Surgical Management: Vagotomy and Pyloroplasty
Most indications for vagotomy and pyloroplasty (VP) are of historical importance, with proton pump inhibitors and eradicating H. pylori all but making the aforementioned obsolete. A bleeding duodenal ulcer, a perforated duodenal/gastric ulcer, an obstructing pyloric channel/duodenal ulcer, and intractable pain from peptic ulcer disease remain indications for such a procedure. The Heineke-Mikulicz approach is best for routine cases, whereas the Finney pyloroplasty is best suited for a J-shaped stomach laying in the longitudinal axis. In the most severe cases of inflammation and scarring of the pylorus, a Jaboulay gastroduodenostomy may be employed which bypasses the pylorus entirely. All described pyloroplasties may be accomplished laparoscopically, and each technique mirrors the open approach and should be attempted by those skilled at laparoscopy. Complications related to the pyloroplasty include dumping syndrome, bile reflux gastritis, inadequate drainage vs. delayed GI function, and leaks. A number of prospective, randomized trials comparing the various surgical options have a reported mortality rate of 0.5–0.8%.
KeywordsPyloroplasty Vagotomy Heineke-Mikulicz Finney Jaboulay
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