Vagotomy

What is a vagotomy?

A vagotomy is a deliberate interruption of the signals carried by your vagus nerve. This is the nerve that, among other things, connects your digestive system with your brain. Different branches of your vagus nerve communicate with different organs. They tell your stomach to secrete acid when food is present, and they tell your other organs to do their jobs in the digestive process.

What is the purpose of a vagotomy?

In practice, a vagotomy usually means cutting one of the branches of your vagus nerve that communicates with your stomach. It’s done to reduce stomach acid secretion. This extreme intervention is reserved for especially severe cases of peptic ulcer disease. Researchers are exploring other possible medical uses for vagotomy, but no others are currently in practice.

What happens when you cut the vagus nerve?

A vagotomy can have different effects depending on where you cut the nerve.

Truncal vagotomy

A truncal vagotomy cuts the nerve at the gastroesophageal junction, the place where your esophagus meets your stomach. From this junction, your vagus nerve travels through the organs of your digestive system, including your liver, gallbladder, pancreas, stomach and intestines. This is considered the “trunk” of the nerve tree that communicates with your digestive organs.

Cutting the nerve here reduces gastric acid secretion, but also reduces functions of your other organs that respond to the nerve. It can reduce bile and enzyme secretions from your liver, gallbladder and pancreas. It can also reduce peristalsis, the muscle movements that carry food through your digestive system. These side effects can cause digestive difficulties, though there are treatments to relieve them.

Highly selective vagotomy

Instead of cutting the trunk of the tree, a highly selective vagotomy cuts only the branch of the vagus nerve that triggers stomach acid. This branch connects to the parietal cells in your stomach that release gastric acid. For this reason, the operation is also called a parietal cell vagotomy. Cutting this branch alone is equally effective as a truncal vagotomy in reducing stomach acid.

A highly selective vagotomy is more specific to the problem of stomach acid, and it doesn’t cause the same side effects as a truncal vagotomy. However, it’s more technically difficult, and not many surgeons are trained to do it. It may be more difficult in people with significant inflammation from ulcers or scarring in their tissues, or in people who’ve already had previous surgery for peptic ulcer disease.

When is vagotomy used?

Most stomach ulcers can be effectively treated with medications. But some difficult cases don’t respond to these treatments. These cases are called “refractory,” meaning they’re persistent or not healing. If long-lasting or refractory ulcers cause persistent pain or complications that require surgery to correct, your healthcare provider might recommend a vagotomy to help prevent them from recurring.

Some examples include:

• Bleeding ulcers. If healthcare providers can’t control the bleeding through other means, they may need to repair these ulcers in surgery.
• Perforated ulcers. If an ulcer eats a hole through your stomach wall, it will need emergency repair. Leaking through the hole could cause a serious infection in your abdomen.
• Gastric outlet obstructions. Scar tissue from chronic ulcers can cause a blockage in the outlet from your stomach into your small intestine. Your surgeon may have to cut out the scar tissue.

Because of the complicated nature of these cases, vagotomy usually isn’t a standalone treatment. It often goes along with another procedure to repair the complications of peptic ulcer disease. Some frequent combinations include:

Vagotomy with gastrectomy

Some people may need part of their stomach removed for severe or complicated peptic ulcer disease. Excessive scar tissue and ulcers that look suspicious for cancer are some reasons why. The most common type is an antrectomy, which is the removal of the lower third of your stomach. This area may be affected by a gastric outlet obstruction. It’s also where the hormone gastrin is secreted in your stomach. Gastrin tells your parietal cells to secrete gastric acid, so removing your antrum can help reduce stomach acid secretion.

So, why do a vagotomy during a gastrectomy? The gastrectomy itself isn’t usually enough to prevent ulcers from returning, even when your antrum is removed. In general, peptic ulcer disease that’s severe enough to require a gastrectomy warrants a vagotomy. Studies also show that a truncal vagotomy, in particular, may help with bleeding, both from ulcers and from surgery. Bleeding ulcers that are treated with surgery more often begin bleeding again when the vagus nerve isn’t cut.

Vagotomy with pyloroplasty

If you aren’t having a gastrectomy, but you’re having a truncal vagotomy to reduce stomach acid, you’ll need pyloroplasty with it. Pyloroplasty is an operation on your pylorus, otherwise known as your gastric outlet. It’s the muscular valve at the bottom of your stomach that lets food pass through to your small intestine. A truncal vagotomy will interrupt the signals that tell your pylorus to open and close. Pyloroplasty opens it up so that food can pass through.

What happens before a vagotomy?

Depending on your specific condition, you might need nonsurgical treatments to optimize your health before surgery. You might need IV fluids if you’ve been vomiting, or a blood transfusion if you have a bleeding ulcer. Your healthcare team will also give you antibiotics to prevent infection and medicine to prevent blood clots prior to surgery. They’ll give you general anesthesia to put you to sleep for the procedure.

What happens during a vagotomy?

Approach

Your surgeon may perform a vagotomy using either open or laparoscopic surgery. Which type you have depends on the experience and judgment of your surgeon, the specifics of your condition and what other procedures you may be having with your vagotomy. Laparoscopic surgery is a less-invasive method that uses small tools and a small camera inserted through small incisions. Open surgery requires a longer incision to open up your abdominal cavity, but it provides easier access in the case of an emergency.

Vagotomy

Your surgeon will locate the gastroesophageal junction, where your stomach and esophagus meet, and cut through the tissue that covers your organs (peritoneum). Here, your vagus nerve has two “trunks” that travel into your digestive system. For a truncal vagotomy, your surgeon will remove a segment of each trunk. For a highly selective (parietal cell) vagotomy, your surgeon will preserve the trunks and sever only the specific nerve branches that connect to the acid-secreting parietal cells in your stomach.

Follow-up

A truncal vagotomy that severs the nerve supply to your pylorus requires a pyloroplasty to open your pylorus. The type you have will depend on the specifics of your condition. In complicated cases where your pylorus is significantly damaged or removed, pyloroplasty may mean bypassing and reconstructing your pylorus. This requires additional surgical steps. With highly selective vagotomy, your pylorus can remain intact. It will continue to function normally, and so will your other organs.

What happens after a vagotomy?

You may need to stay in the hospital for several days, depending on the extent of your operation. Your healthcare team will monitor your condition, and make sure you’re stable and able to move around comfortably on your own before you’re discharged.

What are the advantages of this procedure?

The main advantage for people who’ve had serious or ongoing difficulties with ulcers is that a vagotomy can stop ulcers from recurring. When other treatments haven’t been able to help or prevent complications, surgery can be a final solution.

What are the risks or complications of the procedure?

Complications that can occur during the surgery include:

• Injury to nearby organs, blood vessels or nerves.
• Infection.
• Bleeding.
• Blood clots.

What are the side effects of a vagotomy?

Side effects that can occur after a vagotomy include:

Diarrhea

A truncal vagotomy affects the nerve supply to your gallbladder, reducing gallbladder contractions. This causes excess bile to build up in your gallbladder. When your gallbladder becomes overfull, it dumps the excess bile into your small intestine. When your small intestine can’t absorb all of the bile salts, they pass to your large intestine, causing diarrhea. This is the most common complication following a truncal vagotomy. It’s usually temporary, but for a few, it can be longer-lasting. Your healthcare provider can prescribe medication for it.

Dumping syndrome

This complication results not from vagotomy itself, but from the pyloroplasty that accompanies a truncal vagotomy. The purpose of the pyloroplasty is to prevent your stomach from holding on to your food too long. But sometimes, it causes the opposite problem of rapid gastric emptying, called dumping syndrome. This can cause symptoms of nausea, abdominal discomfort and diarrhea after eating. In some cases, it causes a sudden plunge in your blood sugar several hours after eating, which can make you feel faint. Dumping syndrome is usually temporary and managed with dietary changes.

Gallstones

Gallstones are another possible side effect of a truncal vagotomy that involves your gallbladder. When bile builds up in your gallbladder and bile ducts, it can accumulate into gallstones. Gallstones can cause problems if they block one of your bile ducts. Your healthcare provider can prescribe medication to help prevent them.

What is the recovery time from a vagotomy?

That depends on what other operations you had with it, and whether you had open or laparoscopic surgery. In general, recovery from laparoscopic surgery is faster because the incisions are smaller. It will likely take several weeks to return to your normal diet. While your digestive system is healing from surgery, you’ll begin with a liquid diet and progress slowly to more solid foods.

A note from Cleveland Clinic

A vagotomy is a last resort treatment for peptic ulcer disease. Most people with stomach ulcers won’t need surgery. But for those with chronic or refractory ulcers that won’t respond to medication, vagotomy offers an important alternative. Complicated ulcers represent a serious health risk, not to mention their impact on quality of life. Although a vagotomy can have lasting consequences for your digestive system, relief from ulcers is worth the price for some.