| Vagotomy | |
|---|---|
 Course and distribution of the glossopharyngeal, vagus, and accessory nerves. | |
| ICD-9-CM | 44.0 |
| MeSH | D014628 |
A vagotomy is a surgical procedure that involves removing part of the vagus nerve. It is performed in the abdomen.
| Vagotomy | |
|---|---|
| Course and distribution of the glossopharyngeal, vagus, and accessory nerves. | |
| ICD-9-CM | 44.0 |
| MeSH | D014628 |
A vagotomy is a surgical procedure that involves removing part of the vagus nerve. It is performed in the abdomen.
A plain vagotomy eliminates the parasympathetic supply from the stomach to the left side of the transverse colon. Other techniques focus on branches leading from the retroperitoneum to the stomach. [1]
Highly selective vagotomy refers to denervation of only those branches supplying the lower esophagus and stomach (leaving the nerve of Latarjet in place to ensure the emptying function of the stomach remains intact). It is one of the treatments of peptic ulcer.
Vagotomy is an essential component of surgical management of peptic (duodenal and gastric) ulcer disease (PUD). Vagotomy was once commonly performed to treat and prevent PUD; however, with the availability of excellent acid secretion control with H2 receptor antagonists, such as cimetidine, ranitidine, and famotidine, and proton pump inhibitors (PPIs), such as pantoprazole, rabeprazole, omeprazole, and lansoprazole, the need for surgical management of peptic ulcer disease has greatly decreased. [2]
The basic types of vagotomy are:
All types of vagotomy can be performed at open surgery (laparotomy) or using minimally invasive surgery (laparoscopy).
For the management of PUD, vagotomy is sometimes combined with antrectomy (removal of the distal half of the stomach) to reduce the rate of recurrence. Reconstruction is performed with gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II). It is left intact in highly selective vagotomy so the function of gastric emptying remains intact. [4]
Truncal vagotomy is a treatment option for chronic duodenal ulcers. [5] [6] It was once considered the gold standard, but is now usually reserved for patients who have failed the first-line "triple therapy" against Helicobacter pylori infection: two antibiotics (clarithromycin and amoxicillin or metronidazole) and a proton pump inhibitor (e.g., omeprazole). It is also used in the treatment of gastric outlet obstruction. [7] [8]
In 2007 the use of vagotomy to treat obesity was being studied. [9] The vagus nerve provides efferent nervous signals out from the hunger and satiety centers of the hypothalamus, a region of the brain central to the regulation of food intake and energy expenditure. [10] The circuit begins with an area of the hypothalamus, the arcuate nucleus, that has outputs to the lateral hypothalamus (LH) and ventromedial hypothalamus (VMH), the brain's feeding and satiety centers, respectively. [11] [12] Animals with lesioned VMH will gain weight even in the face of severe restrictions imposed on their food intake, because they no longer provide the signaling needed to turn off energy storage and facilitate energy burning. In humans, the VMH is sometimes injured by ongoing treatment for acute lymphoblastic leukemia or surgery or radiation to treat posterior cranial fossa tumors. [10] With the VMH disabled and no longer responding to peripheral energy balance signals, "[e]fferent sympathetic activity drops, resulting in malaise and reduced energy expenditure, and vagal activity increases, resulting in increased insulin secretion and adipogenesis." [13] "VMH dysfunction promotes excessive caloric intake and decreased caloric expenditure, leading to continuous and unrelenting weight gain. Attempts at caloric restriction or pharmacotherapy with adrenergic or serotonergic agents have previously met with little or only brief success in treating this syndrome." [10] The vagus nerve is thought to be one key mediator of these effects, as lesions lead to chronic elevations in insulin secretion, promoting energy storage in adipocytes. Vagotomy may have an impact upon ghrelin. [14] In an open-label, prospective study of 30 obese patients (26 women), response has been variable; the intervention has generally been safe, although adverse events have included gastric dumping syndrome (n=3), wound infection (n=2), other (n=5), and diarrhea (n=6). [15]
Vagotomy was once popular as a way of treating and preventing PUD [16] and subsequent ulcer perforations. [17] [18] PUD was thought to be due to excess secretion of the acid environment in the stomach, or at least that PUD was made worse by hyperacidity. Vagotomy was a way to reduce the acidity of the stomach, by denervating the parietal cells that produce acid. This was done with the hope that it would treat or prevent peptic ulcers. It also had the effect of reducing or eliminating symptoms of gastroesophageal reflux in those who suffered from it. The incidence of vagotomy decreased following the discovery by Barry Marshall and Robin Warren that H. pylori is responsible for most peptic ulcers, because H. pylori can be treated much less invasively. One potential side effect of vagotomy is a vitamin B12 deficiency. As vagotomy decreases gastric secretion, intrinsic factor production can be impaired. Intrinsic factor is needed to absorb vitamin B12 efficiently from food, and injections or large oral doses of the vitamin may be required after such a procedure in certain populations. [19]
The vagus nerve, also known as the tenth cranial nerve, cranial nerve X, or simply CN X, is a cranial nerve that carries sensory fibers that create a pathway that interfaces with the parasympathetic control of the heart, lungs, and digestive tract. It comprises two nerves—the left and right vagus nerves—but they are typically referred to collectively as a single subsystem. The vagus is the longest nerve of the autonomic nervous system in the human body and comprises both sensory and motor fibers. The sensory fibers originate from neurons of the nodose ganglion, whereas the motor fibers come from neurons of the dorsal motor nucleus of the vagus and the nucleus ambiguus. The vagus was also historically called the pneumogastric nerve.
The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach is involved in the gastric phase of digestion, following chewing. It performs a chemical breakdown by means of enzymes and hydrochloric acid.
Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines is a duodenal ulcer. The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain, and upper abdominal pain that improves with eating. With a gastric ulcer, the pain may worsen with eating. The pain is often described as a burning or dull ache. Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people have no symptoms. Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in as many as 15% of cases.
Zollinger–Ellison syndrome is a disease in which tumors cause the stomach to produce too much acid, resulting in peptic ulcers. Symptoms include abdominal pain and diarrhea.
Gastric acid, gastric juice, or stomach acid is a digestive fluid formed within the stomach lining. With a pH between 1 and 3, gastric acid plays a key role in digestion of proteins by activating digestive enzymes, which together break down the long chains of amino acids of proteins. Gastric acid is regulated in feedback systems to increase production when needed, such as after a meal. Other cells in the stomach produce bicarbonate, a base, to buffer the fluid, ensuring a regulated pH. These cells also produce mucus – a viscous barrier to prevent gastric acid from damaging the stomach. The pancreas further produces large amounts of bicarbonate and secretes bicarbonate through the pancreatic duct to the duodenum to neutralize gastric acid passing into the digestive tract.
A gastrectomy is a partial or total surgical removal of the stomach.
Satiety is a state or condition of fullness gratified beyond the point of satisfaction, the opposite of hunger. It is a state which induces meal termination. When food is present in the GI tract after a meal satiety signals overrule hunger signals and intake ceases, after which satiety slowly fades as hunger increases.
A Cushing ulcer, named after Harvey Cushing, is a gastric ulcer associated with elevated intracranial pressure. It is also called von Rokitansky–Cushing syndrome. Apart from the stomach, ulcers may also develop in the proximal duodenum and distal esophagus.
A gastroenterostomy is the surgical creation of a connection between the stomach and the jejunum. The operation can sometimes be performed at the same time as a partial gastrectomy. Gastroenterostomy was in the past typically performed to treat peptic ulcers, but today it is usually carried out to enable food to pass directly to the middle section of the small intestine when it is necessary to bypass the first section because of duodenal damage. The procedure is still being used to treat gastroparesis that is refractory to other treatments, but it is now rarely used to treat peptic ulcers because most cases thereof are bacterial in nature and there are many new drugs available to treat the gastric reflux often experienced with peptic ulcer disease. Reported cure rates for H. pylori infection range from 70% to 90% after antibiotic treatment.
In anatomy, the G cell or gastrin cell, is a type of cell in the stomach and duodenum that secretes gastrin. It works in conjunction with gastric chief cells and parietal cells. G cells are found deep within the pyloric glands of the stomach antrum, and occasionally in the pancreas and duodenum. The vagus nerve innervates the G cells. Gastrin-releasing peptide is released by the post-ganglionic fibers of the vagus nerve onto G cells during parasympathetic stimulation. The peptide hormone bombesin also stimulates gastrin from G cells. Gastrin-releasing peptide, as well as the presence of amino acids in the stomach, stimulates the release of gastrin from the G cells. Gastrin stimulates enterochromaffin-like cells to secrete histamine. Gastrin also targets parietal cells by increasing the amount of histamine and the direct stimulation by gastrin, causing the parietal cells to increase HCl secretion in the stomach. G-cells frequently express PD-L1 during homeostasis which protects them from Helicobacter pylori-induced immune destruction
Gastrinomas are neuroendocrine tumors (NETs), usually located in the duodenum or pancreas, that secrete gastrin and cause a clinical syndrome known as Zollinger–Ellison syndrome (ZES). A large number of gastrinomas develop in the pancreas or duodenum, with near-equal frequency, and approximately 10% arise as primary neoplasms in lymph nodes of the pancreaticoduodenal region.
Gastric outlet obstruction (GOO) is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that has accumulated in the stomach, but which cannot pass into the small intestine due to the obstruction. The stomach often dilates to accommodate food intake and secretions. Causes of gastric outlet obstruction include both benign causes, as well as malignant causes, such as gastric cancer.
This is a timeline of the events relating to the discovery that peptic ulcer disease and some cancers are caused by H. pylori. In 2005, Barry Marshall and Robin Warren were awarded the Nobel Prize in Physiology or Medicine for their discovery that peptic ulcer disease (PUD) was primarily caused by Helicobacter pylori, a bacterium with affinity for acidic environments, such as the stomach. As a result, PUD that is associated with H. pylori is currently treated with antibiotics used to eradicate the infection. For decades prior to their discovery, it was widely believed that PUD was caused by excess acid in the stomach. During this time, acid control was the primary method of treatment for PUD, to only partial success. Among other effects, it is now known that acid suppression alters the stomach milieu to make it less amenable to H. pylori infection.
Denervation is any loss of nerve supply regardless of the cause. If the nerves lost to denervation are part of the neuronal communication to a specific function in the body then altered or a loss of physiological functioning can occur. Denervation can be caused by injury or be a symptom of a disorder like ALS, post-polio syndrome, or POTS. Additionally, it can be a useful surgical technique to alleviate major negative symptoms, such as in renal denervation. Denervation can have many harmful side effects such as increased risk of infection and tissue dysfunction.
Lester Reynold Dragstedt was an American surgeon who was the first to successfully separate conjoined twins. He was considered nationally known, and a leading authority on ulcers and gastroneuro surgery.
The nervous system, and endocrine system collaborate in the digestive system to control gastric secretions, and motility associated with the movement of food throughout the gastrointestinal tract, including peristalsis, and segmentation contractions.
SADI-S is a bariatric surgical technique to address metabolic disorders and to lose weight. It is a variation on the Duodenal Switch surgery, incorporating a vertical sleeve gastrectomy with a gastric bypass technique.
Pyloroplasty is a surgery performed to widen the opening at the lower part of the stomach, also known as the pylorus. When the pylorus thickens, it becomes difficult for food to pass through. The surgery is performed to widen the band of muscle known as the pyloric sphincter, a ring of smooth, muscular fibers that surrounds the pylorus and helps to regulate digestion and prevent reflux. The widening of the pyloric sphincter enables the contents of the stomach to pass into the first part of the small intestine known as the duodenum.
Sir Andrew Watt Kay FRSE, FRCPSG, FRCSEd was a Scottish academic surgeon who was Regius Professor of Surgery at the University of Glasgow from 1964 to 1981. He developed the augmented histamine test, which bore his name, and was widely used in the investigation and treatment of peptic ulcer disease. He was knighted for services to surgery. From 1972 to 1974 he served as president of the Royal College of Physicians and Surgeons of Glasgow.
Antrectomy, also called distal gastrectomy, is a type of gastric resection surgery that involves the removal of the stomach antrum to treat gastric diseases causing the damage, bleeding, or blockage of the stomach. This is performed using either the Billroth I (BI) or Billroth II (BII) reconstruction method. Quite often, antrectomy is used alongside vagotomy to maximise its safety and effectiveness. Modern antrectomies typically have a high success rate and low mortality rate, but the exact numbers depend on the specific conditions being treated.
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