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252 Atlas of Gastrointestinal Surgery: Small Bowel
After the ileum is separated from the vaginal cuff,
a small clamp is passed into the vagina, and
into the bowel, through the fistula site.
The vaginal cuff is closed with a
single layer of interrupted 3-0
Ileum
End-to-end
enteroenterostomy
synthetic absorbable sutures.
Peritoneal flap
over vaginal cuff
The diseased segment of
ileum is removed by firing
the linear stapler proximally
and distally, 3 or 4 cm from
grossly involved bowel. The
mesentery to this segment of
bowel is divided between Kelly
clamps and ligated with 2-0
2
silks. An end-to-end enteroen-
terostomy is performed with an inner
continuous layer of 3-0 synthetic
Ileum
Omental flap
absorbable suture material and an outer interrupt-
ed layer of 3-0 silk Lembert sutures. The rent in the
mesentery is closed with either continuous or interrupt-
ed sutures. The vaginal cuff closure is covered with a
peritoneal flap (2).
Alternatively, an omen-
tal flap can be used to cover
the closed vaginal cuff (3).
The abdomen is copiously
irrigated with antibiotic-con-
Vagina
taining solution and closed.
3
Crohn’s Disease with
Enterocutaneous Fistula
Operative Technique
When a patient with Crohn’s disease has been operated upon previously, recurrent Crohn’s disease of the small bowel may
become attached to the under surface of the abdominal wall incision. Occasionally a fistula will form, which may eventu-
ally express out through the skin onto the
abdominal wall (1). These are
generally very low output fis-
tulas, but they are trouble-
Skin
Fistula
some to patients and not
Proximal
small bowel
(distended)
Mesentery
Distal
small bowel
1
well tolerated.
254 Atlas of Gastrointestinal Surgery: The Small Bowel
In most instances the patient’s abdomen is re-entered through the old abdominal incision. The diseased segment of ileum
involved with Crohn’s disease is resected by firing the linear stapler proximal and distal to the diseased segment, with a
normal margin of 3 or 4 cm of bowel. The mesentery to this segment of bowel is divided between Kelly clamps and lig-
ated with 2-0 silks.
An end-to-end enteroenterostomy is performed with an inner continuous layer of 3-0 synthetic absorbable suture mate-
rial and an outer interrupted layer of 3-0 silk Lembert sutures. The rent in the mesentery is closed with either continuous or
interrupted sutures. The fistula site on the abdominal wall is freshed up by excising the granulation tissue. Partial abdominal
wall closure is then performed in the region of the prior fistula. A flap of omentum is created and tacked underneath the site
of abdominal wall closure to protect the anastomosis from becoming reattached to the incision at the site of the prior fistula
(2). The abdomen is copiously irrigated with antibiotic-containing solution and the midline wound is closed in layers.
Fistula
closed
Fistula site
on skin
Omental flap
Proximal
small
bowel
Abdominal
wall
Distal small
bowel
2
OTHER SMALL BOWEL PROCEDURES
Resection of Small Bowel
Gastrointestinal Stromal Tumor
Operative Indications
Gastrointestinal stromal tumors, or GISTs, are mesenchymal neoplasms that can arise anywhere in the gastrointestinal tract
from the esophagus to the rectum. The most frequent sites of occurrence are the stomach (approximately 50%), followed
by the small bowel (approximately 25%). Their behavior ranges from benign to highly malignant. The two most impor-
tant criteria for malignancy are size and mitotic rate. Lesions smaller than 3 cm in diameter and with fewer than five mitoses
per high-powered field virtually always behave in a benign fashion. However, lesions greater than 5 cm in diameter, with
more than 10 mitoses per high-powered field, generally behave in a malignant fashion. Surgery remains the main avenue of
therapy. However, targeted therapy for this lesion is now available in the form of imatinib, (Gleevec), a tyrosine kinase
inhibitor, which is highly effective. Histologically, these lesions may appear to arise from either smooth muscle or neural tis-
sue. Proof of diagnosis, however, is now made by finding the proto-oncogene c-KIT. If the proto-oncogene is not pres-
ent, the lesions are no longer considered gastrointestinal stromal tumors, most likely arise from smooth muscle, and are clas-
sified as leiomyomas or leiomyosarcomas.
These lesions tend to be bulky, may be fast growing, and can present with gastrointestinal bleeding or a palpable
abdominal mass. Since these lesions may be fast growing, they can outgrow their blood supply and develop a necrotic
center. This frequently will fistulize into the enteric lumen and cause gastrointestinal bleeding. The lesions, although often
quite large, generally do not invade surrounding tissues, but merely push them away. Thus, the lesions tend to be readily
resectable. GISTs are more apt to spread through the venous system, rather than via lymph nodes, and thus large lym-
phadenectomies are not necessary. The lesions tend to have a fairly characteristic appearance on CT scan. They appear as
a large bulky tumor with a necrotic center. If the CT scan demonstrates evidence of disseminated disease, the patient often
is treated with targeted therapy using Gleevec to reduce the tumor burden before exploratory laparotomy to resect the pri-
mary and disseminated disease.
256 Atlas of Gastrointestinal Surgery: The Small Bowel
Operative Technique
The patient is explored through a midline incision. In the patient illustrat-
ed, the GIST, arising from the small bowel, would be detectable on a rou-
tine physical examination by palpating an abdominal mass, and at the time
of laparotomy the lesion is mobile and not invading adjacent structures.
A segment of small bowel with the accompany-
ing mesentery is resected. The bowel is
divided proximal and distal to the tumor by
firing a linear stapler. The wedge of mesen-
tery is divided between Kelly clamps and
ligated with 2-0 silks (1).
GIST
Small bowel
Mesentery
1
Resection of Small Bowel Gastrointestinal Stromal Tumor 257
Enteric continuity is re-established with an end-to-end enteroenterostomy performed in two layers. The inner layer consists
of a 3-0 continuous synthetic absorbable suture, and the outer layer consists of multiple interrupted 3-0 silk Lembert
sutures. The defect in the mesentery is re-approximated with interrupted 3-0 silk sutures (2). A thorough staging of the
abdominal cavity is done at the time of laparotomy because, as
stated above, targeted therapy for disseminated disease is
available. The abdomen is copiously irrigated with
antibiotic-containing solution, and the wound is
closed in layers.
End-to-end enteroenterostomy
2
Resection of Carcinoid Tumor of
Small Bowel
Operative Indications
Carcinoid tumors are rare neuroendocrine neoplasms that can occur anywhere in the intestine, but are frequently found in
the distal small bowel. The majority of carcinoid tumors are within 2 or 3 ft of the ileocecal valve. These neuroendocrine
tumors can synthesize a wide spectrum of bioactive substances. They arise from enterochromaffin cells that reside in the
crypts of Lieberkuhn. Small bowel carcinoid tumors almost always produce serotonin. The lesions are usually multiple, with
two or three often found within a several-inch length of terminal ileum. Since they arise in the submucosa and do not have
a mucosal extension, diagnosis is frequently delayed. Metastases at the time of diagnosis are common, particularly in mesen-
teric lymph nodes. If widely metastatic to the liver, they may present with the carcinoid syndrome, which includes diar-
rhea, cutaneous flushing, and abdominal cramping. Approximately 20% of patients with small bowel carcinoid tumors
eventually manifest the carcinoid syndrome.
Many patients with carcinoid tumors are not diagnosed until exploratory laparotomy for small bowel obstruction. These
tumors classically elicit an intense desmoplastic reaction that leads to fibrosis and shortening of the adjacent small bowel
mesentery. This may result in kinking of the small bowel and partial or intermittent bowel obstruction. If one suspects a car-
cinoid tumor, a 24-hour urine collection can be analyzed for 5-hydroxyindoleactic acid, a metabolite of serotonin. This test
is 75% sensitive for detecting a carcinoid tumor, and if metastases are present it is 100% sensitive and specific. A CT scan
often shows a characteristic central lesion with calcification with a starburst appearance, secondary to mesenteric involvement.
An OctreoScan is also very specific for these lesions and can be used for staging to detect metastatic disease.
The 5-year survival rate for small bowel carcinoid tumors is between 60 and 70%. If disseminated disease is present,
specifically liver metastases, the 5-year survival drops to approximately 30%. Debulking carcinoid tumors and subsequent-
ly treating them with somatostatin analogs has been demonstrated to extend life expectancy.
Resection of Carcinoid Tumor of Small Bowel 259
Operative Technique
The patient is explored through a midline incision. The peritoneal contents are
carefully examined for evidence of disseminated disease. Since these lesions
have a specific predilection for the liver, the liver should be carefully exam-
ined. Often the primary tumor is difficult to detect, and can only be identi-
fied by careful palpation or even transillumination. In the instance illustrated
here, the carcinoid tumors would be palpable. Not infrequently, the largest
mass detectible consists of lymph nodes containing carcinoid tumor at the root
of the small bowel mesentery. Finding this mass of lymph nodes may lead to
careful palpation and detection of the primary tumor in adjacent small bowel,
when it is very small. If possible, the bowel and all lymph nodes in the mesen-
tery are excised. This sometimes is impossible because of lymph node involve-
ment of a broad area at the base of the mesentery, which would require resecting most or all of the small bowel to excise
all the lymph nodes. However in the illustrated patient, the primary and all lymph nodes can be excised by resecting a
segment of distal ileum and its surrounding mesentery. The linear stapler is fired both proximal and distal to the tumor, and
the corresponding mesentery is divided between Kelly clamps and ligated with 2-0 silks (1).
Carcinoid
tumors
Small
bowel
Mesenteric lymph
nodes
1
260 Atlas of Gastrointestinal Surgery: The Small Bowel
A standard end-to-end anastomosis is performed with
an inner continuous layer of 3-0 synthetic absorbable
suture material and an outer layer of interrupted 3-
0 Lembert silk sutures. The rent in the mesentery
is closed with interrupted 3-0 silks (2). The
abdomen is copiously irrigated with antibiotic-con-
End-to-end enteroenterostomy
taining solution, and the wound is closed in layers.
2
Resection of Desmoid Tumor of
Small Bowel
Operative Indications
Desmoid tumors are interesting lesions that form from fibro-aponeurotic tissue and often follow intra-abdominal surgery.
Many form in patients with Gardner syndrome or familial adenomatous polyposis. These lesions may originate in the root
of the transverse mesocolon after abdominal colectomy and involve the small bowel mesentery, or may actually arise in the
small bowel mesentery. Complete resection may be difficult and result in resection of most of the small bowel. These lesions
are considered benign, but can behave in a malignant fashion with local growth. Treatment with sulindac has shown some
success, as have tamoxifen and other anti-estrogens. More aggressive desmoid tumors may be treated with a variety of
chemotherapeutic agents.
Operative Technique
The patient is explored through a midline incision. The patient illustrated here
did not have familial adenomatous polyposis or Gardner syndrome and thor-
ough examination demonstrated no other pathology. The diagnosis of an intra-
abdominal tumor was made preoperatively by palpating an abdominal mass.
CT scan confirmed the presence of a soft tissue mass in the small bowel
mesentery.
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