Elective PUD operations

The goal is to reduce gastric acid secretion

• Vagotomy - remove vagal stimulation (decreases peak acid output by 50%)
  • Mobilise and divide both anterior and posterior vagal nerves above the hepatic and coeliac branches, 4cm superior to GOJ
  • Mostly should perform a drainage procedure to avoid delayed emptying
    • Heineke-Mikulicz pyloroplasty
    • If duodenal bulb scarred - Finney pyloroplasty or Jaboulay gastroduodenostomy, or even gastrojejunostomy
  • Truncal vagotomy is performed above the hepatic and coeliac branches, whereas a selective vagotomy is performed below, and a highly selective vagotomy is performed by dividing the branches to the proximal stomach while preserving the innervation to the antral and pyloric parts.
  • Truncal vagotomy - denervate all vagal tone to the abdomen
    • One-third had a gastric emptying problem which required a drainage procedure, one-third had a gastric-emptying problem which improved with time, and one-third had no problem at all
  • Selective vagotomy - denervate the stomach, but leave innervation to other organs intact
    • Generally in combination with a drainage procedure
    • Less gastric emptying problems, only about 10%
    • Higher ulcer recurrence rates than truncal vagotomy with no other advantage - therefore abandoned
  • Highly-selective vagotomy - divide only the vagus nerves supplying the acid-producing portion of the stomach within the body and fundus, preserving innervation of antrum and pylorus
    • Lower complication rate - dumping syndrome and diarrhoea, but gastric emptying only 5%
    • Identify nerves of Latarjet anteriorly and posteriorly, and divide the crow's feet innervating the fundus and body of the stomach
    • Divide the nerves up until a point approximately 7cm proximal to the pylorus and 5cm proximal to GOJ, preserving two or three branches to the antrum and pylorus
    • Particularly identify and divide the criminal nerve of Grassi (a very proximal branch of the posterior vagal trunk, which predisposes to ulcer formation if left intact)
• Antrectomy - remove gastrin-driven secretion
  • Relative contraindications:
    • Not generally performed for duodenal ulcers
    • Cirrhosis
    • Extensive scarring of proximal duodenum
  • Requires reconstruction:
    • Billroth I gastroduodenostomy (if no duodenal inflammation) - generally favoured because it avoids the problems of retained antrum syndrome, duodenal stump leak, and afferent loop obstruction associated with the other options
    • Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy (if inflammation/scarring of proximal duodenum, or if subtotal/total gastrectomy is required)
      • Loop of jejunum typically brought retrocolic, through the transverse mesocolon
      • Anastomosis along posterior wall of the greater curvature, to facilitate dependent drainage

• Subtotal gastrectomy - reduce the number of parietal cells
  • Reconstruct with either Bilroth II or Roux-en-Y
• Combination - vagotomy + antrectomy decreases peak acid output by 85%
  • Reduces recurrence of ulcer from 12% to 3% compared with vagotomy alone
  • 20% risk of post-gastrectomy and post-vagotomy syndromes