SURGICAL GASTROENTEROLOGY AND ENDOCRINOLOGY

METHODICAL INSTRUCTIONS FOR 4^th YEAR STUDENTS

METHODOLOGICAL INSTRUCTION TO LESSON №8

 

POSTRESECTION AND POSTVAGOTOMIC SYNDROMES. POSTCHOLECYSTECTOMIC SYNDROME

 

І. AIM. To be able to diagnose, to know symptoms of diseases of operated stomach, depending on clinical type of the disease. Principles of conservative and surgical treatment. To be able to diagnose, to know symptoms and principles of conservative and surgical treatment of of postcholecystectomic syndrome.

 

ІІ. Professional orientation of the student.

Knowledge of symptoms, appearing after performed stomach resections and vagotomies, causes proper approach to choosing of operative intervention and the techniques of its performing.

Cholecystectomy is one of frequently performed operations in surgical clinics. Knowledge of symptoms, clinical signs and diagnosing of the diseases, that are grouped into the term “PCES”, gives us a possibility to prevent its appearing in one cases, and to determine the expediency of conservative or surgical treatment in another ones.

Methodology of Practical Class 9.00-12.00.

 

 

Algorithm of communicative skills:

 

1. To greet and name itself.

2. Friendly behavour.

3. To explain to the patient a purpose of the visit, duration of conversation and to get his agreement.

4. Correct and quiet conversation with a patient.

5. To get the agreement of patient for the performance of the examination.To take complaints. Correct and quiet conversation with a patient. A patient is in vertical position persons to the doctor, neck and shoulders of patient is maximally weakened.

 

Student’s independent work program:

 

Theme №1. POSTRESECTION AND POSTVAGOTOMIC SYNDROMES

1.       Anatomical, morphological and functional peculiarities of stomach (anatomy, topographical anatomy, anatomical pathology, histology).

2.       Etiology, pathogenesis and classification of diseases of operated stomach (pathological physiology, propaedeutical therapy, faculty surgery).

3.       Estimation of x-ray, endoscopic, laboratory findings (rhoetgenology, functional diagnostics).

4.       Mechanism of antiulcerogenic agents action, correction of electrolytes metabolism violation, use of digestive enzymes, hormones, vitamins, methods of operative intervention (pharmacology, faculty surgery).

5.       Rontgenoscopy, estimation of x-ray reports, gastric juices test.

 

Theme №2. POSTCHOLECYSTECTOMIC SYNDROME

1.       Anatomical, morphological and functional peculiarities of biliary tracts (anatomy, topographical anatomy, anatomical pathology).

2.       Classification of postcholecystectomic syndrome (propaedeutical therapy)

3.       Estimation of clinical and laboratory, x-ray, ultrasonographical, endoscopic, findings (rhoetgenology, infectious diseases, biochemistry).

4.       Mechanism of antiinflammatory, spasmolytic, detoxicative, replacement agents action, methods of operative intervention on biliary tracts (pharmacology, topographical anatomy and operative surgery).

5.       Constants of biochemical blood and urine tests.

Break 12.00-12.30

 

Seminar discussion of theoretical issues 12.30-14.00.

 

 

 

 

Basic level of knowledge and skills:

 

The student must know:

1.       Surgical anatomy of stomach and duodenum.

2.       Types of stomach resections at ulcerous disease.

3.       Types of draining prerations on stomach at ulcerous disease.

4.       Choosing the method of surgical treatment of duodenum ulcer

5.       Types of vagotomies, their characteristics: indications, contraindications to their performing.

6.       Classification of postresection syndromes.

7.       Reasons of damping syndrome appearing.

8.       Theories of damping syndrome appearing.

9.       Clinical variants of damping syndrome passing.

10.   X-ray and clinical criteria of disease severeness degree estimation

11.   Conservative treatment of damping syndrome.

12.   Indications to surgical treatment of damping syndrome. Types of operations.

13.   Methods of stomach resection, that prevent damping syndrome.

14.   Afferent loop syndrome: its reasons, classification.

15.   Afferent loop syndrome: clinical variants, diagnosis.

16.   Peptic ulcer of gastroenteroanastomosis: its reasons, complications, diagnosis.

17.   Peptic ulcer of gastroenteroanastomosis: types of surgical interventions.

18.   Coloventricular fistula: clinical and X-ray diagnosis.

19.   Coloventricular fistula: methods of surgical interventions.

20.   Zollinger-Ellison syndrome: diagnosis and treatment.

21.   Factors of stomach and duodenum ulcer relapsing after vagotomy.

22.   Clinical variants of relapsing ulcer after vagotomy.

23.   X-ray and endoscopic signs of stomach and duodenum ulcer relapsing.

24.   Conservative methods of postvagotomic relapsing ulcers treatment.

25.   Surgical treatment of postvagotomic relapsing ulcers.

26.   Postvagotomic diarrhoea: reasons, classification by severeness degrees.

27.   Treatment of postvagotomic diarrhoea.

28.   Postvagotomic gastrostasis: its degrees, treatment.

29.   Surgical anatomy of biliary tracts.

30.   Instrumental methods of examination at PCES.

31.   Classification of PCES by Shalimov.

32.   Types of external draining of common bile duct.

33.   Types of interna.draining of common bile duct.

34.   PCES, determined by changes, not corrected during cholecystectomy.

35.   PCES, that has appeared as a result of cholecystectomy.

36.   PCES: diseases of hepatobiliary system, that were not corrected by cholecystectomy.

37.   PCES: organic and functional disorders of organs and systems, that are not connected with cholecystectomy.

38.   PCES: Nerve-kinetic disorders of hepatic ducts and duodenum.

39.   Cicatric biliary stricture. Types of operatons.

40.   Differential diagnosis of obstructive jaundice.

 

The student has to be able to:

1.       Reveal basic clinical signs of diseases of operated stomach.

2.       Substantiate and formulate the clinical diagnosis.

3.       Make differential diagnosis.

4.       Substantiate pharmacotherapy, indications for surgical treatment.

5.       Reveal basic reasons and clinical signs of postcholecystectomic syndrome.

6.       Substantiate and formulate the clinical diagnosis.

7.       Make differential diagnosis.

8.       Substantiate pharmacotherapy, indications for surgical treatment.

 

Technical means and material provision of lectures (names and numbers of tables, compact discs, instruments quantity, subjectpatients, etc.) –

Multimedia projection of demonstration material (pictures, tables, videofilms) from compact disc “Clinical Surgery”, videofilms with operations.

 

Test evaluation and situational tasks 14.00-15.00.

Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.

(the instructor has tests & situational tasks)

 

 

1. 40-years old patient, 3 years ago had an operation of stomach resection by Hoffmeister-Finsterer because of duodenum ulcer with petetration into the head of pancreas. Duting the last year notices everyday pain in right subcostal region, that are attended by bile vomiting up to 1 l in volume. After vomiting pain disappeares. The patient several times have passed treatment courses in surgical department, but there was no improving of his state. The patient has lost 16 kg of weight. During x-ray examination the contrast gets into the afferent loop.

Your diagnosis?

Surgeon’s tactics?

 

2. 45-year old patient, 3 years ago had an operation of 2/3 stomach resection by Hoffmeister-Finsterer because of stenosing ulcer of the antrum. Now the expressed dumping syndrome of severe degree with ptogressive weight loss is observed, despite repeated courses of in-patient and health resort treatment. Psychoneurological dusorders are expressed slightly. There is no bile vomiting. At x-ray examination of gastric stump the accelerated evacuation is observed.

Your diagnosis?

Surgeon’s tactics?

 

3. 48-years old patient, that has undergone an operation of cholecystectomy 3 years ago, has complaints on cramping pains, that were followed by raised temperature up to 38⁰C, scleral and mucous membranes icteritiousness. Whole bilirubin 128,0 mkmol/l, leukocites – 15,0×10⁹/l, stab neutrophils – 16 %.

What methods of examination should be used?

Your diagnosis?

Treatment tactics?

 

4. 35-year old female patient, a month ago had an operation of cholecystectomy. Now she complains on circumferential pain in abdomen, nausea, vomiting, icteritiousness of scleras and visible mucous membranes. Whole bilirubin is 60,0 mkmol/l. While palpation the patient feels pain in left mesogastral region. Symptoms of rebound stomach tenderness are absent.

Your diagnosis?

Surgeon’s tactics?

 

Information sourses:

 

Main –

1. Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2012.

2. L.Ya.Kovalchuck, Yu.P.Spizhenko, V.F.Sayenko and others “Hospital surgery”. Ternopil: Ukrmendknyga, 1999.

3. Practical classes materials   http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/Surgery/4/Topic%2008%20POSTRESECTION%20AND%20POSTVAGOTOMY%20SYNDROMES.%20CLASSIFICATION.%20CLINICS.htm

 

 

Additional –

1. Manual “Facultative Surgery” under the  edition  of V.O.Shidlovsky – Ternopil: Ukrmedknyga, 2002,  section “Diseases of the rectum and the colon”,

2. Compact disc “Facultative surgery.

3. Schwartz’s Principles of Surgery, Ninth Edition. F. Brunicardi. Philadelphia, Pa: Saunders Elsevier; 2009

4. Zollinger’s Atlas of Surgical Operations, 9th Edition. Robert Zollinger Jr., Elsevier; 2010

5. Chen, Herbert. Illustrative Handbook of General Surgery. Berlin: Springer, 2010.

 

 

The author: As. prof. A. Hospodarskyy

 

Обговорено на засіданні кафедри 

“03” червня 2014 р. протокол №2