Selective vagotomy with Griffith method

In 1948, Franksson and Jackson used the Griffith method for selective vagotomy for clinical use. The main gastric branch (ie, the former Latarjet nerve) is cut off below the hepatic branch of the vagus nerve. After the vagus nerve is dry, the main gastric branch (post Lattajet nerve) is cut off below the abdominal cavity, and the hepatic branch and the abdominal branch are retained. Only the vagus nerve that controls the whole stomach is cut off, so it is also called full gastric vagus nerve cutting. Compared with vagus nerve stemectomy, this procedure reduces the extent of vagus nerve resection and preserves vagus innervation other than the stomach, with less effect on other organ functions in the abdominal cavity. However, due to the control of the stomach, especially the vagus nerve of the antrum of the stomach is also cut off, gastric emptying disorder occurs after surgery. Therefore, additional surgery must be performed, such as pyoplasty, gastric antrum resection or semi-gastrectomy. In 1967, Holee and Hart proposed the idea of selective proximal gastric vagus nerve removal (Selective). In 1970, Johnston and Willian proposed the name of highly selective vagotomy and was used clinically. In the same year, Amdrop and Jenson were named Parietal Cell Vagotomy. In addition, this surgical approach is also known as Acidosecretive Vagotomy and Ultraselective Vagotomy. High-selective vagus nerve ablation only cuts off the vagus nerve that governs the corpus corpus, the area of the inner wall cells, retains the vagus nerve that governs the antrum of the stomach, thereby preserving the peristaltic function of the antrum, without the need for additional gastric drainage. This procedure not only reduces gastric acid secretion, but also preserves the anatomical and functional integrity of the antrum, pylorus and duodenum. It is considered to be an effective and relatively physiological surgical procedure for the treatment of duodenal ulcer. The operative complication rate was the lowest, but the ulcer recurrence rate was higher. Treatment of disease: anastomotic ulcer Indication The Griffith method of selective vagus nerve cutting is applicable to: 1. Intractable duodenal ulcer, high stomach acid. 2. Anastomotic ulcer after partial gastrectomy or gastrojejunostomy. Preoperative preparation Patients with duodenal ulcer must undergo gastric acid secretion test before vagus nerve ablation to understand the function of gastric acid secretion. The main tests include the following tests: 1 Basic gastric acid secretion (BAO): indicates the function of parietal cells to secrete hydrochloric acid without any stimulation; 2 Maximum secretion of gastric acid (MAO): including 5 peptide gastrin to stimulate the maximum secretion of gastric acid (PMAO) and insulin hypoglycemia and hypoglycemia stimulate the maximum secretion of gastric acid (IMAO). PMAO represents the maximal secretion of gastric acid stimulated by hormonal (body fluid) phase, and IMAO represents the maximal response of parietal cells to gastric phase stimulation of gastric acid secretion. This examination is important for selecting the vagus nerve cutting method, estimating the completeness of the vagus nerve cutting and judging the vagus nerve cutting effect and prognosis. Other preoperative preparations are the same as major gastrectomy. Surgical procedure General anesthesia should be used. Because of the high traction and high position in the vagus nerve cutting, general anesthesia can meet the surgical requirements. Epidural anesthesia can not block the visceral traction reaction, often cause vomiting and discomfort during surgery, affecting exposure and operation. Take the head high and low lying position, tilt 10 ° ~ 15 °, the diaphragm and internal organs move down to facilitate the exposure. 1. After the abdomen, the left axillary area is revealed. On the right side of the cardia, there is no vascular small omentum. The hepatic branch separated by the vagus nerve anterior stem is walking toward the hepatic hilum, and the posterior is the hepatic caudate lobe. The small omentum was cut under the right side of the cardia and the vagus nerve branch, and the peritoneum of the left triangle of the cardia was incision. The anterior main gastric branch of the vagus nerve (the former Latarjet nerve) was located between the two incisions. 2. The posterior main gastric branch of the vagus nerve (post-latarjet nerve) is deep in position and is generally not easy to see. It can be determined by finger separation. The operator uses the right hand to extend from the peritoneal incision in the His triangle, and the vagus nerve can be touched when it is separated to the right along the posterior wall of the esophagus. The fingers pass through the loose tissue behind the vagus nerve and enter the esophagus. The side is extended by the incision of the small omentum, and then a rubber band is guided by the finger to pass the back of the esophagus, surrounding the lower end of the esophagus, which should include the anterior, posterior, and abdominal branches of the vagus nerve. The peritoneum in front of the free esophagus includes the vagus nerve anterior trunk and the anterior main gastric branch. The anterior main gastric branch and the anterior esophageal peritoneum are cut off under the hepatic branch, and the anterior wall of the esophagus is separated and stripped to expose the longitudinal muscular layer. 3. Dissipate the vagus nerve from the gastric pancreatic fold, and use another strip to wrap around to the right side, and then re-position the strip from the back around the esophagus and the vagus nerve, along the posterior wall of the esophagus. The vagus nerve passes between the posterior and the lower end of the esophagus is pulled to the left. 4. At this time, the left gastric artery and the esophageal branch that is separated upward and the stomach branch that is divided downward can be seen. In order to completely cut off the vagus nerve branch accompanying the blood vessel into the small curvature of the stomach, the left main artery and the posterior main gastric branch of the vagus nerve are cut off together, so that the vagus nerve is dry, the abdominal branch is completely separated from the cardia and the lower end of the esophagus. After the Latarjet nerve has been completely cut off. During the operation, nerve fibers descending along the surface of the esophageal muscle layer can be seen and separated. Strip the entire esophagus to expose the longitudinal muscle layer. complication Complications of vagus nerve surgery have two types of short-term and long-term complications. Recent surgical complications are often associated with surgical procedures. There are mainly the following: 1. Perforation of the lower esophagus is a serious complication. Mainly due to damage when peeling off the lower end of the esophagus. The reported incidence in the literature is less than 0.5%. After the perforation occurs, if it can be found in the operation and repaired in time, the prognosis is good. Otherwise, it will cause severe underarm infection or mediastinal inflammation. Once this happens, surgery should be performed again. 2. Small curved ischemic necrosis and perforation. In the early stage of high-selective vagus nerve ablation, there have been some reports that it is related to the excessively wide, deep, and localized blood flow supply during the operation, and the incidence rate is less than 0.4%. Once the ischemic necrosis and perforation of the small curvature of the stomach occurs, the mortality rate is as high as 50%. Clinical manifestations of severe peritonitis. Surgical treatment should be performed immediately. This complication has been rare in recent years. In fact, local necrotic perforation of the stomach wall may be associated with surgical damage to the stomach wall. 3. Bleeding after surgery. The literature reports that the incidence of intra-abdominal hemorrhage after vagus nerve cutting is 0.3% to 0.8%. The main reason is that the intraoperative blood vessel ligation is not appropriate, and there are also iatrogenic injuries, such as rupture of the spleen due to traction, damage to the left lobe of the liver. Once it happens, it should be stopped again to stop bleeding. The long-term complications of vagus nerve ablation include the following six items. (1) Swallowing blockage. This is a common complication after vagus nerve ablation. Highly selective vagus nerve ablation is especially common. The incidence rate is 15% to 40%. Loss of innervation at the lower end of the esophagus and muscle relaxation disorder. Patients with obvious symptoms were examined by X-ray barium meal at the lower end of the esophagus. The esophageal pressure test confirmed that the lower segment of the leg was increased and the insufficiency was not complete. This complication is generally temporary, and most patients gradually disappear after 2 to 4 weeks after surgery. Only a very small number of patients have severe symptoms for a long time without remission, requiring esophageal dilation. (2) Diarrhea. The occurrence of diarrhea after vagus nerve cutting occurs mostly after vagus nerve stem cutting. The reason may be: 1 The small intestine loses the vagus innervation after the abdominal branch is cut, the peristalsis is accelerated and the bile acid is poorly absorbed. 2 The vagus nerve branch was cut off and the pancreatic function was decreased, and the secretion of pancreatic enzyme was reduced. 3 Additional gastric drainage or gastric antrum resection resulted in loss of pyloric function. Most of the diarrhea is temporary or intermittent and gradually improves or disappears over time. The incidence of diarrhea after vagus nerve dryness is 20% to 65%, and that of severe diarrhea is about 5%. The incidence of selective vagus nerve cutting is below 10%, and severe cases are below 1%. There are few complications of diarrhea after high-selective vagus nerve ablation. (3) Postoperative gastric emptying disorder. The loss of the vagus nerve in the stomach and the impaired motor function of the stomach are the causes of gastric emptying disorders. Therefore, vagus nerve dry surgery and selective vagus nerve surgery must be followed by gastric drainage or gastric antrum resection to solve the problem of gastric emptying. A small number of patients have delayed gastric emptying in the early postoperative period and have symptoms of fullness or vomiting after eating. Generally, after diet adjustment, the symptoms will gradually disappear. Gastric emptying disorders generally do not occur when the vagus nerve cut-off range of the high-selective vagotomy is correct. If the Latarjet nerve or the "crazed claw" branch is damaged or cut during surgery, gastric emptying disorder may occur, and severe cases require reoperation for gastric antrum resection. (4) biliary dysfunction occurs after vagus nerve stem severance. Due to the removal of the innervation of the liver, The gallbladder contraction function is weakened, and poor emptying may increase the incidence of gallstones. (5) vagus nerve cutting plus drainage or antrum, semi-gastric resection, postoperative dumping syndrome, bile reflux gastritis and other complications. However, its incidence and severity are lower than after partial gastrectomy. These complications rarely occur after high-selective vagus nerve ablation. The treatment was similar to that after partial gastrectomy. (6) Recurrent ulcers. The incidence of recurrent ulcers or ulcers after vagus nerve ablation has been reported to be quite different. It is generally believed that the rate of recurrent ulceration after vagus nerve cutting plus gastric antrum resection is lower than that after vaginal and drainage. The recurrence rate of ulcer after high-selective vagus nerve cutting was significantly higher than the former.