A 45-year-old man with a chronic duodenal ulcer requires surgical treatment after failed H. pylori eradication and refractory symptoms. He has no evidence of malignancy. The preferred elective surgical procedure for duodenal ulcer disease is a truncal vagotomy combined with which drainage procedure, and why?

• A Truncal vagotomy with gastrojejunostomy — to prevent gastric outlet obstruction post-vagotomy
• B Truncal vagotomy with pyloroplasty (Heineke-Mikulicz) — truncal vagotomy abolishes antral pump function requiring a drainage procedure to prevent gastric stasis ✓
• C Truncal vagotomy alone — vagotomy reduces acid without affecting gastric emptying
• D Highly selective (proximal gastric) vagotomy alone — does not require drainage as antral innervation is preserved

Explanation

Truncal vagotomy divides the vagal trunks below the oesophageal hiatus, denervating not only the acid-secreting parietal cells but also the antral pump (pyloric canal musculature), which is essential for gastric emptying. This vagally-denervated antrum cannot adequately propel contents through the pylorus, causing gastric stasis and delayed emptying. A drainage procedure — pyloroplasty (Heineke-Mikulicz, Finney, or Jaboulay) or gastrojejunostomy — is therefore mandatory with truncal vagotomy. Highly selective (proximal gastric) vagotomy preserves the nerve of Latarjet and crow's foot to the antrum, maintaining antral pump function and not requiring drainage.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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