Vagotomy and pyloroplasty are surgical methods of peptic ulcer treatment. Vagotomy involves cutting the fibers of the vagus nerve responsible for the nervous phase of gastric juice secretion. Pyloroplasty, on the other hand, is an incision and then sewing the pylorus at the bottom of the stomach.
Vagotomyandpyloroplastyare procedures used in the surgical treatment of peptic ulcer disease in order to eliminate factors that predispose to its formation.
The indications for this type of treatment are the ineffectiveness of conservative treatment, recurrence of the ulcer despite proper conservative treatment, and the occurrence of complications such as ulcer perforation or massive ulcer haemorrhage.
In the case of surgical treatment of peptic ulcer disease, the most important thing is to interrupt the conduction pathways in the nervous system, and more specifically to cut the vagus nerve trunk, which is responsible for the nervous phase of gastric juice secretion.
Stem vagotomy, selective and highly selective
The vagus nerve trunk can be cut by performing a truncated vagotomy, selective vagotomy, or highly selective (proximal) vagotomy, which involves cutting fibers innervating the parietal cells.
- Stem vagotomy and pyloroplasty
Stem vagotomy involves the complete cutting of all vagal trunks at or above the esophageal opening in the diaphragm.
This results in denervation of the parietal cells of the stomach, the pyloric sphincter mechanism and most of the abdominal cavity, which leads to gastric motility disorders. As a result, it becomes necessary to perform a procedure that facilitates gastric emptying, which prevents the expansion of the antral part of the stomach and stimulating the secretion of gastrin.
For this purpose, pyloroplasty is performed, which consists in cutting the pylorus longitudinally and sewing the cut line transversely.
If this operation cannot be performed, gastrointestinal anastomosis can be performed. However, it should be remembered that the ulcer recurrence is almost always observed afterwards.
In addition, the stem vagotomy can be supplemented with excision of the distal part of the stomach (the so-calledantrectomy ), in which gastrin is produced, and removal of the pylorus.
It makes it easiergastric emptying and at the same time supports the vagotomy effect - a large part of the cells that produce gastrin, which stimulates the secretion of hydrochloric acid, is removed.
Then an anastomosis between the stomach stump and the duodenum is performed (the so-called Bilroth I anastomosis).
An alternative to fusion using the Bilroth I method is the Bilroth II method or using the Roux loop.
In Bilroth II anastomosis, the stomach is not connected with the duodenum, but with the proximal jejunal loop. This type of anastomosis is especially recommended in the case of significant scar changes of the duodenum.
In Roux-en-Y anastomosis, perist altic movements of the small intestine drain food and fluid from the stomach - this reduces the discharge of small intestine contents into the stomach.
This type of anastomosis is especially useful in patients with gastritis due to regurgitation of the alkaline content.
- Selective Vagotomy and Pyloroplasty
Another type of vagotomy isselective vagotomy , which leads to the complete denervation of the entire stomach - from the diaphragm to the pylorus.
This procedure leaves the innervation of the abdominal cavity, but similarly to the truncated vagotomy, it causes the antral pump and the pylorus to be denervated, which makes it necessary to supplement the operation with a procedure that facilitates emptying the stomach.
For this purpose, pyloroplasty is performed - a procedure that consists in longitudinal incision of the pyloric muscle membrane and its dissection.
Thanks to selective vagotomy, a fuller denervation of the stomach is obtained without disturbing the parasympathetic system of other abdominal organs such as the pancreas, liver, gallbladder, small intestine or proximal part of the large intestine.
- Highly selective vagotomy
The last type of vagotomy is highly selective vagotomy. It consists in cutting along the lesser curvature of the stomach only those branches of the vagus nerve that innervate the area of the parietal cells.
This allows the antral pump and the pyloric sphincter mechanism to function properly. It is worth remembering that this type of procedure is not performed in patients with impaired pyloric patency.
Total Gastrectomy
In extreme cases of peptic ulcer disease, complete gastrectomy is necessary. Although it is not possible for the ulcer to recur after such surgery, serious metabolic disorders are observed in patients.
These include, among others lack of production of the internal factor necessary for binding iabsorption of vitamin B12, which results in the reduction of its concentration in the blood and the development of pernicious anemia.
In addition, there may be significant malnutrition and weight loss. Moreover, total gastrectomy is associated with significant mortality due to difficulties in performing oesophageal anastomosis.