Vagotomy for Severe Peptic Ulcer Disease
For patients with severe peptic ulcer disease requiring emergency surgery for intractable bleeding after failed endoscopic and angiographic interventions, vagotomy with drainage is the preferred surgical approach over simple ulcer oversewing alone, as it is associated with significantly lower mortality. 1
Emergency Indications for Vagotomy
The primary modern indication for vagotomy is third-line treatment for bleeding peptic ulcers that have failed both repeated endoscopy and angioembolization. 2
- Vagotomy/drainage demonstrates superior mortality outcomes compared to local ulcer oversewing alone in patients requiring emergency operation for intractable bleeding ulcers, based on large database analysis (ACS-NSQIP). 1
- This approach is particularly indicated for large posterior duodenal ulcers with gastroduodenal artery bleeding, which represent the most complex surgical scenarios with higher 90-day mortality and re-operation rates. 1
- Open surgery remains the recommended approach for refractory bleeding peptic ulcer in emergency settings. 2
Critical Timing Considerations
Surgical delay significantly increases mortality, with each hour of delay associated with 2.4% decreased probability of survival. 2
- Immediate surgery is indicated for unstable patients with bleeding peptic ulcer refractory to endoscopy/angioembolization. 1
- For patients with severe physiological derangement and hemorrhagic shock, damage control surgery should be considered to quickly resolve bleeding and allow prompt ICU admission. 1
Technical Approach
Truncal vagotomy with pyloroplasty is the specific procedure recommended for emergency bleeding cases. 2
- Via duodenotomy, the bleeding vessel on the ulcer floor can be visualized and oversewn with triple-loop suturing of the gastroduodenal artery due to collateral blood supply to transverse pancreatic arteries. 1
- Intraoperative endoscopy should be used to facilitate localization of the bleeding site when the surgeon cannot determine the bleeding origin pre-operatively. 1
- For gastric ulcers, resection or at minimum biopsy is mandatory to exclude malignancy (10-16% are malignant). 3
Elective Indications (Highly Limited)
The elective role of vagotomy has become extremely narrow with modern medical management. 4
- Proximal gastric vagotomy may be considered for young, fit duodenal ulcer patients who fail H. pylori eradication and are either resistant or allergic to proton pump inhibitors. 4, 5
- Vagotomy with Roux-en-Y gastrojejunostomy can be used for severe PUD refractory to medical management in select cases. 4
- Laparoscopic truncal vagotomy with pyloroplasty is safe and efficacious in certain emergent cases for patients who cannot tolerate long-term PPI therapy. 4
Essential Post-Operative Management
All patients require H. pylori testing with eradication therapy if positive to prevent recurrence, as H. pylori-associated bleeding ulcers have a 26% rebleeding rate without eradication. 1, 2
- H. pylori has 20-50% prevalence among bleeding peptic ulcer patients in various countries. 1
- Urea breath test (88-95% sensitivity, 95-100% specificity) or stool antigen testing (94% sensitivity, 92% specificity) are acceptable non-invasive tests. 1
- Continued proton pump inhibitor therapy is essential post-operatively. 2
Common Pitfalls to Avoid
- Do not perform definitive acid-reducing procedures in the emergency setting for perforated ulcers, as they are no longer necessary with modern PPIs and increase operative time/morbidity. 3
- Do not delay surgery for prolonged attempts at coagulation parameter normalization in bleeding cases; administer FFP while preparing for urgent laparotomy. 6
- Avoid simple oversewing alone in emergency bleeding cases when the patient is stable enough to tolerate vagotomy/drainage, as mortality is significantly higher. 1
- For perforated peptic ulcers, simple closure with omental patch is appropriate rather than vagotomy, unless there is a specific indication for acid reduction. 3