Small bowel resection

Definition

A small bowel resection is the surgical removal of one or more segments of the small intestine.

Purpose

The small intestine is the part of the digestive system that absorbs much of the liquid and nutrients from food. It consists of three segments: the duodenum, jejunum, and ileum; and is followed by the large intestine (colon). A small bowel resection may be performed to treat the following conditions:

• Crohn's disease. This condition is characterized by a chronic inflammatory condition that affects the digestive tract. If other treatment does not effectively control symptoms, the physician may recommend surgery to close fistulas or remove part of the intestine where the inflammation is worst.
• Cancer. Cancer of the small intestine is a rare cancer in which malignant cells are found in the tissues of the small intestine. Adenocarcinoma, lymphoma, sarcoma, and carcinoid tumors account for the majority of small intestine cancers. Surgery to remove the cancer is the most common treatment. When the tumor is large, removal of the small intestine segment containing the cancer is usually indicated.
• Ulcers. Ulcers are crater-like lesions on the mucous membrane of the small bowel caused by an inflammatory, infectious, or malignant condition that often requires surgery and in some cases, bowel resection.
• Intestinal obstruction. This condition involves a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through. Intestinal obstruction is usually treated by decompressing the intestine with suction, using a nasogastric
  

  To remove a diseased portion of the small intestine, an incision is made into the abdomen, and the area to be treated is pulled out (A). Clamps are placed around the area to be removed and the section is cut (B). Three layers of sutures repair the remaining bowel (C). (

  Illustration by GGS Inc.

  )
  tube inserted into the stomach or intestine. In cases where decompression does not relieve the symptoms, or if tissue death is suspected, bowel resection may be considered.
• Injuries. Accidents may result in bowel injuries that require resection.
• Precancerous polyps. A polyp is a growth that projects from the lining of the intestine. Polyps are usually benign and produce no symptoms, but they may cause rectal bleeding and develop into malignancies over time. When polyps have a high chance of becoming cancerous, bowel resection is usually indicated.

Demographics

According to the National Cancer Institute, adenocarcinoma, lymphoma, sarcoma, and carcinoid tumors account for the majority of small intestine cancers which, as a whole, account for only 1–2% of all gastrointestinal cancers diagnosed in the United States.

Crohn's disease occurs worldwide with a prevalence of 10–100 cases per 100,000 people. The disorder occurs most frequently among people of European origin; is three to eight times more common among Jews than among non-Jews; and is more common among whites than nonwhites. Although the disorder can start at any age, it is most often diagnosed between 15 and 30 years of age. Some 20–30% of patients with Crohn's disease have a family history of inflammatory bowel disease.

The occurrence of polyps increases with age; the risk of cancer developing in an unremoved polyp is 2.5% at five years, 8% at 10 years, and 24% at 20 years after the diagnosis. The risk of developing bowel cancer after removal of polyps is 2.3%, compared to 8.0% for patients who do not have them removed.

Description

The resection procedure can be performed using an open surgical approach or laparoscopically. There are three types of surgical small bowel resection procedures:

• Duodenectomy. Excision of all or part of the duodenum.
• Ileectomy. Excision of all or part of the ileum.
• Jejunectomy. Excision of all or a part of the jejunum.

Open resection

Following adequate bowel preparation, the patient is placed under general anesthesia and positioned for the operation. The surgeon starts the procedure by making a midline incision in the abdomen. The diseased part of the small intestine (ileum or duodenum or jejunum) is removed. The two healthy ends are either stapled or sewn back together, and the incision is closed. If it is necessary to spare the intestine from its normal digestive work while it heals, a temporary opening (stoma) of the intestine into the abdomen ( ileostomy , duodenostomy, or jejunostomy) is made. The ostomy is later closed and repaired.

Laparoscopic bowel resection

Laparoscopic small bowel resection features insertion of a thin telescope-like instrument called a laparoscope through a small incision made at the umbilicus (belly button). The laparoscope is connected to a small video camera unit that shows the operative site on video monitors located in the operating room . The abdomen is inflated with carbon dioxide gas to allow the surgeon a clear view of the operative area. Four to five additional small incisions are made in the abdomen for insertion of specialized surgical instruments that the surgeon uses to perform the surgery. The small bowel is clamped above and below the diseased section and this section is removed. The small bowel ends are reattached using staples or sutures. Following the procedure, the small incisions are closed with sutures or surgical tape.

Diagnosis/Preparation

As with any surgery, the patient is required to sign a consent form. Details of the procedure are discussed with the patient, including goals, technique, and risks. Blood and urine tests, along with various imaging tests and an electrocardiogram (EKG), may be ordered as required. To prepare for the procedure, the patient is asked to completely clean the bowel and is placed on a low residue diet for several days prior to surgery. A liquid diet may be ordered for at least the day before surgery, with nothing taken by mouth after midnight. Preoperative bowel preparation involving mechanical cleansing and administration of antibiotics before surgery is the standard practice. This involves the prescription of oral antibiotics (neomycin, erythromycin, or kanamycin sulfate) to decrease bacteria in the intestine and help prevent postoperative infection. A nasogastric tube is inserted through the nose into the stomach on the day of surgery or during surgery. This removes the gastric secretions and prevents nausea and vomiting. A urinary catheter (thin tube inserted into the bladder) may also be inserted to keep the bladder empty during surgery, giving more space in the surgical field and decreasing chances of accidental injury.

Aftercare

Once the surgery is completed, the patient is taken to a postoperative or recovery unit where a nurse monitors recovery and ensures that bandages are kept clean and dry. Mild pain at the incision site is commonly experienced and the treating physician usually prescribes pain medication. Postoperative care also involves monitoring of blood pressure, pulse, respiration, and temperature. Breathing tends to be shallow because of the effect of anesthesia and the patient's reluctance to breathe deeply and experience pain that is caused by the abdominal incision. The patient is given instruction on the way to support the operative site during deep breathing and coughing. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage. The nasogastric tube remains in place, attached to low intermittent suction until bowel activity resumes. Fluids and electrolytes are infused intravenously until the patient's diet can gradually be resumed, beginning with liquids and progressing to a regular diet as tolerated. The patient is generally out of bed approximately eight to 24 hours after surgery. Patients are usually scheduled for a follow-up examination within two weeks after surgery. During the first few days after surgery, physical activity is restricted.

Risks

Risks include all the risks associated with general anesthesia, namely, adverse reactions to medications and breathing problems. They also include the risks associated with any surgery, such as bleeding or infection. Additional risks associated specifically with bowel resection include:

• bulging through the incision (incisional hernia)
• narrowing (stricture) of the opening (stoma)
• blockage (obstruction) of the intestine from scar tissue.

Normal results

Complete healing is expected without complications after bowel resection, but the period of time required for recovery from the surgery varies depending on the condition requiring the procedure, the patient's overall health status prior to surgery, and the length of bowel removed.

Morbidity and mortality rates

According to the National Cancer Institute, the predominant treatment for small intestine cancers is surgery when bowel resection is possible, and cure depends on the ability to completely remove the cancer. The overall five-year survival rate for resectable adenocarcinoma is 20%. The five-year survival rate for resectable leiomyosarcoma, the most common primary sarcoma of the small intestine, is approximately 50%.

Crohn's disease is a chronic incurable disease characterized by periods of progression and remission with 99% of patients suffering at least one relapse. Physicians are presently unable to predict the extent and severity of the disease over time; thus, while morbidity is very high for Crohn's disease, mortality is essentially zero.

Alternatives

Alternatives to bowel resection depend on the specific medical condition being treated. For most conditions where bowel resection is advised, the only alternative is treatment with drugs.

Resources

books

Michelassi, F. and J. W. Milsom, eds. Operative Strategies in Inflammatory Bowel Disease. New York: Springer Verlag, 1999.

Peppercorn, Mark, ed. Therapy of Inflammatory Bowel Disease: New Medical and Surgical Approaches. New York: Marcel Dekker, 1989.

Ratnaike, R. N., ed. Small Bowel Disorders. London: Edward Arnold, 2000.

Thompson, J. C., and L. Rose. Atlas of Surgery of the Stomach, Duodenum, and Small Bowel. St. Louis: Mosby, 1992.

periodicals

Bines, J. E., R. G. Taylor, F. Justice, et al. "Influence of Diet Complexity on Intestinal Adaptation Following Massive Small Bowel Resection in a Preclinical Model." Journal of Gastroenterology and Hepatology 17 (November 2002): 1170–1179.

Dahly, E. M., M. B. Gillingham, Z. Guo, et al. "Role of Luminal Nutrients and Endogenous GLP-2 in Intestinal Adaptation to Mid-Small Bowel Resection." American Journal of Physiology and Gastrointestinal Liver Physiology 284 (March 2003): G670–G682.

Libsch, K. D., N. J. Zyromski, T. Tanaka, et al. "Role of Extrinsic Innervation in Jejunal Absorptive Adaptation to Subtotal Small Bowel Resection: A Model of Segmental Small Bowel Transplantation." Journal of Gastrointestinal Surgery 6 (March-April 2002): 240–247.

O'Brien, D. P., L. A. Nelson, J. L. Williams, et al. "Selective Inhibition of the Epidermal Growth Factor Receptor Impairs Intestinal Adaptation After Small Bowel Resection." Journal of Surgical Research 105 (June 2002): 25–30.

organizations

American Board of Colorectal Surgeons (ABCRS). 20600 Eureka Rd., Ste. 600, Taylor, MI 48180. (734) 282-9400. http://www.abcrs.org .

American Society of Colorectal Surgeons (ASCRS). 85 West Algonquin, Suite 550, Arlington Heights, IL 60005. (847) 290 9184. http://www.fascrs.org .

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. http://www.uoa.org .

other

"Bowel Resection; Patient Discharge Instructions." Northwest Memorial Hospital Patient Education Brochure . March 2001 [cited June 25, 2003]. http://www.nmh.org/patient_ed_pdfs/pt_ed_bowel_resection_discharge.pdf. .

"Crohn's Disease." American Society of Colon and Rectal Surgeons Patient Brochure. 1996 [cited June 25, 2003]. http://www.fascrs.org .

Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Bowel resection surgery is performed by a colorectal surgeon, who is a physician fully trained in general surgery as evidenced by certification by the American Board of Surgery (ABS). Colorectal surgeons also are certified by the American Society of Colon and Rectal Surgeons (ASCRS), the leading professional society representing more than 1,000 board-certified colon and rectal surgeons and other surgeons dedicated to advancing and promoting the science and practice of the treatment of patients with diseases and disorders affecting the colon, rectum, and anus.

Bowel resection surgery is performed in a hospital setting.

QUESTIONS TO ASK THE DOCTOR

• What do I need to do before surgery?
• What happens on the day of surgery?
• What type of anesthesia will be used?
• What happens during surgery, and how is the surgery performed?
• What happens after the surgery?
• What are the risks associated with a small bowel resection?
• How long will I be in the hospital?
• When can I expect to return to work and/or normal activities?
• Will there be a scar?