Video- and Robotic-Assisted Thoracoscopic Truncal Vagotomy.

A subset of patients with marginal ulcers after Roux-en-Y gastric bypass (RNYGB) is refractory to medical management. Here we report a retrospective review of a single institution cohort (N = 10) of video- or robotic-assisted thoracoscopic (VATS or RATS) truncal vagotomies performed between 2013 and 2018. All patients had recurrent marginal ulcers following RNYGB complicated by bleeding or perforation, refractory to medical management for a median of 3.5 months prior to undergoing truncal vagotomy. With a median of 23 months' follow-up, only three patients had continued symptoms (70% symptom resolution) post-operatively. Only one patient who had repeat endoscopy after the procedure had documented endoscopic evidence of recurrent marginal ulcer (83% endoscopic resolution). VATS or RATS truncal vagotomy is a safe and effective method to treat complicated marginal ulceration after RNYGB. After an average duration of unsuccessful medical treatment lasting three months, vagotomy led to successful resolution in 70-83% of patients.

Thoracoscopic truncal vagotomy versus surgical revision of the gastrojejunal anastomosis for recalcitrant marginal ulcers.

INTRODUCTION: Marginal ulcer is a common complication following Roux-en-Y gastric bypass with incidence rates between 1 and 16%. Most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. Revision of the gastrojejunal (GJ) anastomosis carries significant morbidity with complication rates ranging from 10 to 50%. Thoracoscopic truncal vagotomy (TTV) may be a safer alternative with decreased operative times. The purpose of this study is to evaluate the safety and effectiveness of TTV in comparison to GJ revision for treatment of recalcitrant marginal ulcers. METHODS: A retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from 1 September 2012 to 1 September 2017. All underwent medical therapy along with lifestyle changes prior to intervention and had preoperative EGD that demonstrated a recalcitrant marginal ulcer. Revision of the GJ anastomosis or TTV was performed. Data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate. RESULTS: Twenty patients were identified who underwent either GJ revision (n = 13) or TTV (n = 7). There were no 30-day mortalities in either group. Mean operative time was significantly lower in the TTV group in comparison to GJ revision (95.7 ± 16 vs. 227.5 ± 89 min, respectively, p = 0.0022). Recurrence of ulcer was not significant between groups and occurred following two GJ revisions (15%) and one TTV (14%). Complication rates were not significantly different with 62% in the GJ revision group and 57% in the TTV group. Approximately 38% (5/13) of GJ revisions and 28% (2/7) of TTV patients experienced complications with Clavien-Dindo scores > 3. There was no difference in postoperative symptoms between both groups. CONCLUSIONS: Our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. However, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups.

Revision using totally hand-sewn gastrojejunostomy and truncal vagotomy for refractory marginal ulcer after laparoscopic Roux-en-y gastric bypass: a case series.

BACKGROUND: Marginal ulcer (MU) is not infrequent after laparoscopic Roux-en-Y gastric bypass (LRYGB). Medication plus lifestyle modification remains the mainstay solution. Patients with refractory MU may be candidates for revisional surgery. OBJECTIVE: To summarize our experience of revisional surgery for treating refractory MU after LRYGB. SETTING: University hospital, Taiwan. METHODS: A retrospective analysis was performed for 11 patients with refractory MU undergoing totally hand-sewn gastrojejunostomy and truncal vagotomy at our institution between August 2005 and May 2015. The mean follow-up after surgery was 28.0±16.2 months (range, 10-48 mo); 9 patients (81.8%) were followed up more than 1 year after. RESULTS: The mean age of the cohort (7 males; 4 females) was 39.5±16.0 years (range, 19-66 yr), with a mean initial body mass index of 37.5±9.3 kg/m2 (range, 32.1-57 kg/m2). Intractability was the dominant manifestation (100%); 8 patients (72%) had stricture at the gastrojejunostomy. The mean interval from initial LRYGB to refractory MU and revisional surgery was 10.2±7.7 months (range, 4-28 mo) and 38.7±21.6 months (range, 10-67 mo), respectively. The average operation time was 150.4±59.8 minutes (range, 80-300 min), and the average length of hospital stay was 4.2±1.4 days (range, 2-7 d). The 9 patients with more than 1 year follow-up all achieved endoscopic resolution of the refractory MU. CONCLUSIONS: Although longer follow-up is warranted, revisional surgery with totally hand-sewn gastrojejunostomy and truncal vagotomy can be an effective solution for refractory MU.

Simple fundoplication versus additional vagotomy and pyloroplasty in neurologically impaired children--a single centre experience.

BACKGROUND AND AIMS: Gastrooesophageal reflux disease (GERD) is a significant problem in children with neurological impairment (NI) with high failure rates for fundoplication. Fundoplication with vagotomy and pyloroplasty (FVP) can improve the outcome by altering the sensory or motor dysfunction associated with the reflux. We report our comparative outcomes for simple fundoplication (SF) and FVP in NI children. METHODS: Case records of all patients having fundoplication under a single consultant at a tertiary UK paediatric surgical centre between January 1997 and December 2012 were retrospectively assessed for recurrent symptoms and redo surgery. The data were collected using a Microsoft Excel database and analysed on Graphpad prism software program. Data are median (range). P value<0.05 was considered significant. RESULTS: Data were available for 244 out of 275 patients who underwent fundoplication during this period (157 SF and 87 FVP). Neurological disease or known syndromes were recorded in 158 patients. Thirty-five children had congenital anatomical abnormalities. Laparoscopic fundoplication was done in 37 cases. Revisional surgery for recurrent symptoms was performed in 22 patients. In the neurologically normal children, all of whom had SF, the revision rate was 6.5%. In the NI children the revision rates were 18.5% for SF and 3.9% for FVP, respectively (Fisher's exact, P<0.05). The median time to redo surgery was 10 (1-63) months, and the median time to follow up was 19.5 (2-177) months. CONCLUSIONS: There appears to be a significantly lower need for redo surgery following FVP than SF in children with NI.

Alterations of the gastric stump and not resected stomach mucosa after truncal vagotomy in rats.

PURPOSE: To evaluate morphological changes of the gastric stump and not resected stomach mucosa after the completion of truncal vagotomy. METHODS: Eighty male Wistar rats were divided into four groups: CT, TV, RY and RYTV. In CT group, abdominal viscera were manipulated and the abdominal cavity was closed, in TV vagal trunks were isolated and sectioned, in RY a partial Roux-en-Y gastrectomy was performed and in RYTV the vagal trunks were sectioned and a partial Roux-en-Y gastrectomy was performed. At the 54th week after surgery, the rats were euthanized. The findings were submitted to histological analyses. RESULTS: None macroscopic or histological alterations in groups TV and CT was observed. Specimens from RY and RYTV groups did not show alterations in the gastric stump mucosa. At the jejunal side of the gastroenterostomy we found shallow ulcerative lesions always single, well-defined and with variable diameter 3 to 6 mm, six times in the RY group and none in the RYTV group (RY>RYTV, p=0.008). Neoplastic or preneoplastic lesions were not diagnosed in all groups. CONCLUSION: Truncal vagotomy is a safe and non-carcinogenic method in not resected and partially resected stomach.

Characterisation of oral and i.v. glucose handling in truncally vagotomised subjects with pyloroplasty.

OBJECTIVE: Glucagon-like peptide 1 (GLP1) is rapidly inactivated by dipeptidyl peptidase 4 (DPP4), but may interact with vagal neurons at its site of secretion. We investigated the role of vagal innervation for handling of oral and i.v. glucose. DESIGN AND METHODS: Truncally vagotomised subjects (n=16) and matched controls (n=10) underwent 50 g-oral glucose tolerance test (OGTT)±vildagliptin, a DPP4 inhibitor (DPP4i) and isoglycaemic i.v. glucose infusion (IIGI), copying the OGTT without DPP4i. RESULTS: Isoglycaemia was obtained with 25±2 g glucose in vagotomised subjects and 18±2 g in controls (P<0.03); thus, gastrointestinal-mediated glucose disposal (GIGD) - a measure of glucose handling (100%×(glucoseOGTT-glucoseIIGI/glucoseOGTT)) - was reduced in the vagotomised compared with the control group. Peak intact GLP1 concentrations were higher in the vagotomised group. Gastric emptying was faster in vagotomised subjects after OGTT and was unaffected by DPP4i. The early glucose-dependent insulinotropic polypeptide response was higher in vagotomised subjects. Despite this, the incretin effect was equal in both groups. DPP4i enhanced insulin secretion in controls, but had no effect in the vagotomised subjects. Controls suppressed glucagon concentrations similarly, irrespective of the route of glucose administration, whereas vagotomised subjects showed suppression only during IIGI and exhibited hyperglucagonaemia following OGTT. DPP4i further suppressed glucagon secretion in controls and tended to normalise glucagon responses in vagotomised subjects. CONCLUSIONS: GIGD is diminished, but the incretin effect is unaffected in vagotomised subjects despite higher GLP1 levels. This, together with the small effect of DPP4i, is compatible with the notion that part of the physiological effects of GLP1 involves vagal transmission.

Biliopancreatic diversion with duodenojejunal exclusion associated with truncal vagotomy: a new proposal for type 2 diabetes mellitus treatment.

PURPOSE: To evaluate the effectiveness of the biliopancreatic diversion surgery with duodenojejunal exclusion in combination with truncal vagotomy in type 2 diabetes mellitus (T2DM) patients with overweight or class I or II obesity. METHODS: The study included ten patients with T2DM and class I or II obesity or overweight who were subjected to biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy. The blood glucose levels during the pre- and postoperative periods were compared using the Friedman test. The significance level adopted was 5%. RESULTS: There were significant differences between preoperative and postoperative blood glucose levels at three months (p=0.01), six months (p=0.001) and 12 months (p=0.001). There was also a significant difference between one month postoperative blood glucose and six months postoperative blood glucose (p=0.01). Glycosylated hemoglobin levels decreased in 80% of patients, there was marked improvement in their lipid profiles, and the average BMI reduction was 7.0±1.5 kg/m² at 12 months after the surgery. CONCLUSION: In patients with type 2 diabetes mellitus associated with class I/II obesity or overweight, performing biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy resulted in glycemic control, reduction of excess weight, and improvement of lipid profile 12 months after the surgery.

Biliopancreatic diversion with duodenojejunal exclusion associated with truncal vagotomy: a new proposal for type 2 diabetes mellitus treatment / Derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular: uma nova proposta para o tratamento do diabetes melito tipo 2

PURPOSE: To evaluate the effectiveness of the biliopancreatic diversion surgery with duodenojejunal exclusion in combination with truncal vagotomy in type 2 diabetes mellitus (T2DM) patients with overweight or class I or II obesity. METHODS: The study included ten patients with T2DM and class I or II obesity or overweight who were subjected to biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy. The blood glucose levels during the pre- and postoperative periods were compared using the Friedman test. The significance level adopted was 5%. RESULTS: There were significant differences between preoperative and postoperative blood glucose levels at three months (p=0.01), six months (p=0.001) and 12 months (p=0.001). There was also a significant difference between one month postoperative blood glucose and six months postoperative blood glucose (p=0.01). Glycosylated hemoglobin levels decreased in 80% of patients, there was marked improvement in their lipid profiles, and the average BMI reduction was 7.0±1.5 kg/m² at 12 months after the surgery. CONCLUSION: In patients with type 2 diabetes mellitus associated with class I/II obesity or overweight, performing biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy resulted in glycemic control, reduction of excess weight, and improvement of lipid profile 12 months after the surgery.

OBJETIVO: Avaliar a eficácia da operação de derivação biliopancreática com exclusão duodeno-jejunal associada com vagotomia troncular em doentes com diabetes tipo 2 com sobrepeso ou obesidade classe I ou II. MÉTODOS: Foram estudados dez doentes com diabetes melito tipo 2 e sobrepeso ou obesidade grau I ou II submetidos à derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular. Os valores de glicemia no pré e no pós-operatório foram comparados pelo teste de Friedman. O nível de significância adotado foi de 5%. RESULTADOS: Houve diferença significante (p=0,01) nas glicemias pré e pós-operatórias de três meses, de seis meses (p=0,001) e de 12 meses (p=0,001). Houve diferença significante entre a glicemia pós-operatória de um mês e glicemia pós-operatória de seis meses (p=0,01). O nível de hemoglobina glicosilada reduziu-se em 80% dos doentes, houve melhora acentuada do perfil lipídico e a média da redução do IMC foi de 7,0±1,5 kg/m² após 12 meses da operação. CONCLUSÃO: No paciente com diabetes melito tipo 2 associado com sobrepeso ou obesidade grau I/II, a realização da derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular proporcionou controle glicêmico, redução do excesso de peso e melhora do perfil lipídico após 12 meses da operação.

Effectiveness of thoracoscopic truncal vagotomy in the treatment of marginal ulcers after laparoscopic Roux-en-Y gastric bypass.

Marginal ulcer is a significant complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Most marginal ulcers resolve with medical management, but nonhealing ulcers may require revision of the gastrojejunostomy, a procedure with significant morbidity and mortality. Traditionally, surgical therapy for refractory peptic ulcers includes a vagotomy. The current study evaluates the effectiveness of thoracoscopic truncal vagotomy (TTV) in the management of refractory marginal ulcers. All patients at two institutions with an intractable marginal ulcer after LRYGB treated with TTV between 2003 and 2010 were reviewed. Data were collected from chart review and telephone interview. Seventeen patients (mean age, 39 ± 13 years; 16 females) were diagnosed with marginal ulceration a median of 18 months after LRYGB and proceeded to TTV at a mean of 39 ± 43 weeks (range, 1 to 114 weeks) after the diagnosis. The median operative time was 89 ± 65 minutes (range, 45 to 318 minutes). Four patients had a complication (sympathetic contralateral pleural effusion, pneumothorax, operative bleeding, and readmission for emesis). Eleven patients had follow-up of 3 months to 6 years (median, 7 months). Nine patients (82%) had symptomatic improvement and/or endoscopic resolution, whereas two (18%) did not. No patient had endoscopic evidence of persistent or recurrent marginal ulcer. TTV achieves symptomatic improvement and/or endoscopic resolution of intractable marginal ulcers in over 80 per cent of patients status post gastric bypass and therefore offers a less morbid alternative to revision of the gastrojejunostomy.

Laparoscopic truncal vagotomy with gastrojejunostomy.

Surgery still remains the treatment of choice for patients of peptic ulceration with gastric outlet obstruction. With the advent of minimal access surgery, laparoscopic truncal vagotomy with gastrojejunostomy is an attractive option. Between September 2006 and May 2010, 18 patients underwent laparoscopic truncal vagotomy with gastrojejunostomy for gastric outlet obstruction with peptic ulcer. Four patients underwent stapled gastrojejunostomy and 14 patients had a sutured anasotomosis. There were no major intra-operative and postoperative complications. We conclude that the laparoscopic approach is beneficial and, with sufficient expertise, a sutured gastrojejunostomy can be safely performed, thus saving on the costs.

Laparoscopic-assisted truncal vagotomy and gastro-jejunostomy: trial of simplification.

BACKGROUND: Truncal vagotomy and gastro-jejunostomy is an effective procedure for Gastric Outlet Obstruction. The authors' experience with the procedure is presented and an alternative technique for creating the gastro-jejunostomy is described. METHODS: From January 2005 through June 2007, 18 patients with gastric outlet obstruction secondary to a cicatrizing peptic duodenal ulcer underwent laparoscopic truncal vagotomy and an ante-colic laparoscopic-assisted stapled gastro-jejunostomy. RESULTS: All procedures were completed laparoscopically with a mean operative time of 81.2 +/- 11.1 minutes. Anastomotic leak was encountered in 1 (5.5%) patient and bile vomiting in 2 patients (11%). The mean follow-up duration was 22.8 +/- 9.8 months. None of the patients developed recurrent obstruction. CONCLUSIONS: The procedure is feasible, safe, and provides an effective cure for gastric outlet obstruction. The laparoscopic-assisted stapled gastro-jejunostomy reduces the operative time and may reduce the cost of the procedure.

Comparison of laparoscopic truncal vagotomy with gastrojejunostomy and open surgery in peptic pyloric stenosis.

BACKGROUND: Little is known about the advantages of laparoscopic truncal vagotomy with gastrojejunostomy (LTVGJ) over open truncal vagotomy with gastrojejunostomy (OTVGJ) for peptic pyloric stenosis (PPS). This study aimed to highlight the role of minimally invasive surgery in the form of LTVGJ for PPS. METHODS: From March 1999 to October 2005, 21 patients with PPS underwent LTVGJ (n = 13) and OTVGJ (n = 8). We analyzed intraoperative and postoperative outcomes retrospectively. RESULTS: Two groups had similar demographic characteristics. Significantly shorter operating time, hospital stay, time to presence of bowel sounds, and time to tolerate a diet were the advantages of LTVGJ, while blood loss was higher in OTVGJ. There were significant differences in weight gain between the two groups after surgery during follow-up. CONCLUSIONS: This study suggests that LTVGJ is a feasible technique, and intermediate follow-up reveals good symptomatic results when used for PPS.

[Videothoracoscopic vagotomy in surgical treatment of patients with peptic ulcer of the gastroenteroanastomosis after resection of the stomach].

Treatment of 130 patients with peptic ulcer of the gastroenteroanastomosis after resection of the stomach included operation by the method of videothoracoscopic truncal vagotomy (22 patients), left-side videothoracoscopic truncal vagotomy (19 patients), and operation from the right-side access (3 patients). Cicatrization of the ulcer in the postoperative period was obtained in 16 patients. Recurrent peptic ulcer was revealed in 2 patients. There were no lethal outcomes.

Laparoscopy-assisted truncal vagotomy with antecolic posterior gastrojejunostomy for benign gastric outlet obstruction.

BACKGROUND: The aim of this study is to highlight the role of minimally invasive surgery in the form of laparoscopy-assisted truncal vagotomy (TV) with ante-colic posterior gastrojejunostomy (PGJ) for benign gastric outlet obstruction (GOO). GOO is relatively common in southern India due to various factors. From 1994 to 2004, 762 patients with GOO were operated on (open TV with PGJ) in our center. METHODS: From November 2003 to November 2004, 18 patients with GOO underwent the laparoscopic procedure in our unit. The procedure involves laparoscopic TV followed by the ante-colic PGJ performed extracorporeally through a 3.5-cm transverse incision in the upper abdomen. RESULTS: The advantages of this procedure are that pain, hospital stay, size of wound, incidence of incisional hernia, and postoperative complications are reduced and the patient returns to work earlier. The results are comparable to those of a totally laparoscopic TV with PGJ. CONCLUSION: This procedure is relatively easy to perform because the anastomosis is done extracorporeally, and it is less expensive than the use of endostaplers. Thus, more surgeons should be encouraged to perform laparoscopic TV with PGJ.