VAGOTOMY
Types of vagotomy
(A) Highly selective vagotomy,
(B) Selective vagotomy with pyloroplasty,
(C) Truncal vagotomy with gastrojejunostomy.
SEQUELAE OF PEPTIC ULCER
SURGERY
DUODENAL BLOWOUT
• It is a very serious
complication of Billroth II
gastrectomy, occurs
usually on 4-5th day after
surgery
• It is due to improper
closure of duodenal
stump, oedematous infl
amed duodenum,
afferent loop block, distal
obstruction, ischaemia of
least vascular duodenum
and sepsis.
RECURRENT ULCERTION
• The easiest problem to treat - heal with potent
antisecretory agents
• Present with complications, particularly bleeding and
perforation
• Gastrojejuno-colic fistula - the anastomotic ulcer
penetrates into the transverse colon.
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Diarrhoea that is severe and follows every meal
Foul breath, vomit formed faeces
Severe weight loss and dehydration
CT with oral contrast or barium enema
Treatment –First correct dehydration and malnutrition and
then perform revision surgery.
SMALL STOMACH SYNDROME
• Early satiety follows most ulcer operations to
some degree, including highly selective
vagotomy (loss of receptive relaxation).
• Fortunately, this problem does tend to get
better with time and revision surgery is not
necessary.
BILE VOMITING
After any form of vagotomy with drainage or
gastrectomy
Vomiting a mixture of food and bile or
sometimes some bile alone after a meal,
eating will precipitate abdominal pain and
reflux symptoms are common.
Bile chelating agents can be tried but are
usually ineffective. In intractable cases,
revision surgery may be indicated.
EARLY DUMPING
Consists of abdominal and vasomotor symptoms that are found in
about 10 per cent of patients following gastrectomy or vagotomy
and drainage.
The small bowel is filled with foodstuffs from the stomach, which have
a high osmotic load, and this leads to the sequestration of fluid
from the circulation into the gastrointestinal tract.
The principal treatment is dietary manipulation. Small, dry meals are
best, and avoiding fluids with a high carbohydrate content also
helps.
The syndrome tends to improve with time. Revision surgery may be
occasionally required. In patients with a gastroenterostomy, the
drainage may be taken down or, in the case of a pyloroplasty,
repaired. Alternatively, antrectomy with Roux-en-Y reconstruction
is often effective, although the procedure is of greater magnitude;
following gastrectomy, it is the revisional procedure of choice.
LATE DUMPING
This is reactive hypoglycaemia.
The carbohydrate load in the small bowel causes
a rise in the plasma glucose, which, in turn,
causes insulin levels to rise, causing a
secondary hypoglycaemia.
The treatment is essentially the same as for
early dumping. Octreotide is very effective in
dealing with this problem.
Early Dumping
Late Dumping
Incidence
5–10%
5%
Relation to meals
Almost immediate
Second hour after
meal
Durations of attack
30–40 minutes
30–40 minutes
Relief
Lying down
Food
Aggravated by
More food
Exercise
Precipitating factor
Food, especially
carbohydrate-rich
and wet
As early dumping
Major symptoms
Epigastric fullness,
sweating,
lightheadedness,
tachycardia, colic,
sometimes
diarrhoea
Tremor, faintness,
prostration
POST VAGOTOMY DIARRHOEA
Most devastating symptom to afflict patients having
peptic ulcer surgery.
Precise aetiology – uncertain
– Rapid gastric emptying
– Denervation of the upper gastrointestinal tract as a result
of thevagotomy
– Exaggerated gastrointestinal peptide responses
The patient should be managed as for early dumping
– Antidiarrhoeal preparations
– Octreotide is not effective in this condition
– The results of revision surgery are too unpredictable to
make this an attractive treatment option
MALIGNANT TRANSFORMATION
Gastrectomy or vagotomy and drainage are independent
risk factors for the development of gastric cancer.
The increased risk appears to be approximately four
times that of the control population
Bile reflux gastritis, intestinal metaplasia and gastric
cancer are linked
The lag phase between operation and the development
of malignancy is at least ten years.
Highly selective vagotomy does not seem to be
associated with an increased incidence of gastric
cancer in the long term.
NTRITIONAL CONSEQUENCES
• More common after gastrectomy than after
vagotomy and drainage.
• Weight loss is common after gastrectomy
• Anaemia may be due to either iron or vitamin
B12 deficiency
GALL STONES
The development of gallstones is strongly
associated with truncal vagotomy
Following truncal vagotomy, the biliary tree, as well
as the stomach, is denervated, leading to stasis
and hence stone formation
Patients developing symptomatic gallstones will
require cholecystectomy. However, this may
induce or worsen other postpeptic ulcer surgery
syndromes such as bilious vomiting and
postvagotomy diarrhoea.
PERFORATED PEPTIC ULCER
• The patient, who may have a history of peptic ulceration,
develops sudden onset severe generalised abdominal pain
due to the irritant effect of gastric acid on the peritoneum.
• Although the contents of an acid-producing stomach are
relatively low in bacterial load, bacterial peritonitis
supervenes over a few hours, usually accompanied by a
deterioration in the patient’s condition.
• Shock with tachycardia
• The abdomen exhibits a boardlike rigidity. The abdomen
does not move with respiration.
• Patients with this form of presentation need an operation,
without which the patient will deteriorate with a septic
peritonitis.
STAGES OF PERFORATION
I. Stage of chemical peritonitis
II. Stage of reaction (Stage of illusion)
III. Stage of bacterial peritonitis
INVESTGATIONS
TREATMENT
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Resuscitation
Analgesia
Laparotomy and closure of the perforation
Antibiotics
PYLORIC STENOSIS
Chronic duodenal ulcer after many years
undergoes scarring and cicatrisation causing
total obstruction of the pylorus, leading to
enormous dilatation of stomach.
CLINICAL FEATURES
• Epigastric pain with feeling of fullness.
• Vomiting—large quantity, foul smelling and
frothy, vomitus contains food consumed on
previous day (partially digested or undigested
food).
• Loss of periodicity.
• Loss of appetite and weight.
• Visible gastric peristalsis (VGP)—may be
elicited by asking the patient to drink a cup of
water.
• Positive succussion splash which is done with
4 hours empty stomach
• Auscultopercussion test shows dilated
stomach
• Mass is never palpable.
INVESTIGATIONS
1. Barium meal study:
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Absence of duodenal cap.
Dilated stomach where greater curvature is below
the level of iliac crest.
Mottled stomach.
Barium will not pass into duodenum
2. Gastroscopy to rule out carcinoma stomach and
to visualise the stenosed area
3. Electrolyte disturbance - hypochloraemic,
hyponatraemic, hypokalaemic, hypocalcaemic,
hypomagnesaemic alkalosis
DIFFERENTIAL DIAGNOSIS
Congenital
Chronic DU - fibrosed/cicatrised
Carcinoma pylorus
Adult pyloric stenosis—it is treated by
pyloroplasty (not by pyloromyotomy)
Pyloric mucosal diaphragm
TREATMENT
• Correction of dehydration and electrolyte disturbances
• TPN support
• Stomach wash to clean the stomach contents (using
normal saline)
• Surgery
i. HSV with gastrojejunostomy
ii. Truncal vagotomy along with gastrojejunostomy of Mayo
iii. Vagotomy, antrectomy (acid secreting area) with Billorth
I anastomosis along with feeding jejunostomy
VAGOTOMY WITH GJ
BLEEDING PEPTIC ULCER
FORREST CLASSIFICATION
Ia Spurting and bleeding
Ib Nonspurting but active bleeding
IIa Visible vessel with red or blue protrusion or
pulsatile pseudoaneurysm
IIb Nonbleeding ulcer with clot overlying
IIc Ulcer with haematin base
III Clean ulcer—no clot, no vessel