Why is an outlet added to truncal vagotomy

Why is an outlet or drainage procedure added to truncal vagotomy? What are the surgical options? 

Truncal vagotomy involves division of both anterior and posterior vagal trunks at the esophageal hiatus.

This procedure results in denervation of the acid-producing mucosa of the gastric fundus as well as the pylorus and antrum, causing an alteration of normal pyloric coordination and impaired gastric emptying.

Thus a procedure to eliminate function of the pyloric sphincter must be performed to allow gastric drainage. There are four primary options for an outlet procedure:

  • Heineke-Mikulicz pyloroplasty: a longitudinal incision of the pyloric sphincter, extending into the duodenum and antrum, is closed transversely. This is the most commonly performed technique.
  • Finney pyloroplasty: a U-shaped incision crossing the pylorus is made and a gastroduodenostomy is created; used in cases of extensive duodenal scarring to create a wider gastroduodenal opening.
  • Jaboulay gastroduodenostomy: a side-to-side gastroduodenostomy is created in which the incision does not cross the pyloric sphincter. Although it is rarely necessary, it is used when severe pyloric scarring precludes division of the pyloric channel.
  • Gastrojejunostomy: Billroth II or Roux-en-Y anastomosis is reserved for significant duodenal bulb scarring that makes pyloroplasty more challenging.
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