vagotomy? when and why to do it?

[europeman]

Can someone please explain to me when you are supposed to do a vagotomy with regard to ulcer disease and why.... i'm more interested in the theoretical reasons (i.e. board answer) than what you do in real life - although real life is nice to know too.

I understand if someone failed medical therapy blah blah blah... but what if someone has never had medical therapy and comes in with a ulcer emergency (perf or bleed?)

say it's a duodenal ulcer and you have to do the classic heineke mikulicz pyloroplasty.... why do you have to do a vagotomy if they have never been on an ant-acid?

are you scared they are going to dump with the vagus nerve there and no pyloris constriction?

why don't you do a vagotomy then for a typical gastro-jej?

thanks

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[Kahreek]

are we including branch selective vagotomy?

 

[europeman]

Let's stick with truncal for now I guess.

 

[SLUser11]

are you scared they are going to dump with the vagus nerve there and no pyloris constriction?


thanks

In your hypothetical scenario, you did a pyloroplasty.


Anyway, if the patient is naive to PPIs, then the correct board answer and real-life answer is to leave the vagus alone, address the acute problem, then place them on a PPI. Also need to check for h. pylori.

Thanks to PPIs, surgery for peptic ulcer disease is becoming uncommon. Usually, if a patient has an acute abdomen from ulcer perforation, or if they're bleeding so much it's refractory to endoscopic interventions, they are extremely sick, and a damage-control approach is appropriate....stop the bleeding or patch the hole, and get out.

In a board scenario, they may give you a patient with disease refractory to PPIs. Make sure you biopsy the ulcer to r/o cancer, and check a serum gastrin level to r/o gastrinoma. Once this is done, it is appropriate to do vagotomy and pyloroplasty....or antrectomy if there is a burnt-out stricture. I can't think of a scenario where a highly-selective vagotomy is the appropriate board answer to a question.

 

[europeman]

Thanks for your reply but I don't think I'm being clear.

If you must deal with a first portion of duodenal bleed ... Then what are the options? Why do you have to do a pyloroplasty at all? And if you do why do you have to so a vagotomy too? Let's assume they never tried ppi.

Why can't you just open duodenum, deal with bleed and close transverse and avoid pylorus all together?

Say you do pyloroplasty why do you have to do vagotomy?

And if you do antrectomy then why do you have to do vagotomy?

Whenever I say vagotomy I mean truncal

 

[Dr.LeoSpaceman]

Thanks for your reply but I don't think I'm being clear.

If you must deal with a first portion of duodenal bleed ... Then what are the options? Why do you have to do a pyloroplasty at all? And if you do why do you have to so a vagotomy too? Let's assume they never tried ppi.

Why can't you just open duodenum, deal with bleed and close transverse and avoid pylorus all together?

SLU answered this. If they're naive to PPIs, you just do the 3-stitch ligation and close, then put them on PPIs. No vagotomy. As to why do a pyloroplasty, it's because it's necessarily part of your duodenotomy for exposure. To avoid incising the pylorus and still be able to identify and stop the bleeding seems fairly tough. I've also heard that the pyloroplasty helps prevent stricture from your closure, though I don't think I've ever seen a study on that.