Vagotomy

A plain vagotomy eliminates afferent and parasympathetic innervation of the stomach and the left side of the transverse colon. Other techniques focus on branches leading from the retroperitoneum to the stomach.{{cite journal |vauthors=Jordan PH, Thornby J |title=Twenty years after parietal cell vagotomy or selective vagotomy antrectomy for treatment of duodenal ulcer. Final report |journal=Ann. Surg. |volume=220 |issue=3 |pages=283–93; discussion 293–6 |date=September 1994 |pmid=8092897 |doi= 10.1097/00000658-199409000-00005|pmc=1234380}}

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 can be used in the 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.{{cite book |last1=Seeras |first1=Kevin |last2=Qasawa |first2=Ryan N. |last3=Prakash |first3=Shivana |title=StatPearls |date=2025 |publisher=StatPearls Publishing |chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK526104/ |chapter=Truncal Vagotomy |pmid=30252360 }}

The basic types of vagotomy are:

• Truncal vagotomy (TV) includes division of the main trunk of the vagus (including its celiac/hepatic branch) and denervation of the pylorus; therefore, a pyloric drainage procedure, such as pyloric dilatation or disruption (pyloromyotomy or pyloroplasty) or gastrojejunostomy, is needed. This procedure also denervates the liver, biliary tree, pancreas, and small and large bowel.
• Highly selective vagotomy includes denervation of only the fundus and body (parietal cell-containing areas) of the stomach (also called parietal cell vagotomy). It preserves the nerve supply of the antrum and pylorus; a pyloric drainage procedure is not needed. It does not denervate the liver, biliary tree, pancreas, or small and large bowel. This procedure is also called proximal gastric vagotomy.{{cite book |doi=10.1016/B978-1-4377-2206-2.00056-7 |chapter=Operations for Peptic Ulcer |title=Shackelford's Surgery of the Alimentary Tract |date=2013 |last1=Tavakkolizadeh |first1=Ali |last2=Ashley |first2=Stanley W. |pages=701–719 |isbn=978-1-4377-2206-2 }}

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.{{EMedicine|article|1950689|Surgical Treatment of Perforated Peptic Ulcer}}

Truncal vagotomy is a treatment option for chronic duodenal ulcers.{{cite journal

| title = Surgical management of peptic ulcer disease

| author = Kuremu RT

| journal = East African Medical Journal

| date = September 2002

| volume = 79

| pages = 454–6

| issue = 9

| doi = 10.4314/eamj.v79i9.9115

| pmid = 12625684| doi-access = free

}}{{cite journal

| title = Long-term results of duodenectomy with highly selective vagotomy in the treatment of complicated duodenal ulcers

|vauthors=Chang TM, Chan DC, Liu YC, Tsou SS, Chen TH | journal = American Journal of Surgery

| date = April 2001

| volume = 181

| pages = 372–6

| issue = 4

| doi = 10.1016/S0002-9610(01)00580-3

| pmid = 11438277}} 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.{{Cite journal |vauthors=Siu WT, Tang CN, Law BK, Chau CH, Yau KK, Yang GP, Li MK |date=October 2004 |title=Vagotomy and gastrojejunostomy for benign gastric outlet obstruction |journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A |volume=14 |issue=5 |pages=266–9 |doi=10.1089/lap.2004.14.266 |pmid=15630940}}{{cite journal

| title = Laparoscopic truncal vagotomy and gastroenterostomy for pyloric stenosis

|vauthors=Wyman A, Stuart RC, Ng EK, Chung SC, Li AK | journal = American Journal of Surgery

| date = June 1996

| volume = 171

| pages = 600–3

| issue = 6

| doi = 10.1016/S0002-9610(95)00030-5

| pmid = 8678208}}

Following observations that obese patients with PUD lost substantial weight after truncal vagotomy, vagotomy was started in 1978 as a dedicated therapy for obesity.{{Cite journal |last=Kral |first=JohnG. |date=February 1978 |title=Vagotomy for Treatment of Severe Obesity |url=https://linkinghub.elsevier.com/retrieve/pii/S0140673678900740 |journal=The Lancet |language=en |volume=311 |issue=8059 |pages=307–308 |doi=10.1016/S0140-6736(78)90074-0|url-access=subscription }} In 2007, the use of vagotomy to treat obesity was being studied.{{cite news |last1=Neergaard |first1=Lauran |title=Could Nerve-Snipping Spur Weight Loss? |url=https://www.oklahoman.com/story/news/2007/07/02/could-nerve-snipping-spur-weight-loss/61761908007/ |work=The Oklahoman |date=2 July 2007 }} 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.{{cite journal|last=Lustig|first=Robert H. |author2=Pamela S. Hinds |author3=Karen Ringwald-Smith |author4=Robbin K. Christensen |author5=Sue C. Kaste |author6=Randi E. Schreiber |author7=Shesh N. Rai |author8=Shelly Y. Lensing |author9=Shengjie Wu |author10=Xiaoping Xiong|title=Octreotide therapy of pediatric hypothalamic obesity: a double-blind, placebo-controlled trial|journal=Journal of Clinical Endocrinology & Metabolism|date=June 2003|volume=88|issue=6|pages=2586–92|doi=10.1210/jc.2002-030003|pmid=12788859|doi-access=free}} The circuit begins with an area of the hypothalamus, the arcuate nucleus, which has outputs to the lateral hypothalamus (LH) and ventromedial hypothalamus (VMH), the brain's feeding and satiety centers, respectively.{{cite journal | author=Flier JS | title=Obesity wars: Molecular progress confronts an expanding epidemic | journal=Cell | year=2004 | pages=337–50 | volume=116 | issue=2 | pmid=14744442 | doi = 10.1016/S0092-8674(03)01081-X| doi-access=free }}{{cite book |author1=Boulpaep, Emile L. |author2=Boron, Walter F. |title=Medical physiologya: A cellular and molecular approach |publisher=Saunders |location=Philadelphia |year=2003 |page=1227 |isbn=0-7216-3256-4}}

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 expenditure and fat 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. Disabling the VMH renders it unresponsive to peripheral energy balance signals; this, in turn, suppresses sympathetic activity (which leads to malaise and decreased energy expenditure) and stimulates vagal activity (which augments insulin production and adipogenesis (fat cell expansion)).{{cite journal|last=Lustig|first=Robert H|title=Hypothalamic obesity after craniopharyngioma: mechanisms, diagnosis, and treatment|journal=Front Endocrinol (Lausanne)|date=November 2011|volume=2|issue=60|pages=60|doi=10.3389/fendo.2011.00060|pmid=22654817|pmc=3356006|doi-access=free}} Research shows that VMH dysfunction affects both energy intake and energy expenditure and is associated with constant weight gain, which results from a chronic positive energy balance caused by excessive energy intake and reduced metabolic rate. In the past, adrenergic or serotonergic agonists were investigated for the treatment of obesity by suppressing appetite and stimulating thermogenesis, but neither calorie restriction nor treatment with these thermogenic agents has been very successful in achieving and maintaining weight reduction. The vagus nerve is thought to be one key mediator of these effects, as lesions lead to chronic elevations in insulin secretion, inhibiting fat oxidation and promoting energy storage in adipocytes.

Vagotomy may have an impact upon ghrelin.{{cite journal |vauthors=Williams DL, Grill HJ, Cummings DE, Kaplan JM |title=Vagotomy dissociates short- and long-term controls of circulating ghrelin |journal=Endocrinology |volume=144 |issue=12 |pages=5184–7 |date=December 2003 |pmid=14525914 |doi=10.1210/en.2003-1059 |doi-access=free }} 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).{{cite journal|last=Boss|first=Thad J|author2=Jeffrey Peters |author3=Marco G Patti |author4=Robert H Lustig |author5= John G Kral |title=Laparoscopic Truncal Vagotomy for Weight-loss: A Prospective, Dual-center Safety and Efficacy Study |journal=Surgical Endoscopy|date=April 2008|volume=22|issue=1 Supplement|pages=191–293|doi=10.1007/s00464-008-9822-2 }}

Vagotomy was once popular as a way of treating and preventing PUD{{Cite journal |vauthors=Lygidakis NJ |date=March 1984 |title=Posterior truncal vagotomy and anterior curve superficial seromyotomy as an alternative for the surgical management of chronic ulcer of the duodenum |journal=Surg Gynecol Obstet |volume=158 |issue=3 |pages=251–4 |pmid=6422569}} and subsequent ulcer perforations.{{cite journal

| doi = 10.1097/00000658-198209000-00013

| title = Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial

|vauthors=Boey J, Lee NW, Koo J, Lam PH, Wong J, Ong GB | journal = Annals of Surgery

| date = September 1982

| volume = 196

| pages = 338–44

| issue = 3

| pmid = 7114938

| pmc = 1352612}}{{cite journal

| title = Proximal gastric vagotomy. The preferred operation for perforations in acute duodenal ulcer

|vauthors=Boey J, Branicki FJ, Alagaratnam TT, Fok PJ, Choi S, Poon A, Wong J | journal =Annals of Surgery

| date = August 1988

| volume = 208

| pages = 169–74

| issue = 2|doi=10.1097/00000658-198808000-00006 | pmid = 3401061

|pmc=1493603 }} 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.{{cite web |url=http://www.pernicious-anaemia-society.org/ |title=Home |website=pernicious-anaemia-society.org}} Large cohort studies from Asia demonstrated that vagotomy for PUD is associated with a decreased incidence in type 2 diabetes,{{Cite journal |last=Wu |first=Shih-Chi |last2=Chen |first2=William Tzu-Liang |last3=Fang |first3=Chu-Wen |last4=Muo |first4=Chih-Hsin |last5=Sung |first5=Fung-Chang |last6=Hsu |first6=Chung Y. |date=December 2016 |title=Association of vagus nerve severance and decreased risk of subsequent type 2 diabetes in peptic ulcer patients: An Asian population cohort study |url=https://journals.lww.com/00005792-201612060-00030 |journal=Medicine |language=en |volume=95 |issue=49 |pages=e5489 |doi=10.1097/MD.0000000000005489 |issn=0025-7974 |pmc=5266005 |pmid=27930533}} ischemic stroke,{{Cite journal |last=Fang |first=Chu‐Wen |last2=Tseng |first2=Chun‐Hung |last3=Wu |first3=Shih‐Chi |last4=Chen |first4=William Tzu‐Liang |last5=Muo |first5=Chih‐Hsin |date=December 2017 |title=Association of Vagotomy and Decreased Risk of Subsequent Ischemic Stroke in Complicated Peptic Ulcer Patients: an Asian Population Study |url=https://onlinelibrary.wiley.com/doi/10.1007/s00268-017-4127-z |journal=World Journal of Surgery |language=en |volume=41 |issue=12 |pages=3171–3179 |doi=10.1007/s00268-017-4127-z |issn=0364-2313|url-access=subscription }} liver cirrhosis and cancer,{{Cite journal |last=Wu |first=Shih-Chi |last2=Cheng |first2=Han-Tsung |last3=Wang |first3=Yu-Chun |last4=Tzeng |first4=Chia-Wei |last5=Hsu |first5=Chia-Hao |last6=Muo |first6=Chih-Hsin |date=2021-08-02 |title=Decreased risk of liver and intrahepatic cancer in non-H. pylori-infected perforated peptic ulcer patients with truncal vagotomy: a nationwide study |url=https://www.nature.com/articles/s41598-021-95142-z |journal=Scientific Reports |language=en |volume=11 |issue=1 |doi=10.1038/s41598-021-95142-z |issn=2045-2322 |pmc=8329055 |pmid=34341400}} and ischemic heart disease.{{Cite journal |last=Wu |first=Shih-Chi |last2=Fang |first2=Chu-Wen |last3=Chen |first3=William Tzu-Liang |last4=Muo |first4=Chih-Hsin |date=December 2016 |title=Acid-reducing vagotomy is associated with reduced risk of subsequent ischemic heart disease in complicated peptic ulcer: An Asian population study |url=https://journals.lww.com/00005792-201612160-00045 |journal=Medicine |language=en |volume=95 |issue=50 |pages=e5651 |doi=10.1097/MD.0000000000005651 |issn=0025-7974 |pmc=5268059 |pmid=27977613}}

{{Reflist}}

• {{MeshName|Vagotomy}}
• {{Chorus|00934}}
• [http://www.surgeryencyclopedia.com/St-Wr/Vagotomy.html Overview and illustrations at surgeryencyclopedia.com]
• [http://www.endoscopy-sages.com/manual/chapter19.html Four types, at endoscopy-sages.com] {{Webarchive|url=https://web.archive.org/web/20161109151722/http://www.endoscopy-sages.com/manual/chapter19.html |date=2016-11-09 }}
• [http://www.healthatoz.com/healthatoz/Atoz/ency/vagotomy.jsp Overview at healthatoz.com] {{Webarchive|url=https://web.archive.org/web/20060314235803/http://www.healthatoz.com/healthatoz/Atoz/ency/vagotomy.jsp |date=2006-03-14 }}
• [http://www.news8austin.com/content/headlines/?ArID=203956&SecID=2 News article — interview] {{Webarchive|url=https://web.archive.org/web/20100729024316/http://www.news8austin.com/content/headlines/?ArID=203956&SecID=2 |date=2010-07-29 }}

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Category:Neurosurgery