or lesser omentum, which contains nerve fibers that extend to the liver. In about 10% of people, it may include an additional artery, known as the left hepatic artery.
– Gastrocolic, also known as the greater omentum, connects the lower side of the stomach to a part of the large intestine (the transverse colon).
– Gastrosplenic contains an artery that supplies blood to the stomach and the short gastric arteries.
The celiac trunk and superior mesenteric artery are responsible for supplying blood to the stomach, through four main arteries:
1. The Left gastric artery, which is connected to the celiac trunk and is the largest artery. It supplies blood to the lesser curvature of the stomach.
2. The Right gastric artery connects with the artery supplying blood to the liver and provides blood to stomach’s lesser curvature.
3. The Left gastroepiploic artery comes from the splenic artery and provides blood to the greater curvature of the stomach.
4. The Right gastroepiploic artery comes from the gastroduodenal artery and also provides blood to stomach’s greater curvature.
The stomach is controlled by nerve signals with the help of the vagus nerves:
– The anterior trunk controls the liver and gallbladder systems and also sends signals along the front part of the stomach through the anterior nerve of Latarjet.
– The posterior trunk sends signals to the stomach’s back side and has the ‘criminal nerve of Grassi’ which controls the top part of the stomach.
– The nerves collectively known as the ‘crow’s foot’ control the lower region of the stomach.
Acid in your stomach is released by special cells known as parietal cells. This release of acid is activated by three substances: gastrin, acetylcholine and histamine.
Secretion of acid happens in three phases:
1. Cephalic Phase: During this phase, the smell, taste, or even thought of food can trigger acid production. This happens through the vagus nerves and accounts for 30% of the total acid production.
2. Gastric Phase: This phase begins when food enters the stomach. The stomach expands, triggering the release of more acid, accounting for 60% total acid production.
3. Intestinal Phase: This phase is triggered by food entering the small intestines and accounts for the remaining 10% of total acid production.
There are also different procedures called vagotomies which cut or block the vagus nerve to reduce acid production.
– Truncal Vagotomy: The main vagus nerve is cut, reducing acid secretion, but it may affect how the stomach empties out food, requiring further procedures to aid stomach emptying.
– Selective Vagotomy: This procedure cuts branches of the vagus nerve, and usually requires an additional procedure to keep food moving through the digestive system.
– Highly Selective Vagotomy (HSV): This procedure involves cutting the nerves that control acid secretion while preserving others so that stomach emptying is not affected.
Why do People Need Truncal Vagotomy
A vagotomy is a surgery that involves removing parts of the vagus nerve to reduce acid production in the stomach. Different types of vagotomies (HSV, TV, or SV) have different risks and benefits. For example, the HSV kind is associated with the highest rate of ulcers returning but has the lowest complications and death rates. Meanwhile, the TV or SV types carry the lowest rate of ulcer recurrence but have the highest instances of complications and death rates. SV often includes removal of part of the stomach (antrectomy).
Over time, most cases involving stomach acid-related issues, such as peptic ulcers, have been treated with medication instead of surgery. Surgery is usually a last resort, for patients with severe, complicated cases of ulcers who failed to respond to medication. The type of surgery used depends on various factors, such as the ulcer type (either in the duodenum or stomach) and location, and the nature of complications such as bleeding, a hole (perforation), blockage (obstruction), or resistance to treatment.
Here are some examples of how a vagotomy can be used to treat specific conditions:
- Bleeding duodenal ulcer: If a patient has not responded to medication, surgery may be needed. The original surgery involves opening the beginning portion of the small intestine (the duodenum) and the outlet of the stomach, to improve stomach drainage (pyloroplasty). Alongside this, a truncal vagotomy may be performed to lower the rate of ulcer recurrence.
- Bleeding gastric ulcer: Most stomach ulcers are not linked with high acid production. The typical care is to remove the ulcer surgically. In certain complex cases, a truncal vagotomy might be included with the stomach surgery.
- Perforated duodenal ulcer: Generally, the hole is patched up with a procedure known as a Graham patch repair. An HSV treatment (removal of nerves that stimulate stomach acid production) might be encouraged if the patient is stable, at high risk for recurrence, has no response to maximum medical therapy, and is free from an ulcer-causing bacteria, H. pylori.
- Perforated gastric ulcers: This is treated in a similar way as bleeding ulcers.
- Gastric outlet obstruction: The first-choice treatment is typically performing an endoscopic balloon dilation together with medication to reduce acid production. If this approach doesn’t work, a combination of a truncal vagotomy and antrectomy may be needed.
- Intractability: An HSV may be suggested for patients with duodenal or certain types of gastric ulcers. In gastric ulcers that aren’t associated with an overproduction of acid, the section of the stomach containing the ulcers may be removed, but a vagotomy is usually not necessary.
- Recurring ulcer after previous vagotomy: If a patient cannot be managed using medication, then a combination of truncal vagotomy and antrectomy may be needed.
When a Person Should Avoid Truncal Vagotomy
Usually, there are several reasons why a patient might not be able to have a certain surgery. These are related to the overall health status of the patient and might include:
If the patient is experiencing pre-operative shock which is a severe and life-threatening condition where the body isn’t getting enough blood flow.
If the patient has severe generalized peritonitis, which is a severe inflammation of the peritoneum (the thin layer of tissue that lines the inside of the abdomen), this can make surgery too risky.
If the patient has an intra-abdominal abscess which is a pocket of pus in the abdomen, it can complicate the surgery.
If the doctor didn’t diagnose the condition or start treatment within 24 hours, this may make the surgery too risky or less successful.
If the patient has a severe concurrent medical illness, it may make prolonging the surgery unsafe. This means if they have another serious health problem at the same time, it might not be safe to make the surgery last longer than planned.
Equipment used for Truncal Vagotomy
Depending on the type of surgery, specific equipment is necessary. The surgery could be a laparotomy, which is a big incision made in the abdomen, or a laparoscopy, which uses a small camera sent through a minute incision to perform the surgery. In either case, specialized tools are needed.
A liver retractor is often used in these surgeries. This tool is like a small spatula that the physicians use to gently move the liver aside, giving them a clear view of the surgical area.
When the vagal trunks are being divided or cut, surgical clips are commonly used. These are tiny devices that are put in place to stop the flow of blood or other fluids, kind of like how a clothespin works. This ensures that the body part being operated on can be cleanly and safely handled.
Who is needed to perform Truncal Vagotomy?
For the part of your hospital visit where the actual surgery takes place, there will be a team of medical professionals working together to ensure your safety and the success of the procedure. This team includes:
– An anesthesiologist, who is a doctor that will help manage your pain and make you comfortable by giving you medicine that makes you sleep during the surgery.
– The primary surgeon, who is the main doctor that will perform your surgery.
– A scrub technician, who is a medical expert in charge of all the tools and equipment used in the surgery. They will make sure the surgeon has clean and functioning tools needed.
– A first assistant, who helps the primary surgeon by handling and organizing the required tools and materials during the operation.
– A circulating nurse, who helps the entire team by keeping the operating room organized and safe. They are responsible for making sure everything runs smoothly.
– A pathologist, who is a doctor that helps by studying samples from your body under a microscope to understand and diagnose your condition better.
Preparing for Truncal Vagotomy
Preparing for surgery can be different for each person depending on their unique health situation. When it comes to planned surgeries, doctors usually give patients antibiotics half an hour before the surgery begins. This is done to prevent any potential infections. Also, medication to prevent a condition called venous thromboembolism (an issue where blood clots form in the veins) is given.
In the area where you’ll be prepared for surgery, any hair on your abdomen (the area of your body where your belly is) will be cut using electric clippers. When you’re lying on your back on the surgery table, the anesthesia, which makes you sleep and not feel any pain during the surgery, will be given.
After you’re asleep, the medical team will insert a Foley catheter, a soft, thin tube, into your bladder to collect urine. This is done because anesthesia often decreases your body’s reflex to urinate. In addition, a nasogastric tube is also placed in your stomach through your nose. This is done to keep your stomach empty during surgery, to prevent any complications. During all of this, the surgeon will typically be standing on your right side.
How is Truncal Vagotomy performed
There are two main ways a surgeon can operate on your stomach: open surgery and laparoscopic surgery.
Open Technique
Entering the stomach cavity
For this operation, the surgeon makes a cut on the upper-middle part of your stomach, just above the belly button. This cut extends almost all the way to the base of your rib cage. Once this cut is made, the surgeon then opens the belly and looks inside. Special retractors (medical devices) are used to hold the cut open and move the liver for better visibility.
Freeing the lower part of the esophagus
To reach the part where your esophagus (the pipe that food travels down) meets your stomach, the surgeon will need to clear some space. An assistant will pull your stomach downwards and the surgeon will gently remove a thin layer of tissue covering your esophagus. A type of surgical rubber band will be placed around the esophagus and will typically be positioned 4 to 5 cm above the junction with the stomach. If the liver is blocking the view, a part of it might be temporarily moved to clear the way.
Cutting certain nerves
In most people, there is a nerve located 2 to 4 cm above where the esophagus meets the stomach. This trunk of the vagus nerve, an important nerve responsible for many functions in the body, is carefully moved a little bit to clear some space. The trunk is then cut and sealed to minimize any bleeding. This is done to help with the operation and to avoid damaging surrounding organs and tissues. The same process is repeated for a similar nerve located along the right edge of the esophagus.
Confirming that everything is correct
Pathologists are experts who study body tissues and can tell if they’re healthy or not. Frozen section pathology is when these experts quickly freeze, slice, and examine a small piece of tissue removed during surgery. This helps the surgical team confirm what they’re seeing and decide the next steps.
Creating a new path for food or removing part of the stomach
If you have a problem with the way your stomach empties (drains), the surgeon can create a new pathway for food. This could include making a connection between the stomach and the small intestine, opening and stretching the bottom part of the stomach, or even creating a new opening in the stomach. If you have an ulcer (a sore) in your stomach, the surgeon may remove part of the stomach. This is known as gastric resection and the part that goes typically includes the antrum, the lower part of the stomach. After that, the surgeon will reconstruct the digestive tract to let food pass normally. The method of reconstruction can vary, but it often involves creating a new connection between the stomach and the small intestine, either directly or by way of a small side loop.
Closing up the cut
At the end of the surgery, the surgeon will close the cut in your stomach using stitches or staples. Remember, even though this is a complex procedure, the surgeon’s main goal is to make you feel better.
Possible Complications of Truncal Vagotomy
Truncal vagotomy is a surgical procedure that involves cutting specific nerves connected to your stomach. Like any other surgery, there are potential complications both during and after the procedure. The most severe complications that can happen during surgery include excessive bleeding, and damage to either the stomach or the esophagus, which is the tube connecting your throat to your stomach. Certain problems like leaks along the lines where tissue is stapled together, or where connections have been made during surgery, and internal hernias, could potentially occur depending on how your intestines are reconstructed during surgery.
After the surgery, the cut nerves can no longer send their usual signals to the lower part of the stomach, liver, gallbladder, pancreas, and both the small and large intestines. This can cause a number of changes in the body.
For instance, your stomach might take longer to empty, especially when it comes to solid food. This happens because a specific part of your stomach, called the pylorus, can’t relax properly and let food through. A common solution to this is performing a special procedure during surgery to help drain the stomach.
Another possible complication is postvagotomy diarrhea, which happens when certain substances from your liver enter your colon, causing water to be drawn into the colon – this results in watery stools. This type of diarrhea is more commonly seen after truncal vagotomy and can usually be managed with certain medicines. If the diarrhea doesn’t stop with medication, a different surgical procedure might be needed.
Hypergastrinemia is another possible complication after surgery. This means your body makes too much gastrin, a hormone that usually controls stomach acid. Because the nerves controlling stomach acid have been cut, gastrin is produced uncontrollably. This can lead to stomach ulcers coming back, although usually the complication risk is lower with truncal vagotomy compared to other similar surgeries. Sometimes, a part of your stomach will be removed during surgery to help prevent ulcers from returning.
Finally, “dumping syndrome,” where food moves too fast from the stomach to the small intestine, usually only occurs if a part of your stomach is removed during surgery or drainage procedures are performed alongside the truncal vagotomy.
What Else Should I Know About Truncal Vagotomy?
Acid-reducing surgery, while not as common today, remains a valuable tool for doctors treating certain stomach problems. It comes into play mainly for people with recurring or complex peptic ulcers – painful sores in the stomach lining – who haven’t responded well to medication. Understanding the different techniques and potential after-effects of these surgeries is necessary.
Vagotomy, one common type of acid-reducing surgery, involves cutting part of the vagus nerve to reduce stomach acid. This method is still widely used today because it is relatively simpler compared to other techniques, like the highly selective vagotomy (HSV).
Whoever, most doctors agree that alongside a vagotomy, a follow-up procedure called a drainage procedure is usually needed. This is to prevent potential side effects like bloating and nausea. Like all surgeries, this comes with its own risks and doctors always need to weigh the benefits against the downsides.
