Operative techniques

The evolution of operations for ulcer disease has progressed as surgical techniques and understanding of gastric physiology advanced. Gastrojejunostomy and subtotal

Gastroenterostomy Peptic Ulcer
Fig. 1. Gastroenterostomy. An anastomosis is made on the dependent portion of the greater curvature of the antrum The direction of peristalsis of the stomach matches the small bowel (isoperistaltic anastomosis) to enhance gastric emptying. The vagus nerves are intact.

gastrectomy were initially used in the treatment of gastric cancer, but their value in treating ulcer disease was quickly appreciated. Gastrojejunostomy (Fig. 1) was thought to decrease overall gastric acidity and decrease acid exposure by accelerating gastric emptying. As the procedure was technically simple and was effective in the short term, it became the treatment of choice for ulcer disease in the early part of the 20th century. As the high incidence of recurrent ulceration with gastroenterostomy became appreciated, subtotal gastrectomy gradually became the operation of choice (Fig. 2).

The association of gastric hyperacidity with ulcer disease has been recognized since the 19th century. As the role of the vagus nerve in gastric secretion became better understood, truncal vagotomy was introduced into gastric surgery. Vagotomy alone was found to have an ulcer recurrence rate similar to subtotal gastrectomy, but the mortality rate was much higher after subtotal gastrectomy, so vagotomy was accepted as a safer alternative. In many patients, truncal vagotomy disrupted pyloric function resulting in gastric outlet obstruction, and the need for a drainage procedure. Thus, pyloroplasty was routinely added to vagotomy. Vagotomy and pyloroplasty became the operation of choice in the 1940s (Fig. 3).

Subtotal Gastrectomy Surgery
Fig. 2. Subtotal gastrectomy with Billroth II anastomosis. The anastomosis is isoperistaltic and no vagotomy done. The afferent limb is kept short to prevent kinking.
Billroth Anastomosis
Fig. 3. Truncal vagotomy and pyloroplasty. (A) A 5-cm gastroduodenotomy is made across the pylorus. (B) The incision is closed transversely (Heineke-Michulicz pyloroplasty) and truncal vagotomy accomplished.
Truncal Vagotomy And Gastrojejunostomy

Fig. 4. Truncal vagotomy and antrectomy with Billroth I anastomosis. (A) A distal 40-50% of the stomach is removed, taking more of the lesser curvature where the antrum extends more proximal. (B) A gastroduodenotomy is done on the greater curvature side of the gastric remnant and truncal vagotomy accomplished.

Fig. 4. Truncal vagotomy and antrectomy with Billroth I anastomosis. (A) A distal 40-50% of the stomach is removed, taking more of the lesser curvature where the antrum extends more proximal. (B) A gastroduodenotomy is done on the greater curvature side of the gastric remnant and truncal vagotomy accomplished.

With the identification of gastrin and its role in acid secretion, the concept of antrectomy and vagotomy emerged. By removing both the gastrin and vagal stimulation of the partial cells, acid output could be greatly decreased. Vagotomy and antrectomy resulted in recurrent ulcer rates less than 1%. With improved operative techniques the mortality rate of a gastric resection was decreasing, and by 1970, vagotomy and antrectomy was considered the best operation for ulcer disease (Fig. 4). An important randomized study compared vagotomy and pyloroplasty, subtotal gastrectomy, and vagotomy and antrectomy found that recurrent ulcer was least with vagotomy and antrectomy but postgastrectomy side effects were greatest (1). This study helped to define how to best treat ulcer disease. With the young patients having the greatest threat of recurrence, vagotomy and antrectomy was used. With the elderly, and those with comorbidities, having the greatest threat of postgastrectomy syndrome, vagotomy and pyloroplasty was used.

Although vagotomy and antrectomy solved the problem of recurrent ulceration, postgastrectomy syndromes resulted in significant morbidity in 25% of the patients. Vagotomy decreased gastric contractions and also obliterated the reflex of the stomach to dilate with smell or eating food. Ablation of the pylorus resulted in uncontrolled emptying of the stomach, and loss of a barrier to bile entering the stomach. The postgastrectomy syndromes of dumping, alkaline reflux gastritis, and gastric stasis resulted, and proved to be a high price to pay for cure of ulcer disease.

The next evolution of ulcer surgery came when a way to decrease gastric acid secretion and yet preserve the pylorus was found. This advance was the development of proximal gastric vagotomy (Fig. 5) (2). This operation allowed denervation of the acid

Proximal Gastric Vagotomy

Fig. 5. Proximal gastric vagotomy. The branches of the anterior and posterior vagus nerves to the portion of the stomach with parietal cells are divided. This preserves normal antropyloric function and obviates the need for a gastric drainage procedure. (A) Normal stomach. (B) After proximal gastric vagotomy. Shaded area = vagal denervation.

Fig. 5. Proximal gastric vagotomy. The branches of the anterior and posterior vagus nerves to the portion of the stomach with parietal cells are divided. This preserves normal antropyloric function and obviates the need for a gastric drainage procedure. (A) Normal stomach. (B) After proximal gastric vagotomy. Shaded area = vagal denervation.

producing parietal cells, but the grinding function of the antrum and the emptying ability of the pylorus are preserved. Proximal gastric vagotomy (also called highly selective vagotomy or parietal cell vagotomy) was technically more demanding, and high recurrent ulcer rates were seen until the procedure was standardized. Once all the nuances of the procedure were appreciated, recurrent ulcer rates were 10% or less and postgastrectomy side effects were much less than those seen with vagotomy and pyloroplasty (3). Proximal gastric vagotomy was not as effective for gastric ulcers and was not used by most surgeons for this indication.

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  • pupa
    What is isoperistaltic anastomosis in gastrojejunostomy?
    2 years ago

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