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Selective Gastric Vagotomy: Physiologic Basis and Technique
Selective Gastric Vagotomy: Physiologic Basis and Technique From the Department of Surgery, University of Washington School of Medicine, Seattle
CHARLES A. GRIFFITH, M.D. Clinical Assistant Professor of Surgery
HENRY N. HARKINS, M.D. Professor of Surgery and Chairman, Department of Surgery
COMPLICATIONS of conventional truncal or total abdominal vagotomy occur in both the early postoperative and late long-term phases. Early postoperative morbidity and mortality are largely factors of surgeon error (Table 1). Late long-term morbidity is largely a factor of sequelae inherent to the operation itself (Table 2). Selective gastric vagotomy takes advantage of the fact that the anatomic distribution of the vagal trunks to the abdominal viscera permits complete and total vagal denervation of the stomach with preservation of vagal innervation to all other abdominal viscera. Details of the anatomy and technique of selective gastric vagotomy have been previously reported.H In this report we shall emphasize those details that we have found important in decreasing morbidity and mortality as outlined in Tables 1 and 2.
TECHNIQUE
1. Incisions and Exposure
A prime requisite for the safe and proper performance of complete gastric vagotomy is adequate access to the area of the esophageal hiatus. All of the complications listed in Table 1 are often the direct or indirect result of poor surgical exposure. If we satisfy the requirements of adequate surgical assistance, anesthetic relaxation and light, conventional transverse or vertical upper abdominal incisions usually provide adequate exposure. These incisions,
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HARKINS
Early Postoperative Morbidity and Mortality from Surgeon Error
1. Pneumothorax: Pleural injury 2. Sepsis: Esophageal perforation 3. Hemorrhage: Esophageal vessels, vasa brevia, and spleen 4. Hiatus hernia (early and late): Failure to repair disrupted phrenoesophageal fascia 5. Dysphagia: Excessive vagal denervation or surgical trauma of distal esophagus 6. Persistent or early recurrent ulcer: One or both vagal trunks left intact
however, may not provide good exposure of the esophageal hiatus in obese or muscular, deep-chested patients. Removing the xyphoid often proves an excellent supplement to a vertical incision. 21 The incision described by Ross20 affords even better exposure, and is therefore of inestimable value in patients of difficult body habitus, particularly when surgical assistance is less than optimum. We have not found sternal splitting or thoracoabdominal incisions necessary. To protect the spleen and vasa brevia, and also to keep the gastric fundus clear of the surgical field, we usually displace the spleen and fundus carefully to the left with a moist pack. We displace the left lobe of the liver forwaru without cutting the left triangular ligament. Weinberg's deep broad-bladed retractor* is particularly designed for this purpose and obviates the use of two or even three narrower conventional retractors. We clear the omentum from a portion of the greater curve in order to gain secure manual purchase on the stomach for its downward retraction. This traction stretches out the lesser omentum and vagal fibers within it. Placing the vagal fibers under tension in this manner permits their identification by direct inspection and palpation. 2. Anterior Selective Vagotomy
Foolproof identification of the anterior vagal trunk in any of its variable positions at the hiatus is guaranteed by demonstrating its hepatic and anterior gastric divisions in their constant positions adjacent to the liver and lesser curve. Visual and palpable identification of the hepatic and gastric divisions may be supplemented by palpating them from behind with a finger inserted into the lesser peritoneal space through an avascular area in the lesser omentum. This maneuver also verifies the presence of an aberrant left hepatic artery, which in approximately 10 to 15 per cent of the population arises from the left gastric artery and runs to the left lobe of the liver alongside the hepatic vagal division. Inadvertent injury of this aberrant left hepatic artery has been reported to result in fatal left lobar necrosis. 9 The anterior gastric division is exposed in its constant position just
* George P. Pilling &
Son Co., Philadelphia.
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Fig. 1. Anterior selective vagotomy. The anterior gastric division and all gastric branches arising from the anterior vagal trunk are transected. In order to dissect the anterior trunk and its hepatic division completely clear of the esophagus and lesser curve, some of the branches of the ascending esophageal artery from the left gastric artery require ligation and transection.
beneath the peritoneum adjacent the cardia and proximal lesser curve. Traction on the gastric division at this point tenses the anterior vagal trunk so that it can be seen and felt to the hiatus. The peritoneum can now be accurately incised from the cardia to the hiatus alongside the trunk. This incision provides a field of dissection for absolute demonstration of the anterior vagal trunk and all hepatic and gastric branches arising below the hiatus. Anterior selective vagotomy is performed as illustrated in Figure 1. 3. Posterior Selective Vagotomy
Because of its variable and more inaccessible positions at the esophageal hiatus, the posterior vagal trunk is missed much more frequently than the anterior trunk. The posterior trunk usually lies adjacent the esophagus, and continues as the celiac division alongside the dorsal aspect of the left gastric artery in the gastropancreatic peritoneal fold
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Fig. 2. Posterior selective vagotomy. The posterior gastric division and all gastric branches arising from the posterior vagal trunk are transected. This technique entails ligating and transecting additional ascending esophageal vessels. The left gastric artery is also ligated and transected just distal to its hairpin turn in order to interrupt any vagal branches from the celiac division that uncommonly accompany this artery to the stomach. This devascularization does not threaten viability of either the whole stomach or gastric remnant if hemigastrectomy is performed.
to the celiac plexus. However, the posterior trunk may lie closely applied to the right crus quite apart from the esophagus, and may continue to the celiac plexus closely applied to the right crus and aorta. Foolproof identification of the posterior vagal trunk in any of its variable positions at the hiatus therefore depends upon demonstrating its constant continuation as the celiac division to the celiac plexus. With downward traction on the stomach, the tensed posterior trunk or its large celiac division is first sought by palpation with a finger directed alongside the right posterior aspect of the distal esophagus or cardia. If not located here (but it usually is), the posterior trunk is felt as a taut cord with the finger directed toward and against the right crus. After the posterior vagal trunk is verified by visualizing or palpating its continuation to the celiac plexus, the posterior trunk is dissected to the
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Fig. 3. Mediastinal dissection. Only the anterior vagal trunk is illustrated. The same dissection is conducted posteriorly. A, A vagal fiber is felt to sink into the esophageal muscle. This fiber supplies the esophagus and is therefore left intact. B, Another vagal fiber is felt arising from the trunk. This fiber can be bluntly dissected off the esophagus and traced to the stomach (C). It is therefore resected.
hiatus. Posterior selective vagotomy is performed as illustrated in Figure 2. 4. Mediastinal Dissection
With both vagal trunks and their hepatic and celiac divisions completely freed from the stomach and esophagus to the hiatus, the only intact vagal fibers to the stomach that can possibly remain are small individual terminal branches that uncommonly arise from the vagal trunks or esophageal plexus above the hiatus, and supply only the most proximal portion of the stomach. If present, these gastric branches always lie to the patient's left of the trunks and in the same fascial plane as the trunks. This fascial plane is readily entered by insinuating a finger in" between each trunk and the esophagus upward into the mediastinum. By means of this careful anatomic technique, perforation of the esophagus or pleura is avoided. The finger often palpates large branches of the esophageal plexus forming the two vagal trunks. In addition, small twigs may be felt that arise from the plexus or trunks and sink into the esophageal muscle. These twigs innervate the esophagus and do not continue distally to innervate
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the stomach. They are therefore not avulsed, but are left intact to prevent dysphagia. However, gastric branches can be gently lifted off the esophageal muscle with the fascia propria. These branches are traced to the cardia to verify that they are gastric branches of suprahiatal origin and are then excised (Figure 3). 5. Preventing Vagal Reinnervation
Murrayl8. 19 has demonstrated in animals that vagal reinnervation may take place by a process of so-called sprouting. Sprouts arise from the sides of intact vagal fibers and reach the stomach via the sheaths of degenerating gastric vagal fibers distal to the level of vagotomy. Because vagal reinnervation cannot take place unless the distal nerve sheaths are accessible to receive the proximal sprouts, we bury the distal nerves by sutures that invert the raw dissected edge of the lesser curve. Sprouts cannot penetrate the gastric seromuscular coat. 6. Preventing Hiatus Hernia
Surgical dissection necessary to accomplish complete gastric vagotomy disrupts both the phrenoesophageal fascia and the extraperitoneal connective tissue that enmeshes the left gastric and ascending esophageal vessels and supports the abdominal esophagus and cardia. Therefore, we restore anatomic fixations by suturing the cardia and most proximal lesser curve to the right crus, repairing the phrenoesophageal fascia, and tightening the hiatus (if lax) with sutures posterior to the esophagus. 7. Preventing Gastric Stasis Franksson8 performed selective gastric vagotomy as described herein without a drainage procedure and produced severe gastric atony and stasis with negative secretory response of free acid to insulin hypoglycemia. Our experimentaP2.24 and clinical observations confirm this result of complete and total vagal denervation of the stomach by the selective technique. Provision for gastric drainage is therefore just as important with selective gastric vagotomy as with conventional truncal vagotomy. Hemigastrectomy, pyloroplasty and gastrojejunostomy all have their advantages and disadvantages. Hemigastrectomy performed properly with a high resection of the lesser curve (1) eliminates the antral phase of gastric secretion and therefore adds to the protection against recurrent ulcer, (2) prevents vagal reinnervation by removing the distal vagal sheaths, (3) removes any residual gastric parasympathetic innervation that may reach the stomach via sympathetic and splanchnic pathways, which, however, carry extravagal parasympathetic fibers to only the antrum and not to the acid-pepsin secreting corpus and fundus,I5. 17 and (4) removes enough stomach to prevent stasis in a dilated atonic gastric sac, which is particularly apt to develop in stomachs of fish-hook configuration despite properly performed pyloroplasty or gastrojejunostomy.
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Hemigastrectomy provides more assurance of good drainage and eliminates the need for prolonged gastric decompression by nasogastric or stab gastrostomy tubes, which introduce their own complications and morbidity. We have never had to use any drugs such as Urecholine to stimulate gastric contraction and promote gastric emptying after vagotomy with hemigastrectomy. Hemigastrectomy does not remove enough stomach to impair gastric reservoir function, and it does not significantly increase the incidence and severity of dumping compared to pyloroplasty. Hemigastrectomy plus selective gastric vagotomy has not eliminated dumping, but in our experience has minimized its incidence and severity compared to Billroth I and II subtotal gastric resections. These advantages of hemigastrectomy over pyloroplasty are balanced by the over-all higher mortality rates of hemigastrectomy. Pyloroplasty is obviously less extensive and time-consuming. Weare becoming more impressed with the merits of pyloroplasty for in situ ligation of the vessel causing massive hemorrhage from the duodenal ulcer 7 • 23. 26 and excision of the chronic duodenal ulcer with acute perforation. 3 (Simple closure or continuous gastric suction is preferable for the acute duodenal ulcer that perforates without previous history.) PHYSIOLOGIC RESULTS
As indicated in Table 2, vagal denervation of the biliary tract, pancreas and bowel (in addition to the stomach) by conventional total abdominal vagotomy may well cause some of the undesirable sequelae of the postvagotomy state. This consideration is by no means a new concept, but was initially and independently proposed as an advantage of selective gastric vagotomy by Jackson16 and Franksson,8 and more recently by Burge. 5 We have also reported our preliminary clinical observations and impressions that selective gastric vagotomy, by confining vagal denervation to the stomach and preserving vagal innervation to other viscera, eliminates some postvagotomy sequelae. n . 13 Like dumping, the various side effects of vagotomy of viscera other Table 2.
Late Long-Term Morbidity of Total Abdominal Vagotomy from the Inherent Nature of the Procedure
1. G(UJtric hypomotility and st(UJis: Need for gastrojejunostomy, or
pyloroplasty, or hemigastrectomy Dumping: Secondary to drainage procedures or hemigastrectomy Biliary tract hypomotility and st(UJis: Gallstones Pancreatic juice decre(UJe: Steatorrhea Intestinal hypomotility and stasis: Vague, nondescript discomfort, bloating, diarrhea 6. Recurrent ulcer: Incomplete vagotomy, vagal reinnervation, gastric stasis (when drainage procedures fail to relieve gastric stasis) 2. 3. 4. 5.
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than the stomach are not manifest in all patients. Furthermore, when these side effects occur, they vary greatly in character and severity. We believe the following factors may pertain. INCOMPLETE VAGOTOMY. Either incomplete hepatic or incomplete celiac vagotomy (or both) undoubtedly occurs associated with either complete or incomplete gastric vagotomy. Furthermore, just as incomplete gastric vagotomy varies according to anatomic type 10 , 11 and physiologic degree/, 22, 25 so must occur variable types and degrees of incomplete hepatic and celiac vagotomy. But we have no way of knowing when hepatic or celiac vagotomy is complete or incomplete. This variable and unknown occurrence of complete and incomplete hepatic and celiac vagotomy may have much to do with the variable occurrence and severity of postvagotomy sequelae. INADVERTENT AND UNKNOWN HEPATIC AND CELIAC VAGOTOMY BY GASTRIC RESECTION. The hepatic and celiac divisions lie in vulnerable locations. We are certain that, prior to learning their anatomic positions (Figs. 1 and 2), we have unknowingly sectioned one or both of these branches during many gastric resections. We wonder whether this unknown occurrence of hepatic and celiac vagotomy may account for the fact that some of the inexplicable sequelae of gastric resection are the same as the sequelae of vagotomy. In particular, we wonder whether hepatic and celiac vagotomy is a common factor for the occurrence of steatorrhea, diarrhea and the long-term development of gallstones after either or both gastric resection alone and vagotomy alone. EXTRAVAGAL PARASYMPATHETICS. Another possible explanation of the variable occurrence and severity of postvagotomy symptoms is that extravagal parasympathetics may minimize the effects of massive denervation in some patients and not in others. The evidence for this consideration is strictly unknown. VAGAL REINNERVATION. Undesirable sequelae in many patients gradually disappear within a few months, which, as shown by Murray, 18 is the usual length of time for reinnervation by sprouting to become effective. Furthermore, and in accordance with Murray's observations, the fact that the hepatic and celiac vagal divisions traverse autonomic plexuses makes hepatic and celiac reinnervation more possible than gastric reinnervation. Gastric vagal fibers reach the stomach directly. However, in some patients the sequelae of hepatic and celiac vagotomy are apparently as permanent as the sequelae of gastric vagotomy. UNKNOWN PATHWAYS TO PANCREAS AND BILIARY TRACT. Although the celiac vagal branch supplies the entire midgut, we do not know whether the pancreas and biliary tract receive their vagal supply from either one or both the hepatic and celiac branches. We therefore have no real baseline for interpreting the relative clinical importance of these branches. However. Burge et al. 6 believe that both are important in
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preventing the pale bulky stool after vagotomy, but that the hepatic branch is apparently more important than the celiac branch. VAGO-VAGAL REFLEXES. The fact that fibers in the vagal trunks are 90 per cent efferentl indicates probably unknown reflexes that influence secretion and motility of the stomach, bowel, biliary tract and pancreas. A few of these reflexes have been explored with significant findings.4. 14. 27. 28 The over-all effects of eliminating some or all of these reflexes are unknown as they may relate to postvagotomy sequelae. In view of all these considerations, many of which are admittedly speculation, we believe that massive vagal denervation of all viscera by total abdominal vagotomy proves to be of little to no consequence in some patients, but in other patients causes undesirable side effects of variable character and severity. SUMMARY AND CONCLUSIONS
1. Conventional techniques of vagotomy may be refined by increasing the field of dissection from the hiatus to include the area of the abdominal esophagus, cardia and proximal lesser curve. This surgical field permits identification of the gastric, hepatic and celiac truncal divisions. which in turn leads to more accurate identification of the anterior and posterior vagal trunks at the hiatus. The trunks may then be dissected upward into the mediastinum to locate vagal branches that occasionally arise from the trunks above the hiatus. 2. Because of its anatomic accuracy, this method of surgical dissection provides more assurance of accomplishing a complete gastric vagotomy, and also provides better protection of the esophagus, pleura, spleen and vessels from recognized and unrecognized injury. 3. This dissection also permits preservation of the hepatic and celiac vagal divisions, which innervate the biliary tract, pancreas and bowel. Preservation of vagal innervation to these viscera eliminates long-term morbidity of conventional vagotomy due to massive vagal denervation of all abdominal viscera. 4. Selective gastric vagotomy accomplishes complete and total vagal denervation of the stomach, and therefore does not alter the occurrence of either gastric stasis or dumping (the latter secondary to either drainage procedures necessary for providing gastric drainage or to hemigastrectomy). REFERENCES 1. Agostoni, E., Chinnock, J. E., Daly, M. De B. and Murray, J. G.: Functional
and Histological Studies of Vagus Nerve and Its Branches to Heart, Lungs, and Abdominal Viscera in Cat. J. Physiol. 135: 182-205, 1957. 2. Bachrach, W. H.: Personal communication, 1962.
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3. Berne, C. J. and Mikkelsen, W. P.: Management of Perforated Peptic Ulcer. Surgery 44: 591-603, 1958. 4. Blair, E. L., Harper, A. A., Kidd, C. and Scratcherd, T.: Post-Activation Potentiation of Gastric and Intestinal Contractions in Response to Stimulation of Vagus Nerves, J. Physiol. 148: 437-449, 1959. 5. Burge, H. W.: Vagal Nerve Section in Chronic Duodenal Ulceration. Ann. Roy. ColI. Surgeons, England 26: 231-244, 1960. Idem: Personal communication, 1960. 6. Burge, H. W. et al.: Selective Vagotomy in Prevention of Post-Vagotomy Diarrhea. Lancet 2: 897-899, 1961. 7. Dorton, H. E.: Vagotomy, Pyloroplasty, and Suture-A Safe and Effective Remedy for Duodenal Ulcer That Bleeds. Ann. Surg. 153: 378-382, 1961. 8. Franksson, C.: Selective Abdominal Vagotomy. Acta chir. scandinav. 96: 409412, 1948. Idem: Personal communication, 1960. 9. Friesen, S. R.: Significance of Anomalous Origin of Left Hepatic Artery from Left Gastric Artery in Operations upon Stomach and Esophagus. Am. Surgeon 23: 1103-1108, 1957. 10. Griffith, C. A.: Gastric Vagotomy vs. Total Abdominal Vagotomy. Arch. Surg. 81: 781-788,1960. 11. Griffith, C. A.: Selective Gastric Vagotomy. Part I. Eliminating Occurrence of Incomplete Gastric Vagotomy by Refined Technics of Total Abdominal and Selective Gastric Vagotomy, West. J. Surg. 70: 107-119, 1962. Part II. Eliminating Undesirable Sequelae of Total Abdominal Vagotomy by Selective Gastric Vagotomy. West. J. Surg. 70: 175-180, 1962. 12. Griffith, C. A. and Harkins, H. N.: Partial Gastric Vagotomy: An Experimental Study. Gastroenterology 32: 96-102, 1957. 13. Griffith, C. A., Stavney, L. S., Kato, T. and Harkins, H. N.: Selective Gastric Vagotomy. To be published (Am. J. Surg. 105: (Jan.) 1963). 14. Harper, A. A., Kidd, C. and Scratcherd, T.: Vago-vagal Reflex Effects on Gastric and Pancreatic Secretion and Gastro-intestinal Motility. J. Physiol. 148: 417-436, 1959. 15. Imparato, A. M. and Hinton, J. W.: Gastric Secretion following Vago-Splanchnic and Splanchno-Vagal Anastomosis: Their Possible Clinical Implications. Ann. Surg. 141:853-861, 1955. 16. Jackson, R. G.: Anatomic Study of Vagus Nerves, with a Technique of Transabdominal Selective Gastric Vagus Resection. Univ. Hosp. Bull., Univ. Michigan, Ann Arbor 13: 31-35, 1947. Idem: Anatomic Study of Vagus Nerves, with a Technique of Transabdominal Selective Gastric Vagus Resection. Arch. Surg. 57: 333-352, 1948. Idem: Anatomic Study of Vagus Nerves, with a Technique of Transabdominal Selective Gastric Vagus Resection. Personal communications, 1959 and 1962. 17. Kure, K., Ichiko, K. and Ishikawa, K.: On the Spinal Parasympathetic. Physiological Significance of Spinal Parasympathetic System in Relation to Digestive Tract. Quart. J. Exper. Physiol. 21: 1-19, 1931. 18. Murray, J. G.: Consequences of Injury and Disease of Nervous Tissue: Recent Advances in Know ledge. J. Roy. ColI. Surgeons, Edinburgh 4: 199-217, 1959. 19. Murray, J. G.: Sprouting of Nerves: Some Consequences of Vagotomy and Sympathectomy (Editorial). Gastroenterology 42: 197-200, 1962. 20. Ross, D. E.: A New Upper Abdominal Incision. Am. J. Surg. 79: 841-842, 1950. Idem: Personal communication, 1962. 21. Saint, J. H. and Braslow, L. E.: Removal of Xyphoid Process as an Aid in Operations on Upper Abdomen. Surgery 33: 361-366, 1953. 22. Silva, T. F., Jr., Farmer, D. A. and Smithwick, R. H.: Completeness of Vagotomy as Judged by Postoperative Studies of Gastric Pepsin Concentration. Surgical Forum 12: 297-298, 1961. 23. Smith, G. K. and Farris, J. M.: Vagotomy and Pyloroplasty in Chronic Duodenal Ulcer with Special Reference to Technique. Arch. Surg. 78: 652-659, 1959. 24. Stavney, L. S., Kato, T., Griffith, C. A., Nyhus, L. M. and Harkins, H. N.: A Physiologic Demonstration of Selective Gastric Vagotomy. Submitted for publication.
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25. Stein, 1. F. and Meyer, K. A.: Studies on Vagotomy in Treatment of Peptic Ulcer. Surg. Gynec. & Obst. 93: 625-635,1951. 26. Weinberg, J. A.: Vagotomy and Pyloroplasty for Surgical Treatment of Duodenal Ulcer. In Harkins, H. N. and Nyhus, L. M. (eds.). Surgery of the Stomach and Duodenum. Boston, Little, Brown and Company, 1962, pp. 473-486. 27. White, T. T., Lundh, G. and Magee, D. F.: Evidence for Existence of a Gastropancreatic Reflex. Am. J. Physiol. 198: 725-728, 1960. 28. White, T. T., Hayama, T. and Magee, D. F.: Alternate Nervous Pathways for Gastropancreatic Reflex. Gastroenterology 39: 615-617, 1960.
Department of Surgery University of Washington School of Medicine Seattle 5, Washington
CHARLES A. GRIFFITH, M.D. Clinical Assistant Professor of Surgery
HENRY N. HARKINS, M.D. Professor of Surgery and Chairman, Department of Surgery
COMPLICATIONS of conventional truncal or total abdominal vagotomy occur in both the early postoperative and late long-term phases. Early postoperative morbidity and mortality are largely factors of surgeon error (Table 1). Late long-term morbidity is largely a factor of sequelae inherent to the operation itself (Table 2). Selective gastric vagotomy takes advantage of the fact that the anatomic distribution of the vagal trunks to the abdominal viscera permits complete and total vagal denervation of the stomach with preservation of vagal innervation to all other abdominal viscera. Details of the anatomy and technique of selective gastric vagotomy have been previously reported.H In this report we shall emphasize those details that we have found important in decreasing morbidity and mortality as outlined in Tables 1 and 2.
TECHNIQUE
1. Incisions and Exposure
A prime requisite for the safe and proper performance of complete gastric vagotomy is adequate access to the area of the esophageal hiatus. All of the complications listed in Table 1 are often the direct or indirect result of poor surgical exposure. If we satisfy the requirements of adequate surgical assistance, anesthetic relaxation and light, conventional transverse or vertical upper abdominal incisions usually provide adequate exposure. These incisions,
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Table 1.
A.
GRIFFITH, HENRY
N.
HARKINS
Early Postoperative Morbidity and Mortality from Surgeon Error
1. Pneumothorax: Pleural injury 2. Sepsis: Esophageal perforation 3. Hemorrhage: Esophageal vessels, vasa brevia, and spleen 4. Hiatus hernia (early and late): Failure to repair disrupted phrenoesophageal fascia 5. Dysphagia: Excessive vagal denervation or surgical trauma of distal esophagus 6. Persistent or early recurrent ulcer: One or both vagal trunks left intact
however, may not provide good exposure of the esophageal hiatus in obese or muscular, deep-chested patients. Removing the xyphoid often proves an excellent supplement to a vertical incision. 21 The incision described by Ross20 affords even better exposure, and is therefore of inestimable value in patients of difficult body habitus, particularly when surgical assistance is less than optimum. We have not found sternal splitting or thoracoabdominal incisions necessary. To protect the spleen and vasa brevia, and also to keep the gastric fundus clear of the surgical field, we usually displace the spleen and fundus carefully to the left with a moist pack. We displace the left lobe of the liver forwaru without cutting the left triangular ligament. Weinberg's deep broad-bladed retractor* is particularly designed for this purpose and obviates the use of two or even three narrower conventional retractors. We clear the omentum from a portion of the greater curve in order to gain secure manual purchase on the stomach for its downward retraction. This traction stretches out the lesser omentum and vagal fibers within it. Placing the vagal fibers under tension in this manner permits their identification by direct inspection and palpation. 2. Anterior Selective Vagotomy
Foolproof identification of the anterior vagal trunk in any of its variable positions at the hiatus is guaranteed by demonstrating its hepatic and anterior gastric divisions in their constant positions adjacent to the liver and lesser curve. Visual and palpable identification of the hepatic and gastric divisions may be supplemented by palpating them from behind with a finger inserted into the lesser peritoneal space through an avascular area in the lesser omentum. This maneuver also verifies the presence of an aberrant left hepatic artery, which in approximately 10 to 15 per cent of the population arises from the left gastric artery and runs to the left lobe of the liver alongside the hepatic vagal division. Inadvertent injury of this aberrant left hepatic artery has been reported to result in fatal left lobar necrosis. 9 The anterior gastric division is exposed in its constant position just
* George P. Pilling &
Son Co., Philadelphia.
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Fig. 1. Anterior selective vagotomy. The anterior gastric division and all gastric branches arising from the anterior vagal trunk are transected. In order to dissect the anterior trunk and its hepatic division completely clear of the esophagus and lesser curve, some of the branches of the ascending esophageal artery from the left gastric artery require ligation and transection.
beneath the peritoneum adjacent the cardia and proximal lesser curve. Traction on the gastric division at this point tenses the anterior vagal trunk so that it can be seen and felt to the hiatus. The peritoneum can now be accurately incised from the cardia to the hiatus alongside the trunk. This incision provides a field of dissection for absolute demonstration of the anterior vagal trunk and all hepatic and gastric branches arising below the hiatus. Anterior selective vagotomy is performed as illustrated in Figure 1. 3. Posterior Selective Vagotomy
Because of its variable and more inaccessible positions at the esophageal hiatus, the posterior vagal trunk is missed much more frequently than the anterior trunk. The posterior trunk usually lies adjacent the esophagus, and continues as the celiac division alongside the dorsal aspect of the left gastric artery in the gastropancreatic peritoneal fold
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Fig. 2. Posterior selective vagotomy. The posterior gastric division and all gastric branches arising from the posterior vagal trunk are transected. This technique entails ligating and transecting additional ascending esophageal vessels. The left gastric artery is also ligated and transected just distal to its hairpin turn in order to interrupt any vagal branches from the celiac division that uncommonly accompany this artery to the stomach. This devascularization does not threaten viability of either the whole stomach or gastric remnant if hemigastrectomy is performed.
to the celiac plexus. However, the posterior trunk may lie closely applied to the right crus quite apart from the esophagus, and may continue to the celiac plexus closely applied to the right crus and aorta. Foolproof identification of the posterior vagal trunk in any of its variable positions at the hiatus therefore depends upon demonstrating its constant continuation as the celiac division to the celiac plexus. With downward traction on the stomach, the tensed posterior trunk or its large celiac division is first sought by palpation with a finger directed alongside the right posterior aspect of the distal esophagus or cardia. If not located here (but it usually is), the posterior trunk is felt as a taut cord with the finger directed toward and against the right crus. After the posterior vagal trunk is verified by visualizing or palpating its continuation to the celiac plexus, the posterior trunk is dissected to the
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Fig. 3. Mediastinal dissection. Only the anterior vagal trunk is illustrated. The same dissection is conducted posteriorly. A, A vagal fiber is felt to sink into the esophageal muscle. This fiber supplies the esophagus and is therefore left intact. B, Another vagal fiber is felt arising from the trunk. This fiber can be bluntly dissected off the esophagus and traced to the stomach (C). It is therefore resected.
hiatus. Posterior selective vagotomy is performed as illustrated in Figure 2. 4. Mediastinal Dissection
With both vagal trunks and their hepatic and celiac divisions completely freed from the stomach and esophagus to the hiatus, the only intact vagal fibers to the stomach that can possibly remain are small individual terminal branches that uncommonly arise from the vagal trunks or esophageal plexus above the hiatus, and supply only the most proximal portion of the stomach. If present, these gastric branches always lie to the patient's left of the trunks and in the same fascial plane as the trunks. This fascial plane is readily entered by insinuating a finger in" between each trunk and the esophagus upward into the mediastinum. By means of this careful anatomic technique, perforation of the esophagus or pleura is avoided. The finger often palpates large branches of the esophageal plexus forming the two vagal trunks. In addition, small twigs may be felt that arise from the plexus or trunks and sink into the esophageal muscle. These twigs innervate the esophagus and do not continue distally to innervate
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the stomach. They are therefore not avulsed, but are left intact to prevent dysphagia. However, gastric branches can be gently lifted off the esophageal muscle with the fascia propria. These branches are traced to the cardia to verify that they are gastric branches of suprahiatal origin and are then excised (Figure 3). 5. Preventing Vagal Reinnervation
Murrayl8. 19 has demonstrated in animals that vagal reinnervation may take place by a process of so-called sprouting. Sprouts arise from the sides of intact vagal fibers and reach the stomach via the sheaths of degenerating gastric vagal fibers distal to the level of vagotomy. Because vagal reinnervation cannot take place unless the distal nerve sheaths are accessible to receive the proximal sprouts, we bury the distal nerves by sutures that invert the raw dissected edge of the lesser curve. Sprouts cannot penetrate the gastric seromuscular coat. 6. Preventing Hiatus Hernia
Surgical dissection necessary to accomplish complete gastric vagotomy disrupts both the phrenoesophageal fascia and the extraperitoneal connective tissue that enmeshes the left gastric and ascending esophageal vessels and supports the abdominal esophagus and cardia. Therefore, we restore anatomic fixations by suturing the cardia and most proximal lesser curve to the right crus, repairing the phrenoesophageal fascia, and tightening the hiatus (if lax) with sutures posterior to the esophagus. 7. Preventing Gastric Stasis Franksson8 performed selective gastric vagotomy as described herein without a drainage procedure and produced severe gastric atony and stasis with negative secretory response of free acid to insulin hypoglycemia. Our experimentaP2.24 and clinical observations confirm this result of complete and total vagal denervation of the stomach by the selective technique. Provision for gastric drainage is therefore just as important with selective gastric vagotomy as with conventional truncal vagotomy. Hemigastrectomy, pyloroplasty and gastrojejunostomy all have their advantages and disadvantages. Hemigastrectomy performed properly with a high resection of the lesser curve (1) eliminates the antral phase of gastric secretion and therefore adds to the protection against recurrent ulcer, (2) prevents vagal reinnervation by removing the distal vagal sheaths, (3) removes any residual gastric parasympathetic innervation that may reach the stomach via sympathetic and splanchnic pathways, which, however, carry extravagal parasympathetic fibers to only the antrum and not to the acid-pepsin secreting corpus and fundus,I5. 17 and (4) removes enough stomach to prevent stasis in a dilated atonic gastric sac, which is particularly apt to develop in stomachs of fish-hook configuration despite properly performed pyloroplasty or gastrojejunostomy.
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Hemigastrectomy provides more assurance of good drainage and eliminates the need for prolonged gastric decompression by nasogastric or stab gastrostomy tubes, which introduce their own complications and morbidity. We have never had to use any drugs such as Urecholine to stimulate gastric contraction and promote gastric emptying after vagotomy with hemigastrectomy. Hemigastrectomy does not remove enough stomach to impair gastric reservoir function, and it does not significantly increase the incidence and severity of dumping compared to pyloroplasty. Hemigastrectomy plus selective gastric vagotomy has not eliminated dumping, but in our experience has minimized its incidence and severity compared to Billroth I and II subtotal gastric resections. These advantages of hemigastrectomy over pyloroplasty are balanced by the over-all higher mortality rates of hemigastrectomy. Pyloroplasty is obviously less extensive and time-consuming. Weare becoming more impressed with the merits of pyloroplasty for in situ ligation of the vessel causing massive hemorrhage from the duodenal ulcer 7 • 23. 26 and excision of the chronic duodenal ulcer with acute perforation. 3 (Simple closure or continuous gastric suction is preferable for the acute duodenal ulcer that perforates without previous history.) PHYSIOLOGIC RESULTS
As indicated in Table 2, vagal denervation of the biliary tract, pancreas and bowel (in addition to the stomach) by conventional total abdominal vagotomy may well cause some of the undesirable sequelae of the postvagotomy state. This consideration is by no means a new concept, but was initially and independently proposed as an advantage of selective gastric vagotomy by Jackson16 and Franksson,8 and more recently by Burge. 5 We have also reported our preliminary clinical observations and impressions that selective gastric vagotomy, by confining vagal denervation to the stomach and preserving vagal innervation to other viscera, eliminates some postvagotomy sequelae. n . 13 Like dumping, the various side effects of vagotomy of viscera other Table 2.
Late Long-Term Morbidity of Total Abdominal Vagotomy from the Inherent Nature of the Procedure
1. G(UJtric hypomotility and st(UJis: Need for gastrojejunostomy, or
pyloroplasty, or hemigastrectomy Dumping: Secondary to drainage procedures or hemigastrectomy Biliary tract hypomotility and st(UJis: Gallstones Pancreatic juice decre(UJe: Steatorrhea Intestinal hypomotility and stasis: Vague, nondescript discomfort, bloating, diarrhea 6. Recurrent ulcer: Incomplete vagotomy, vagal reinnervation, gastric stasis (when drainage procedures fail to relieve gastric stasis) 2. 3. 4. 5.
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than the stomach are not manifest in all patients. Furthermore, when these side effects occur, they vary greatly in character and severity. We believe the following factors may pertain. INCOMPLETE VAGOTOMY. Either incomplete hepatic or incomplete celiac vagotomy (or both) undoubtedly occurs associated with either complete or incomplete gastric vagotomy. Furthermore, just as incomplete gastric vagotomy varies according to anatomic type 10 , 11 and physiologic degree/, 22, 25 so must occur variable types and degrees of incomplete hepatic and celiac vagotomy. But we have no way of knowing when hepatic or celiac vagotomy is complete or incomplete. This variable and unknown occurrence of complete and incomplete hepatic and celiac vagotomy may have much to do with the variable occurrence and severity of postvagotomy sequelae. INADVERTENT AND UNKNOWN HEPATIC AND CELIAC VAGOTOMY BY GASTRIC RESECTION. The hepatic and celiac divisions lie in vulnerable locations. We are certain that, prior to learning their anatomic positions (Figs. 1 and 2), we have unknowingly sectioned one or both of these branches during many gastric resections. We wonder whether this unknown occurrence of hepatic and celiac vagotomy may account for the fact that some of the inexplicable sequelae of gastric resection are the same as the sequelae of vagotomy. In particular, we wonder whether hepatic and celiac vagotomy is a common factor for the occurrence of steatorrhea, diarrhea and the long-term development of gallstones after either or both gastric resection alone and vagotomy alone. EXTRAVAGAL PARASYMPATHETICS. Another possible explanation of the variable occurrence and severity of postvagotomy symptoms is that extravagal parasympathetics may minimize the effects of massive denervation in some patients and not in others. The evidence for this consideration is strictly unknown. VAGAL REINNERVATION. Undesirable sequelae in many patients gradually disappear within a few months, which, as shown by Murray, 18 is the usual length of time for reinnervation by sprouting to become effective. Furthermore, and in accordance with Murray's observations, the fact that the hepatic and celiac vagal divisions traverse autonomic plexuses makes hepatic and celiac reinnervation more possible than gastric reinnervation. Gastric vagal fibers reach the stomach directly. However, in some patients the sequelae of hepatic and celiac vagotomy are apparently as permanent as the sequelae of gastric vagotomy. UNKNOWN PATHWAYS TO PANCREAS AND BILIARY TRACT. Although the celiac vagal branch supplies the entire midgut, we do not know whether the pancreas and biliary tract receive their vagal supply from either one or both the hepatic and celiac branches. We therefore have no real baseline for interpreting the relative clinical importance of these branches. However. Burge et al. 6 believe that both are important in
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preventing the pale bulky stool after vagotomy, but that the hepatic branch is apparently more important than the celiac branch. VAGO-VAGAL REFLEXES. The fact that fibers in the vagal trunks are 90 per cent efferentl indicates probably unknown reflexes that influence secretion and motility of the stomach, bowel, biliary tract and pancreas. A few of these reflexes have been explored with significant findings.4. 14. 27. 28 The over-all effects of eliminating some or all of these reflexes are unknown as they may relate to postvagotomy sequelae. In view of all these considerations, many of which are admittedly speculation, we believe that massive vagal denervation of all viscera by total abdominal vagotomy proves to be of little to no consequence in some patients, but in other patients causes undesirable side effects of variable character and severity. SUMMARY AND CONCLUSIONS
1. Conventional techniques of vagotomy may be refined by increasing the field of dissection from the hiatus to include the area of the abdominal esophagus, cardia and proximal lesser curve. This surgical field permits identification of the gastric, hepatic and celiac truncal divisions. which in turn leads to more accurate identification of the anterior and posterior vagal trunks at the hiatus. The trunks may then be dissected upward into the mediastinum to locate vagal branches that occasionally arise from the trunks above the hiatus. 2. Because of its anatomic accuracy, this method of surgical dissection provides more assurance of accomplishing a complete gastric vagotomy, and also provides better protection of the esophagus, pleura, spleen and vessels from recognized and unrecognized injury. 3. This dissection also permits preservation of the hepatic and celiac vagal divisions, which innervate the biliary tract, pancreas and bowel. Preservation of vagal innervation to these viscera eliminates long-term morbidity of conventional vagotomy due to massive vagal denervation of all abdominal viscera. 4. Selective gastric vagotomy accomplishes complete and total vagal denervation of the stomach, and therefore does not alter the occurrence of either gastric stasis or dumping (the latter secondary to either drainage procedures necessary for providing gastric drainage or to hemigastrectomy). REFERENCES 1. Agostoni, E., Chinnock, J. E., Daly, M. De B. and Murray, J. G.: Functional
and Histological Studies of Vagus Nerve and Its Branches to Heart, Lungs, and Abdominal Viscera in Cat. J. Physiol. 135: 182-205, 1957. 2. Bachrach, W. H.: Personal communication, 1962.
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3. Berne, C. J. and Mikkelsen, W. P.: Management of Perforated Peptic Ulcer. Surgery 44: 591-603, 1958. 4. Blair, E. L., Harper, A. A., Kidd, C. and Scratcherd, T.: Post-Activation Potentiation of Gastric and Intestinal Contractions in Response to Stimulation of Vagus Nerves, J. Physiol. 148: 437-449, 1959. 5. Burge, H. W.: Vagal Nerve Section in Chronic Duodenal Ulceration. Ann. Roy. ColI. Surgeons, England 26: 231-244, 1960. Idem: Personal communication, 1960. 6. Burge, H. W. et al.: Selective Vagotomy in Prevention of Post-Vagotomy Diarrhea. Lancet 2: 897-899, 1961. 7. Dorton, H. E.: Vagotomy, Pyloroplasty, and Suture-A Safe and Effective Remedy for Duodenal Ulcer That Bleeds. Ann. Surg. 153: 378-382, 1961. 8. Franksson, C.: Selective Abdominal Vagotomy. Acta chir. scandinav. 96: 409412, 1948. Idem: Personal communication, 1960. 9. Friesen, S. R.: Significance of Anomalous Origin of Left Hepatic Artery from Left Gastric Artery in Operations upon Stomach and Esophagus. Am. Surgeon 23: 1103-1108, 1957. 10. Griffith, C. A.: Gastric Vagotomy vs. Total Abdominal Vagotomy. Arch. Surg. 81: 781-788,1960. 11. Griffith, C. A.: Selective Gastric Vagotomy. Part I. Eliminating Occurrence of Incomplete Gastric Vagotomy by Refined Technics of Total Abdominal and Selective Gastric Vagotomy, West. J. Surg. 70: 107-119, 1962. Part II. Eliminating Undesirable Sequelae of Total Abdominal Vagotomy by Selective Gastric Vagotomy. West. J. Surg. 70: 175-180, 1962. 12. Griffith, C. A. and Harkins, H. N.: Partial Gastric Vagotomy: An Experimental Study. Gastroenterology 32: 96-102, 1957. 13. Griffith, C. A., Stavney, L. S., Kato, T. and Harkins, H. N.: Selective Gastric Vagotomy. To be published (Am. J. Surg. 105: (Jan.) 1963). 14. Harper, A. A., Kidd, C. and Scratcherd, T.: Vago-vagal Reflex Effects on Gastric and Pancreatic Secretion and Gastro-intestinal Motility. J. Physiol. 148: 417-436, 1959. 15. Imparato, A. M. and Hinton, J. W.: Gastric Secretion following Vago-Splanchnic and Splanchno-Vagal Anastomosis: Their Possible Clinical Implications. Ann. Surg. 141:853-861, 1955. 16. Jackson, R. G.: Anatomic Study of Vagus Nerves, with a Technique of Transabdominal Selective Gastric Vagus Resection. Univ. Hosp. Bull., Univ. Michigan, Ann Arbor 13: 31-35, 1947. Idem: Anatomic Study of Vagus Nerves, with a Technique of Transabdominal Selective Gastric Vagus Resection. Arch. Surg. 57: 333-352, 1948. Idem: Anatomic Study of Vagus Nerves, with a Technique of Transabdominal Selective Gastric Vagus Resection. Personal communications, 1959 and 1962. 17. Kure, K., Ichiko, K. and Ishikawa, K.: On the Spinal Parasympathetic. Physiological Significance of Spinal Parasympathetic System in Relation to Digestive Tract. Quart. J. Exper. Physiol. 21: 1-19, 1931. 18. Murray, J. G.: Consequences of Injury and Disease of Nervous Tissue: Recent Advances in Know ledge. J. Roy. ColI. Surgeons, Edinburgh 4: 199-217, 1959. 19. Murray, J. G.: Sprouting of Nerves: Some Consequences of Vagotomy and Sympathectomy (Editorial). Gastroenterology 42: 197-200, 1962. 20. Ross, D. E.: A New Upper Abdominal Incision. Am. J. Surg. 79: 841-842, 1950. Idem: Personal communication, 1962. 21. Saint, J. H. and Braslow, L. E.: Removal of Xyphoid Process as an Aid in Operations on Upper Abdomen. Surgery 33: 361-366, 1953. 22. Silva, T. F., Jr., Farmer, D. A. and Smithwick, R. H.: Completeness of Vagotomy as Judged by Postoperative Studies of Gastric Pepsin Concentration. Surgical Forum 12: 297-298, 1961. 23. Smith, G. K. and Farris, J. M.: Vagotomy and Pyloroplasty in Chronic Duodenal Ulcer with Special Reference to Technique. Arch. Surg. 78: 652-659, 1959. 24. Stavney, L. S., Kato, T., Griffith, C. A., Nyhus, L. M. and Harkins, H. N.: A Physiologic Demonstration of Selective Gastric Vagotomy. Submitted for publication.
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25. Stein, 1. F. and Meyer, K. A.: Studies on Vagotomy in Treatment of Peptic Ulcer. Surg. Gynec. & Obst. 93: 625-635,1951. 26. Weinberg, J. A.: Vagotomy and Pyloroplasty for Surgical Treatment of Duodenal Ulcer. In Harkins, H. N. and Nyhus, L. M. (eds.). Surgery of the Stomach and Duodenum. Boston, Little, Brown and Company, 1962, pp. 473-486. 27. White, T. T., Lundh, G. and Magee, D. F.: Evidence for Existence of a Gastropancreatic Reflex. Am. J. Physiol. 198: 725-728, 1960. 28. White, T. T., Hayama, T. and Magee, D. F.: Alternate Nervous Pathways for Gastropancreatic Reflex. Gastroenterology 39: 615-617, 1960.
Department of Surgery University of Washington School of Medicine Seattle 5, Washington