Principles of Gastric Surgery

Peptic Ulcer Surgery and Vagotomy

The procedure of choice for the surgical treatment of gastroduodenal ulcer is subtotal gastrectomy ( Fig. 41.1 ). Two thirds to three quarters of the distal portion of the stomach is removed, to reduce the acid-secreting mucosa to such a degree that the gastric juice becomes anacidic (achlorhydric), or at least hypoacidic. Complete removal of the entire antrum is necessary. Several procedures have been developed, but only a few have stood the test of time.

The Viennese surgeon Billroth was the first to perform partial gastrectomy, which included the pylorus and connected the distal end of the remaining stomach with the open end of the duodenum (Billroth I). In some cases, however, because of technical difficulties, a sufficiently wide duodenal cuff is not available, or fibrosis in the area or anatomic restrictions may make the procedure difficult. Therefore, Billroth developed another type of gastrectomy (Billroth II), in which the duodenal stump is closed, and the stump of the stomach is connected to a loop of jejunum. Such a gastrojejunostomy can be constructed in front of the transverse colon or in retrocolic fashion. In the antecolic procedure, surgeons are careful to ensure that the afferent loop is free from the colon, and a side-to-side anastomosis of the afferent and efferent loops is created.

Vagotomies were performed before the development of PPIs and the excellent drugs that reduce acid secretion. Although now rarely used, vagotomy may be performed during a procedure for bleeding or may be necessary during radical surgery for cancer.

Surgery for peptic ulcer disease is rarely performed. Occasionally, however, it is performed after intractable bleeding or when a patient has difficulty using medications. For these patients, truncal vagotomy with drainage, highly selective vagotomy, or truncal vagotomy and antrectomy may be selected, depending on the surgical experience and the patient. Truncal vagotomy requires identification and destruction of the anterior and posterior vagi at the level of the distal esophagus. Highly selective vagotomy attempts to preserve other functions of the vagus but eliminates vagal innervation to the acid-producing stomach by dissecting the vagal distribution along the stomach. This procedure is difficult, and risk of ulcer recurrence depends on the surgical experience. When vagotomy is performed, complementary surgery—either gastrojejunostomy, to increase drainage through the pylorus, or antrectomy—is also usually performed to ensure the stomach can empty.