- Alexander Perez, MD
Alexander Perez, MD
- Assistant Professor of Surgery
- Duke University
- Section Editors
- David I Soybel, MD
David I Soybel, MD
- Editor-in-Chief — General Surgery
- Section Editor — Upper GI Surgery
- David L. Nahrwold Professor
- Penn State Hershey Medical Center
- J Thomas Lamont, MD
J Thomas Lamont, MD
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — Anorectal Disorders and Misc. Lower GI Disease; Nutrition, Malabsorption, and Misc. Upper GI Disease
- Professor of Medicine
- Harvard Medical School
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 . 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, proton pump inhibitors, along with the discovery of the role Helicobacter pylori plays in peptic ulcer disease . 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. .
The use of vagotomy in treating complicated peptic ulcer disease and 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: Management".)
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 .
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".)
- Latarjet A. Resection des nefs de l’estomac. Bull Acad Natl Med 1922; 97:681.
- Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet 1984; 1:1311.
- Katkhouda N, Mouiel J. A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy. Am J Surg 1991; 161:361.
- Lagoo J, Pappas TN, Perez A. A relic or still relevant: the narrowing role for vagotomy in the treatment of peptic ulcer disease. Am J Surg 2014; 207:120.
- Reuben BC, Stoddard G, Glasgow R, Neumayer LA. Trends and predictors for vagotomy when performing oversew of acute bleeding duodenal ulcer in the United States. J Gastrointest Surg 2007; 11:22.
- de la Fuente SG, Khuri SF, Schifftner T, et al. Comparative analysis of vagotomy and drainage versus vagotomy and resection procedures for bleeding peptic ulcer disease: results of 907 patients from the Department of Veterans Affairs National Surgical Quality Improvement Program database. J Am Coll Surg 2006; 202:78.
- Hoffmann J, Devantier A, Koelle T, Jensen HE. Parietal cell vagotomy as an emergency procedure for bleeding peptic ulcer. Ann Surg 1987; 206:583.
- Miedema BW, Torres PR, Farnell MB, et al. Proximal gastric vagotomy in the emergency treatment of bleeding duodenal ulcer. Am J Surg 1991; 161:64.
- Sverdén E, Sondén A, Leinsköld T, et al. Minimal versus definitive surgery in managing peptic ulcer bleeding: a population-based cohort study. Dig Surg 2014; 31:276.
- Schroder VT, Pappas TN, Vaslef SN, et al. Vagotomy/drainage is superior to local oversew in patients who require emergency surgery for bleeding peptic ulcers. Ann Surg 2014; 259:1111.
- Kuwabara K, Matsuda S, Fushimi K, et al. Reappraising the surgical approach on the perforated gastroduodenal ulcer: should gastric resection be abandoned? J Clin Med Res 2011; 3:213.
- Jordan PH Jr, Thornby J. Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy. Ann Surg 1995; 221:479.
- Bell RH Jr, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg 2009; 249:719.
- Csendes A, Maluenda F, Braghetto I, et al. Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Am J Surg 1993; 166:45.
- Taylor TV, Lythgoe JP, McFarland JB, et al. Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer. Br J Surg 1990; 77:1007.
- Katkhouda N, Heimbucher J, Mouiel J. Laparoscopic posterior vagotomy and anterior seromyotomy. Endosc Surg Allied Technol 1994; 2:95.
- Gomez-Ferrar, F. Gastrectomie lineaire anterieure et vagotomie tronculaire posteriere una nouvelle technique laparocopique dans le traitment de líulcere duodenal. J Chir (Paris) 1992; 4:35.
- Petrakis I, Vassilakis SJ, Vrachassotakis N, et al. Laparoscopic modified taylor procedure in the treatment of duodenal ulcer: technique and outcome after 5-year follow-up. Eur Surg Res 1999; 31:471.
- Petrakis I, Vassilakis SJ, Chalkiadakis G. Anterior lesser curve seromyotomy using a stapling device and posterior truncal vagotomy for the treatment of chronic duodenal ulcer: longterm results. J Am Coll Surg 1999; 188:623.
- Croce E, Azzola M, Golia M, et al. Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy. Endosc Surg Allied Technol 1994; 2:113.
- Croce E, Olmi S, Russo R, et al. Laparoscopic treatment of peptic ulcers. A review after 6 years experience with Hill-Barker's procedure. Hepatogastroenterology 1999; 46:924.
- Hill GL, Barker MC. Anterior highly selective vagotomy with posterior truncal vagotomy: a simple technique for denervating the parietal cell mass. Br J Surg 1978; 65:702.
- Ashley SW, Evoy D, Daly JM. Stomach. In: Principles of Surgery, 7th ed, Schwartz SS (Ed), McGraw-Hill, New York 1999. p.1181.
- Towfigh S, Chandler C, Hines OJ, McFadden DW. Outcomes from peptic ulcer surgery have not benefited from advances in medical therapy. Am Surg 2002; 68:385.
- Rockall TA. Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for the National Audit of Acute Upper Gastrointestinal Haemorrhage. J R Soc Med 1998; 91:518.
- Johnston D. Operative mortality and postoperative morbidity of highly selective vagotomy. Br Med J 1975; 4:545.
- Hejazi RA, Patil H, McCallum RW. Dumping syndrome: establishing criteria for diagnosis and identifying new etiologies. Dig Dis Sci 2010; 55:117.
- Frederiksen HJ, Johansen TS, Christiansen PM. Postvagotomy diarrhoea and dumping treated with reconstruction of the pylorus. Scand J Gastroenterol 1980; 15:245.
- Taylor TV, Lambert ME, Torrance HB. Value of bile-acid binding agents in post-vagotomy diarrhoea. Lancet 1978; 1:635.
- Herrington JL Jr, Edwards WH, Carter JH, Sawyers JL. Treatment of severe postvagotomy diarrhea by reversed jejunal segment. Ann Surg 1968; 168:522.