Vagotomy is the surgical severing of branches of the vagus nerve that supply the secretory cells of the stomach or duodenum. The operation is mainly used in patients with gastric and duodenal ulcers, as such ulcers are due to excessive acid secretion. Meanwhile, conservative drug solutions have largely replaced vagotomy.
What is vagotomy?
Vagotomy is the surgical severing of branches of the vagus nerve that supply the secretory cells of the stomach or duodenum. Approximately 50 out of every 100,000 people suffer from gastric ulcers. Ulcers of the duodenum have even a four times higher prevalence. This means that gastric and duodenal ulcers are among the more common diseases. To treat these ulcers, physicians have surgical methods available, such as vagotomy. During the operation, the surgeon cuts various branches of the cranial nerves involved in supplying the stomach or duodenum. After these branches are cut, less acidic gastric secretions are produced. Although the operation has effectiveness, it is rarely if ever performed in modern times. Modern developments in medicine are responsible for this. For example, so-called proton pump inhibitors are now available for the treatment of patients with gastric or duodenal ulcers, and they still surpass surgery in terms of effectiveness. Before the introduction of these modern therapies, vagotomy had a significant role in relation to patients with gastric or duodenal ulcer, most notably in the form of selective proximal vagotomy.
Function, effect, and goals
The cause of gastric and duodenal ulcers is a mismatch of protective factors of the gastric mucosa and HCl secretory substances secreted by the parietal cells. The secretion of the cells depends on a stimulus realized by the vagus nerve. The name vagotomy already indicates that the surgical procedure corresponds to an intervention on the vagus nerve. The operation aims to abolish or reduce the stimuli that drive the parietal cells of the stomach or duodenum to secrete. For this reason, the surgeon cuts the branches of the nerve that supply the stomach or duodenum during surgery. Various subprocedures with this goal are additionally available. Normally, on the right and left main trunk of the vagus nerve, the corresponding parts of the nerve are cut at different anatomical levels. In this context, a thoracic vagotomy is always referred to when the transection of the main nerve trunks takes place in the region of the thorax. In the truncal form of vagotomy, the main trunks in the truncus vagalis are cut anteriorly and posteriorly starting from the abdominal cavity in the region of the lower esophagus. Gastric vagotomy is based on nerve transection of the nerve portions that extend to the stomach. This preserves the nerve branches to the liver and other organs. Selective proximal vagotomy is also known as parietal cell vagotomy and is one of the most commonly performed vagotomies in the past. In this procedure, the nerve branches to the stomach are transected while preserving the nerve portions that extend to the gastric portal, called the pylorus. This procedure can be traced back to N. Latarjet. Vagotomies are always performed on an inpatient basis and require conscientious surgical preparation and patient education. In the meantime, however, proximal selective vagotomy is almost no longer performed at all.
Risks, side effects, and hazards
Vagotomy is associated with general and specific surgical risks. General surgical risks include, for example, bleeding occurring during or after surgery, which in the worst case can lead to death. In addition, surgery is always associated with the risk of infection and, in extreme cases, can result in necrotization of tissue or fatal sepsis. In addition, there is some risk associated with anesthesia during any surgery. This risk particularly affects patients with circulatory problems and those who are overweight. Circulatory shock can occur during surgery in response to the anesthetic and can lead to cardiac arrest. In addition, many patients experience nausea or vomiting due to anesthetics.Allergic reactions to the anesthetic may also be within the realm of possibility. Even more frequently, patients complain of sore throat, hoarseness and difficulty swallowing after an operation, as they can occur as a reaction to artificial respiration during an operation. Although the risk of the described complications and side effects is usually considered low, the patient must still be informed of the risks prior to surgery. The specific risks of vagotomy include, above all, the incorrect severing of nerve branches that are relevant to the function of the stomach or intestines. Transection of incorrect nerve branches could result in paralysis of peristalsis and thus functionally impair digestion. If sensory nerve fibers are cut, sensory disturbances may occur. Special diets are also often required before and especially after gastric or duodenal surgery to avoid overloading the organs immediately after the stressful event. Because of the expense and risks involved, vagotomy is now rarely used. Modern alternatives involve less effort as well as fewer risks and side effects for the patient. Among the most important modern solutions are effective secretion-inhibiting pharmaceuticals. These pharmaceuticals may correspond to proton pump inhibitors or H2 blockers, for example. Accordingly, the invasive procedure of vagotomy has been replaced by conservative drug solutions to avoid undue burden on the patient. In exceptions, vagotomy still takes place, predominantly in therapy-refractory severe courses.
