What are the different types of vagotomy?

Types of Vagotomy

The main types of vagotomy are truncal vagotomy, selective vagotomy, and highly selective vagotomy, each with distinct anatomical targets and clinical outcomes for treating peptic ulcer disease.

Types of Vagotomy and Their Characteristics

1. Truncal Vagotomy

• Involves complete division of both anterior and posterior vagal trunks at the level of the esophagus
• Denervates the entire stomach, leading to impaired gastric emptying
• Usually combined with a drainage procedure (pyloroplasty) to prevent gastric outlet obstruction
• Associated with higher rates of post-surgical complications including dumping syndrome and diarrhea 1
• Relatively quick to perform (average 44 minutes) compared to other vagotomy techniques 2
• Still relevant in emergency settings, particularly for patients resistant or allergic to proton pump inhibitors 1

2. Selective Vagotomy

• Preserves the hepatic and celiac branches of the vagus nerve
• Divides only the gastric branches of the vagus
• Still requires a drainage procedure
• Has fewer side effects than truncal vagotomy but more technical complexity
• Less commonly performed in modern practice due to technical challenges 1

3. Highly Selective Vagotomy (HSV)

• Also known as parietal cell vagotomy or proximal gastric vagotomy
• Most targeted approach - selectively divides only the nerve fibers to the acid-producing portion of the stomach
• Preserves innervation to the antrum and pylorus, maintaining gastric emptying function
• Does not require a drainage procedure
• Associated with fewer side effects but technically more demanding (average 72 minutes to perform) 2
• Has shown excellent or very good results in 86-87% of patients 3, 2
• Lower mortality rate (0% compared to 0.7% with truncal vagotomy and pyloroplasty) 3
• Significantly lower rates of diarrhea (7% vs 39% with truncal vagotomy) 2

Clinical Outcomes and Comparative Effectiveness

Long-term studies comparing these techniques have shown:

• HSV provides better weight maintenance compared to truncal vagotomy with antrectomy (94% sustained weight gain vs. more than half experiencing weight loss) 4
• HSV results in fewer post-operative sequelae like diarrhea, flatulence, and epigastric fullness 2
• Recurrence rates are comparable between HSV (1.5% at 5 years) and truncal vagotomy with pyloroplasty (5.6%) 3, 2
• Both procedures achieve similar reductions in gastric acid output: 80% reduction in basal acid output and 50-60% reduction in maximal acid output 3

Current Relevance in Modern Practice

The role of vagotomy has significantly narrowed with the advent of:

• Proton pump inhibitors
• Understanding of Helicobacter pylori's role in peptic ulcer disease
• Improved medical management options

Currently, vagotomy is primarily reserved for:

1. Emergency management of complicated ulcers in patients who cannot tolerate medical therapy
2. Treatment of severe peptic ulcer disease refractory to medical management
3. Specific complications like obstruction, where HSV with duodenectomy has shown favorable outcomes 4, 1

Common Pitfalls and Considerations

• Transient dysphagia occurs more frequently after HSV (19 patients) compared to truncal vagotomy with pyloroplasty (8 patients) 2
• Technical expertise significantly impacts outcomes, especially for HSV
• Patient selection is crucial - consider comorbidities and likelihood of compliance with medical therapy
• Long-term follow-up is essential to monitor for recurrence and manage potential complications