Overview
Definition:
Highly selective vagotomy (HSV), also known as proximal gastric vagotomy (PGV) or parietal cell vagotomy, is a surgical procedure involving the transection of the vagus nerve fibers innervating the gastric parietal cells, thereby reducing basal and food-stimulated gastric acid secretion while preserving other vagal functions.
Indications:
Primary indications include recurrent duodenal ulcers refractory to medical management, marginal ulcers after gastric surgery, and as an adjunct to gastric surgery in certain cases of peptic ulcer disease (PUD) where maximal acid reduction is desired with minimal physiological consequences.
Clinical Significance:
HSV represents a refinement in surgical management of PUD, aiming to achieve effective acid suppression without the significant side effects of more extensive vagotomies (like total or truncal vagotomy), such as impaired gastric emptying and malabsorption
It allows for a more targeted approach to acid control, preserving pyloric function and intestinal motility.
Indications
Refractory Duodenal Ulcers:
Recurrent or non-healing duodenal ulcers despite optimal medical therapy with proton pump inhibitors (PPIs) or H2 receptor antagonists.
Marginal Ulcers:
Recurrent marginal ulcers (stomal ulcers) following Billroth I or Billroth II reconstructions for PUD.
Zolligerellison Syndrome:
In select cases of Zollinger-Ellison syndrome, particularly when gastrinomas are resectable, HSV can be combined with gastrinoma resection to maximally reduce acid output.
Avoidance Of Complications:
Used when avoiding the complications of more extensive vagotomies, such as dumping syndrome, diarrhea, and weight loss, is paramount.
Surgical Management
Preoperative Preparation:
Patients require thorough preoperative assessment including history, physical examination, and relevant investigations (endoscopy, acid secretion studies if indicated)
Optimization of nutritional status and management of any active infection are crucial
Antibiotic prophylaxis is usually administered.
Procedure Steps:
The procedure is typically performed laparoscopically or via laparotomy
The surgeon identifies the anterior and posterior vagal trunks at the lower esophagus and dissects them distally to the gastric cardia
Only the nerve fibers supplying the parietal cell mass (fundus and body of the stomach) are divided, preserving fibers to the antrum and pylorus
Care is taken to avoid damaging the blood supply to the stomach
The gastric mucosa is often inspected for any concomitant pathology.
Technique Details:
Key steps involve meticulous dissection to identify nerve fibers, preservation of the nerve of Latarget (an anterior vagal branch that influences pyloric function), and careful hemostasis
The goal is to achieve approximately 80-90% reduction in acid secretion.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, and pain control is essential
Nasogastric tube decompression may be used initially
Early mobilization is encouraged to prevent thromboembolic complications.
Dietary Management:
A gradual reintroduction of oral intake is initiated, starting with clear liquids and progressing to soft, then regular meals as tolerated
Patients are advised to eat smaller, more frequent meals and to avoid trigger foods that might stimulate acid production or cause discomfort.
Pharmacological Support:
Proton pump inhibitors (PPIs) are often prescribed postoperatively, though typically at a lower dose and duration than in purely medical management, to ensure adequate acid suppression and promote ulcer healing
Patients are usually advised to continue PPIs long-term, although the duration varies.
Complications
Early Complications:
Bleeding from the vagotomy sites or surrounding tissues
Gastric stasis (delayed gastric emptying) due to damage to antral or pyloric innervation
Injury to adjacent organs (esophagus, duodenum)
Wound infection
Pneumonia
Deep vein thrombosis (DVT) and pulmonary embolism (PE).
Late Complications:
Recurrent ulceration (failure of surgery or missed fibers)
Diarrhea (less common than with truncal vagotomy)
Nutritional deficiencies (less common)
Weight loss
Bile reflux gastritis
Post-vagotomy neuropathy.
Prevention Strategies:
Meticulous surgical technique to preserve nerve fibers to the antrum and pylorus
Careful dissection to avoid collateral damage
Appropriate preoperative optimization and postoperative care, including judicious use of PPIs and dietary modifications
Careful patient selection is also crucial.
Prognosis
Expected Outcomes:
HSV generally offers good long-term results with a low recurrence rate when performed correctly
Significant reduction in acid secretion is achieved, leading to ulcer healing and prevention.
Factors Affecting Prognosis:
The success of HSV is highly dependent on the surgeon's skill and experience, the precise identification and division of only the parietal cell-innervating fibers, and the patient's adherence to postoperative management and medical therapy
Presence of H
pylori infection must be eradicated.
Follow Up:
Regular clinical follow-up is recommended, including endoscopic surveillance for recurrence or complications
Patients are typically advised to remain on a PPI long-term, though the exact regimen is individualized.
Key Points
Exam Focus:
Understand the selective nature of HSV, preserving antral/pyloric innervation
Differentiate from truncal and selective vagotomy
Recall indications for HSV (refractory PUD, marginal ulcers)
Recognize common complications like gastric stasis and recurrent ulcers.
Clinical Pearls:
Laparoscopic HSV has become the preferred approach, offering faster recovery and reduced morbidity
The nerve of Latarget preservation is critical for avoiding gastric emptying issues
Postoperative PPI use is standard, even with surgery.
Common Mistakes:
Dividing too many nerve fibers leading to significant gastric stasis
Failing to identify and divide all necessary fibers, leading to recurrent ulcers
Not eradicating H
pylori infection pre- or post-operatively
Omitting or inadequately managing postoperative PPI therapy.