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6 Stomach
Research
Reference Findings
199
van Beek AP, Emous M, Laville M, Tack J.Dumping
syndrome after esophageal, gastric or bariatric
surgery: Pathophysiology, diagnosis, and
management. Obes Rev. 2017;18(1):68–85
Davis JL, Ripley RT.Postgastrectomy syndromes and
nutritional considerations following gastric surgery.
Surg Clin North Am. 2017;97(2):277–93
Suspected dumping syndrome can be conrmed using
symptom-based questionnaires, glycemia measurements
and oral glucose tolerance tests. First-line management
of dumping syndrome involves dietary modication, as
well as acarbose treatment for persistent hypoglycemia.
If these approaches are unsuccessful, somatostatin
analogues should be considered in patients with
dumping syndrome and impaired quality of life
Postgastrectomy syndromes are common sequelae of
surgery for gastric cancer. Nutritional deciencies and
perioperative nutritional supplementation are common.
Afferent and efferent loop syndromes commonly require
operative intervention for symptom resolution
Superior mesenteric artery syndrome
Etiology Acquired condition usually seen after signicant weigh loss or surgery for conditions
such as scoliosis
Presentation Compression of the third part of the duodenum as it crosses between aorta and
SMA➔nausea, vomiting, weight loss, and epigastric pain
Diagnosis CT scan showing aorto-superior mesenteric artery angle <25° (Normal angle 38–65°)
Management Correction of electrolytes
Refeeding
When nutritional status is restored➔duodenojejunostomy
Small Bowel
Gastrointestinal tract
ladder)
(Omphalomesenteric duct)
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LeoAmodu, CarolineE.Williams, HelenLiu,
SuedehRanjbar, MichaelKhalife, andDavidShin
Anatomy
Vitelline duct joins the yolk sac to the juncture of the
cranial and caudal limbs of the midgut loop
Persistent vitelline duct→Meckel diverticulum
7
Cloaca (b
Allantois
L. Amodu · H. Liu · S. Ranjbar
General Surgery Residency, NYU Long Island
School of Medicine, NYU Langone—Long Island
Hospital, Mineola, NY, USA
e-mail: leo.amodu@nyulangone.org;
helen.liu@nyulangone.org;
suedeh.ranjbar@nyulangone.org
C. E. Williams (*)
General Surgery Residency, University of Central
Florida/HCA Healthcare, Pensacola, FL, USA
e-mail: caroline.williams2@ucf.edu
M. Khalife · D. Shin
Department of Surgery, NYU Long Island School of
Medicine, NYU Langone—Long Island Hospital,
Mineola, NY, USA
e-mail: michael.khalife@nyulangone.org;
david.shin@nyulangone.org
Vitelline duct
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Ajouz et al. (eds.), The ABSITE Blueprints, https://doi.org/10.1007/978-3-031-32643-1_7
201
202
a
Jejunum
Arterial supply
Duodenum→superior anterior/posterior
pancreaticoduodenal arteries and inferior anterior/posterior
pancreaticoduodenal arteries
Jejunum and ileum→arterial arcades of SMA
SMA courses anterior to the uncinate process of pancreas
and third portion of duodenum
SMA supplies the pancreas, distal duodenum, entire small
intestine, and ascending and transverse colon
Venous drainage
Duodenum→pancreaticoduodenal vein→SMV→portal
vein
Jejunum and ileum→venous arcades of SMV→portal
vein
L. Amodu et al.
SMV joins the splenic vein behind the neck of the pancreas
to form portal vein
Small intestine: 300–500cm
Four portions:
Bulb
Duodenum
Descending-retroperitoneal
Transverse-retroperitoneal
Ascending
Absorption of iron
Larger circumference and thicker than the
Jejunum
ileum
One or two arcades
Long, straight vasa recta to the mesenteric
border
Maximum site of absorption
4–5 separate arcades
Ileum
Shorter vasa recta
Absorption of B12, bile acid, and folate
1-2 arcades
Long vascular recta
IIeum
4-5 arcades
Short vascular rect
7 Small Bowel
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Layers of the small bowel
Serosa
Outer longitudinal layer
203
Muscularis
propria
Submucosa Strongest layer
Mucosa Three layers: Muscularis mucosae, lamina
Main cell types found in the small bowel mucosal layer
• Absorptive enterocytes
• Goblet cells (secretes mucus)
• Paneth cells (secrete lysozyme, tumor necrosis factor)
• Enteroendocrine cells (produce gastrointestinal
hormones)
• Brunner cells (secrete alkaline)
Inner circular layer
Myenteric [Auerbach] plexus between the
muscle layers
propria, and epithelial layers
Characterized by transverse folds (plicae
circulares), which are prominent in the distal
duodenum and jejunum
Small Bowel Obstruction
Small bowel obstruction
Causes Adhesive disease (most common cause), hernia, malignancy, foreign body
Intussusception: Lead points are mostly neoplasms in adults
Nausea, vomiting, crampy abdominal pain, and obstipation
Presentation
Vomiting→loss of hydrochloric acid→decreases H+ & Cl−→alkalosis→renal system retains
hydrogen ions and excretes potassium in urine
→Hypochloremic metabolic alkalosis
Clinical signs and symptoms of bowel ischemia include: Fever, leukocytosis, tachycardia,
worsening abdominal pain, metabolic acidosis, tachypnea, peritonitis
204
Small bowel obstruction
L. Amodu et al.
Radiographic
ndings
Computed tomography of abdomen and pelvis with intravenous contrast
Pathology CT ndings CT images
Small bowel
obstruction
Air-uid levels
a
b
(A and B) axial abdominal CT images with
IV contrast demonstrates dilated small bowel
loops with a stack-of-coins appearance
(arrows). There are two transition points,
indicating a closed-loop obstruction
Coin stacking (thickened,
adjacent folds of small
bowel)
(arrowhead)
Transition point
Closed-loop
obstruction
Internal hernia Mesenteric swirling
Bowel ischemia
Closed-loop obstruction
Portal venous gas
Pneumatosis intestinalis (air
in bowel wall)
Mesenteric edema or
hemorrhage
Poor bowel enhancement
Bowel wall thickening
Free intraperitoneal uid
Fecalization of small bowel
Coronal abdominal CT image with IV
contrast demonstrates multiple dilated loops
of small bowel (arrow) with an abrupt
transition point (arrowhead) in the mid to
upper abdomen, consistent with small bowel
obstruction
a
7 Small Bowel
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Small bowel obstruction
205
b
Axial (A) and coronal (B) abdominal CT
images with IV contrast demonstrate multiple
dilated loops of small bowel with a “coinstacking” appearance and air-uid levels
(arrows). On coronal CT, a swirling
appearance of the mesenteric vessels
(arrowhead) can be seen, raising concern for
closed-loop obstruction
Axial abdominal CT image with IV contrast
demonstrates dilated small bowel, with air
inside the bowel wall and relatively poor
enhancement (arrows). Also note the small
bowel feces sign (arrowhead)
206
Small bowel obstruction
Fluid resuscitation/NPO/NGT
Indications for surgery: Clinical or radiologic signs of bowel compromise, clinical deterioration,
Management
leukocytosis or metabolic acidosis, and surgically correctable causes (closed-loop obstruction,
volvulus, intussusception, incarcerated hernia, gallstone ileus, foreign body ingestion, small bowel
tumor)
Case Management
L. Amodu et al.
Patient with SBO
and peritonitis or
swirling of
mesentery or
evidence of
compromised
bowels
Patient with
nonreducible
ventral hernia
causing SBO
Patient with SBO
and worsening
abdominal exam
Patient with
adhesive SBO and
no indications for
surgical
intervention
Patient with partial
SBO
Patient with SBO
and
pneumoperitoneum
Diagnostic laparoscopy or exploratory laparotomy
Diagnostic laparoscopy or exploratory laparotomy
Diagnostic laparoscopy or exploratory laparotomy
Nonoperative management+water-soluble contrast medium challenge
(gastrogran challenge)
Surgical intervention is strongly recommended if contrast has not reached the
colon at 12h after administration of gastrogran or if there is clinical
deterioration or failure to regain bowel function after 3–5days
Conservative management (NPO/resuscitation/NGT)
80% of partial SBO resolve within 72h
Diagnostic laparoscopy or exploratory laparotomy
Research
Reference
Zielinski MD, Haddad NN, Cullinane DC, etal.
Multi-institutional, prospective observational
study comparing the Gastrogran challenge
versus standard treatment in adhesive small bowel
obstruction. J Trauma Acute Care Surg.
2017;83(1):47–54
Zielinski MD, Eiken PW, Bannon MP, Heller SF,
Lohse CM, Huebner M, Sarr MG.Small bowel
obstruction-who needs an operation? A
multivariate prediction model. World J Surg.
2010;34(5):910–9. https://doi.org/10.1007/
s00268-010-0479-3. PMID: 20217412; PMCID:
PMC4882094
Findings
A multi-institutional, prospective, observational study was
performed on patients appropriate for gastrogran challenge
with adhesive SBO
They found out that evidence of gastrogran in the colon
even beyond 8h was predictive of successful nonoperative
management
Results showed that patients that received gastrogran for
adhesive disease had lower rates of exploration and shorter
hospital stays
This review from Mayo Clinic found that the small bowel
feces sign was associated with a greater than vefold
decreased risk of the need for an operation. Mesenteric
edema and free intraperitoneal uid were associated with
3.6- and a 3.8-fold increased risk
7 Small Bowel
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Research
Reference
Azagury D, Liu RC, Morgan A, Spain DA.Small
bowel obstruction: A practical step-by-step
evidence-based approach to evaluation, decision
making, and management. J Trauma Acute Care
Surg. 2015;79(4):661–8
207
Findings
The aim was to provide a practice summary of the optimal
evaluation and management of SBO from initial evaluation
to operative technique at a single institution. The goal is to
identify the need for urgent operative intervention or trialing
a combination of traditional conservative management and
having an institutionalized Gastrogran protocol adapted by
a multidisciplinary team
Millet I, Ruyer A, Alili C, etal. Adhesive smallbowel obstruction: Value of CT in identifying
ndings associated with the effectiveness of
nonsurgical treatment. Radiology.
2014;273(2):425–32
Zielinski MD, Eiken PW, Bannon MP, etal. Small
bowel obstruction—who needs an operation? A
multivariate prediction model. World J Surg.
2010;34(5):910–9
Millet I, Taourel RA, Molinari N.Value of CT
ndings to predict surgical ischemia in small
bowel obstruction: a systematic review and
meta-analysis. Eur Radiol. 2015;25:1823–35.
https://doi.org/10.1007/s00330-014-3440-2
This retrospective study found that an anterior parietal
adhesion, a feces sign, and the lack of a beak sign were
associated with successful nonsurgical treatment, whereas
two beak signs or more, a whirl sign, a C- or U-shaped
appearance of the bowel loop, and a high degree of
obstruction were associated with nonsurgical treatment
failure
Single center retrospective study to identify preoperative risk
factors associated with strangulating SBO and the need for
operative intervention. Identied clinical features predictive
of requiring operative intervention include: Intraperitoneal
free uid, mesenteric edema, lack of “small bowel feces
sign,” and a history of emesis
CT ndings identied and associated with the effectiveness
of nonsurgical management of adhesive SBO are the number
of beak signs and the location of the transition zone in
relation to the anterior peritoneal layer
Common etiologies of small bowel obstruction and their management
Adhesive Disease Gallstone Ileus
Etiology Previous abdominal
surgery
The mechanism involves stulization
between the gallbladder and
gastrointestinal tract→large stone
passes through the stula into the small
bowel→a bowel obstruction at the
ileocecal valve
Intussusception
Malignancy, polyps,
benign masses
Presentation Small bowel obstruction Intermittent obstruction Obstruction and current
jelly stool
Imaging Transition point without
masses
Calcied gallstone in the right lower
quadrant, air-uid levels, pneumobilia
“Target” sign
208
Common etiologies of small bowel obstruction and their management
Adhesive Disease Gallstone Ileus
Radiology
Coronal abdominal CT image with IV
contrast demonstrates a 5cm gallstone
(arrow) in mid-jejunal small bowel with
more proximal small bowel dilation
(arrowhead), representing gallstone
ileus
L. Amodu et al.
Intussusception
Management
Nonoperative
management+watersoluble contrast medium
challenge (gastrografn
challenge)
Surgical intervention is
strongly recommended if
contrast has not reached the
colon at 12h after
administration of
Gastrogran, or if there is
clinical deterioration or
failure to regain bowel
function after 3–5days
Operative intervention
Run the entire small bowel looking for
other stones
Milk the stone back away from the
ileocecal valve
Create an enterotomy to extract the stone
Remove any remaining gallstones, and
only perform cholecystectomy if the
patient is stable and the operation is
feasible
Research
Reference
Clark LH, Soliman PT, Odetto D, etal.
Incidence of trocar site herniation following
robotic gynecologic surgery. Gynecol Oncol.
2013;131(2):400–3
Goussous N, Kemp KM, Bannon MP, etal. Early
postoperative small bowel obstruction: Open vs
laparoscopic. Am J Surg. 2015;209(2):385–90
Operative
intervention→resection
of intussuscepted bowel
Findings
Trocar herniation is a known, but rare complication from
robotic surgery. Results demonstrate that larger port sites,
especially those >10mm are at an increased risk for
herniation. It is advisable to close these port sites
Early postoperative small bowel obstruction was observed less
frequently in patients who underwent laparoscopic procedures.
Additionally, an index laparoscopic surgery had a more benign
and focal disease process that manifested as localized
adhesions. Patients who had index laparoscopic procedures
had a more benign postoperative course, while those with
open developed a higher incidence of severe complications
after the reoperation (e.g., ICU stay, serosal tear, enterotomy,
and mortality)
7 Small Bowel
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Research
Reference
Stewart D, Waxman K.Management of
postoperative ileus. Dis Mon. 2010;56(4):204–14
209
Findings
Postoperative ileus is an abnormal pattern of gastrointestinal
motility and may occur after both abdominal and
nonabdominal operations. Etiologies include postoperative
pain, use of narcotics, electrolyte imbalance and manipulation
of the bowel intraoperatively. Here, a review of multiple
medications is seen, as well as early refeeding and gum
chewing
Kim CH, Joo JK, Kim HR, Kim YJ.The
incidence and risk of early postoperative small
bowel obstruction after laparoscopic resection
for colorectal cancer. J Laparoendosc Adv Surg
Tech A. 2014;24(8):543–9
Robb WB, Mariette C.Strategies in the
prevention of the formation of postoperative
adhesions in digestive surgery: a systematic
review of the literature. Dis Colon Rectum.
2014;57:1228–40
Zeng Q, Yu Z, You J, Zhang Q.Efcacy and
safety of Sepralm for preventing postoperative
abdominal adhesion: systematic review and
meta-analysis. World J Surg 2007; 31:2125
Adhesiolysis
Adhesiolysis
Choose the entry site to the abdomen (laparoscopic or open) away from surgical scars to avoid
underlying bowel
Early postoperative small bowel obstruction following
laparoscopic resection for colorectal cancer occurred in 5.9%
of patients
Factors for predicting the development of early postoperative
small bowel obstruction are variables reective of a more
difcult surgery, rather than pathologic disease severity or
anatomical location
Most patients improved with conservative treatment, and
surgical treatment was rarely needed
For patients undergoing intestinal surgery demonstrated that
treatment with hyaluronic acid sheets reduced intra- abdominal
adhesions and the extent of adhesions signicantly but did not
reduce the incidence of postoperative intestinal obstruction
Hyaluronic acid sheet use increased septic complications such
as abdominal abscess and anastomotic leak
Key steps
Intraoperative
complications
Use sharp dissection to release the adhesions between small bowel loops and between small
bowel and abdominal wall
Address the site of obstruction and any other major adhesions, but complete lysis of adhesions is
not indicated
Run the small bowel from the ileocecal valve to ligament of Treitz to ensure no other sites of
obstruction and enterotomies
Case Management
Serosal injury Primary repair with interrupted lambert
Small bowel injury <50% of circumference Primary repair with interrupted lambert
Small bowel injury >50% of circumference Resection of affected area and anastomosis
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