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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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220
Ileus
L. Amodu et al.
Correct reversible causes such as intra- abdominal abscess or retroperitoneal bleeding, sepsis
Replete electrolytes
Discontinue medications that cause ileus (discontinue opioids or use them sparingly)
Bowel rest and replacement uid therapy
NGT if patient for moderate-to-severe or continuous vomiting, or signicant abdominal distention
Management
Prevention
Nutritional support if postoperative ileus is prolonged
Serial abdominal examination to evaluate the amount of distention and tenderness
If above management fails→obtain a computed tomography scan to look for other causes (such as
obstruction)
Adoption of enhanced recovery protocols
Adopting minimally invasive surgery when possible
Multimodal analgesia instead of opioids
Strategic uid management (avoid volume overloading)
Pneumatosis
Pneumatosis
Characteristics Benign pneumatosis intestinalis can occur with chronic obstructive pulmonary disease (COPD),
mechanical ventilation, jejunal feeding, and after endoscopy
The most common location of pneumatosis intestinalis is the jejunum
Etiology Mechanical theory (due to direct trauma), mucosal damage, bacterial theory, and pulmonary
hypotheses (due to COPD, ventilation)
Presentation Most patients are asymptomatic
Can present with abdominal pain, obstruction, bleeding
7 Small Bowel
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Pneumatosis
221
Abdominal radiograph, CT abdomen, and pelvis
Diagnosis
Management
Cystic pneumatosis:
Collection of air in
submucosa
Radiology
Axial abdominal CT image
with oral and IV contrast
demonstrates focal cysticappearing submucosal
air-collections (arrow),
indicating cystic pneumatosis
When pneumatosis is accompanied by decreased mural contrast enhancement, presence of
associated portal venous gas, pneumoperitoneum→high suspicion of intestinal ischemia
Case Management
Patient with pneumatosis
intestinalis and no other
worrisome features on CT
scan and benign abdominal
exam
No surgical intervention
Linear pneumatosis: Collection of
air within muscularis and subserosa
Axial abdominal CT image without
contrast demonstrates linear
pneumatosis in dilated small bowel
loops (arrows), which is highly
consistent with necrosis
Patient with pneumatosis
intestinalis and peritonitis
Patient with pneumatosis
intestinalis and portal
venous gas or decreased
contrast enhancement of
bowel wall
Exploratory laparotomy
Exploratory laparotomy
Research
Reference
Treyaud MO, Duran R, Zins M, Knebel JF, Meuli
RA, Schmidt S.Clinical signicance of
pneumatosis intestinalis- correlation of MDCTndings with treatment and outcome. Eur Radiol.
2017;27(1):70–9
Tahiri M, Levy J, Alzaid S, Anderson D.An
approach to pneumatosis intestinalis: factors
affecting your management. Int J Surg Case Rep.
2015;6C:133–7
Findings
Pneumatosis intestinalis accompanied with decreased bowel
wall enhancement, and severe atherosclerosis highly
signicantly correlate with an intestinal ischemia
The risk for bowel wall compromise is higher if pneumatosis
is accompanied with acute abdomen, hypotension, elevated
serum lactate, white cell count or creatinine, low serum
bicarbonate, age above 60 and complemented by radiological
ndings such as bowel dilatation, ascites or portal venous
gas. In the presence of these factors, surgical exploration is
warranted
222
L. Amodu et al.
Radiation Enteritis
Radiation enteritis
Histologic ndings Occlusive vasculitis, diffuse collagen deposition with mucosal and serosal
thickening→brosis of submucosa, arteritis, vascular sclerosis, mucosal atrophy
Presentation Diarrhea, crampy abdominal pain, nausea, emesis, diminished appetite, diarrhea, and fecal
urgency
Diagnosis Endoscopy and biopsy (ndings: Pallor with friability and telangiectasias, strictures,
perforation, stulas, and necrosis)
CT/MR enterography showing segmental inammation
Dietary modication: Avoidance of high ber diet
Management
Antidiarrheal agents (loperamide): Improves bile acid absorption, slows transit time, and
improves diarrheal symptoms
Bile acid sequestrants (cholestyramine): Used in patients with persistent diarrhea despite
antidiarrheals
Antibiotics: Only if bacterial overgrowth is suspected
Surgery should be avoided due to the frequency of dense adhesions and the risk for
unintentional enterotomies and possible short gut
Indications for surgery: Obstruction, perforation, bleeding, stula
Research
Reference
Wedlake L., Silia F., Benton B., Lalji A., Thomas K.,
Dearnaley D., etal. Evaluating the efcacy of statins
and ACE-inhibitors in reducing gastrointestinal
toxicity in patients receiving radiotherapy for pelvic
malignancies. Eur J Cancer 2012;48:2117–24
Leonard C., Shapiro H., Henkenberns, Cornish P.,
Dahl K. (2005) Amifostine used as a normal tissue
protectant in patients receiving pelvic radiotherapy.
Int J Radiat Oncol Biol Phys 63:S448
Findings
Angiotensin-converting enzyme inhibitors and statins
have been shown to limit radiation enteritis
Amifostine, which is converted into an active metabolite
that binds free radicals, is the most effective medication
to protect against the negative effects of radiation on the
small bowel
Short Bowel Syndrome
Short bowel syndrome
Determinants of
intestinal function
after bowel resection
Length of remaining small bowel and colon
Length of remaining ileum (ileum has greater capacity to adapt)
Presence or absence of ileocecal valve
7 Small Bowel
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Short bowel syndrome
Intestinal insufciency: Patients who are able to compensate for malabsorption by
increasing oral intake or using pharmacotherapy
Intestinal failure
versus intestinal
insufciency
Intestinal adaptation
Intestinal sites of
nutrient absorption
Intestinal failure: Patients who are unable to compensate with oral intake or
pharmacotherapy and are dependent on parenteral nutrition
Capacity to adapt: Ileum≫jejunum≫colon
The best stimulant of intestinal adaptation is the presence of nutrients in the intestinal
lumen
Glucagon-like peptide 2 (GLP-2) is an important mediator of intestinal adaptation
Duodenum
Duodenum/ Proximal jejunum:
- Fats
- Sugars
- Peptides / amino acids
- iron
- Folate
- Calcium
Jejunum / Proximal ileum:
- Fats
- Sugars
- Peptides / amino acids
- Waer- soluble vitamins (A,E,D,K)
223
Categories of bowel
anatomy after
resection and its
implication to
absorption
Distal ileum:
- Bile salts
- Vitamin B
Colon:
- Potassium
- Short-chain fatty acids
12
Jejuno-colic anastomosis
Jejunum
IIeum
Colon
Because ileum is resected→severe malabsorption+loss of
vitamin B12 receptors, fat-soluble vitamins, and bile salts
Ileo-colic anastomosis Best prognosis because portion of ileum preserved
End-jejunostomy Worst prognosis because entire ileum is resected, and colon
is resected or present but disconnected
224
Short bowel syndrome
Management Case Management
L. Amodu et al.
Acute phase (initial
3–4weeks after intestinal
resection)
Patients with intestinal
failure not responsive to
supportive management
Stabilize large uid and electrolyte losses
Maintain uid and acid/base balance (IVF, acid suppression,
TPN, enteral feeds, antimotility agents, and antidiarrheal
agents)
Transition to oral feedings over a period of weeks to months
In patients with a colon-in-continuity→diet high in complex
carbohydrates and modest in fat and oxalate
Teduglutide (longer-acting GLP-2 analog→promotes
intestinal adaptation and absorption)
Restoration of intestinal continuity and other surgical
options:
Serial transverse enteroplasty→improve motility (if small
bowel is dilated)
Segmental reversal of small bowel→improve motility (if no
small bowel dilation)
Sequential intestinal lengthening→increase mucosal surface
area
Intestinal transplantation
Research
Reference
DiBaise JK, Young RJ, Vanderhoof JA.Intestinal
rehabilitation and the short bowel syndrome:
part 1. Am J Gastroenterol 2004;99:1386
Jeppesen PB, Pertkiewicz M, Messing B, etal.
Teduglutide reduces need for parenteral support
among patients with short bowel syndrome with
intestinal failure. Gastroenterology
2012;143:1473
Jeppesen PB.Spectrum of short bowel syndrome
in adults: intestinal insufciency to intestinal
failure. JPEN J Parenter Enteral Nutr.
2014;38(suppl 1):8S–13S
Findings
The best-established stimulant of intestinal adaptation is the
presence of nutrients in the intestinal lumen
Teduglutide, a longer-acting GLP-2 analog, promotes
intestinal adaptation and absorption and has modest benets
with respect to weaning of parental support in adults with
short bowel syndrome
Metabolic bone disease, parenteral nutrition-associated liver
disease, cholelithiasis, nephrolithiasis, and catheter-related
bloodstream infections are potential complications from
chronic total parenteral nutrition use and short bowel
syndrome
7 Small Bowel
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Small Intestinal Neoplasms
Small bowl masses
Small bowel mass Characteristics
Predisposing conditions: Celiac disease and
immunodeciency states
Lymphomas
Most commonly found in ileum
Presentation: Abdominal pain, weight loss,
obstructive symptoms, and perforation
Perforation in 25%
225
Management
No symptoms→chemotherapy
Obstruction or perforation→small
bowel resection
Neuroendocrine tumors
(carcinoids)
Adenoma
Arise from enterochromafn cells
Found in appendix>distal
ileum>colon>stomach>rectum
Presentation: Abdominal pain (most common),
intestinal obstruction and bleeding
Multicentric in 20–30% of patients
Coexist with a second primary malignant tumor
(most commonly a synchronous
adenocarcinoma of the large intestine)
Associated with multiple endocrine neoplasia
type 1 syndrome in 10% of cases
Diagnosis: Serum chromogranin A level
together with a 24-h urine 5-hydroxyidoleacetic
acid (5-HIAA) level
15% of all benign small bowel tumors
Types: True adenomas, villous adenomas, and
Brunner gland adenomas
Found in ileum (50%)>jejunum>duodenum
Most common presenting symptoms: Bleeding
and obstruction
Small bowel resection; if wide
mesenteric
Tumors in the terminal ileum→right
hemicolectomy
Metastatic NETs→surgical
debulking to provide symptomatic
relief
Endoscopic mucosal resection
Villous adenomas most commonly in the
duodenum, and may be associated with FAP
Primary adenocarcinoma Most common in duodenum
May have associated ulcers
Lead to obstruction and/or bleeding
A positive surgical margin has been found to be
associated with a poor prognosis
Hamartomas Associated with Peutz-Jeghers syndrome
Arise in jejunum and terminal ileum
Small bowel resection and wide
mesenteric lymphadenectomy
Endoscopic resection, polypectomy
via enterotomy, and bowel resection
226
Small Intestinal Resection
Small intestinal resection
Preserve as much bowel and mesentery as possible
L. Amodu et al.
Key steps to bowel
resection
Types of anastomosis
Assess bowel viability
Ensure good blood supply at the cut edge of the bowel
Conrm that the mesentery is not twisted or kinked prior to creating the anastomosis
Make sure that the anastomosis is tension-free
End-to-end anastomosis Replicate normal gut motility (physiologic)
Side-to-side anastomosis Most commonly used with linear stapled anastomoses
End-to-side anastomosis Used when there is a size mismatch between the bowel
Clinical judgment Apply a warm laparotomy pad (to improve circulation)
Doppler ultrasound Assess for audible arterial signals within the mesentery
Wood lamp (with uorescein
dye)
Fluorescence angiography
with intravenous indocyanine
green
Research
Reference
Joosten JJ, Longchamp G, Khan MF, etal. The use of
uorescence angiography to assess bowel viability in the
acute setting: an international, multi-center case series.
Surg Endosc 2022;36(10):7369–75
loops to be anastomosed
over the area of small bowel in question and check the
viability of bowel
and bowel wall
After administering uorescein
intravenously→perfused regions as bright green while
areas of ischemia will appear darker by comparison
Intraoperative uorescence angiography is shown to
have value for evaluation of adequate perfusion in
gastrointestinal anastomoses in the elective setting
Findings
In the acute setting, the intraoperative use of
uorescene angiography impacts surgical decisions
regarding bowel resection for intestinal ischemia,
potentially enabling bowel preservation in
approximately one out of four patients
7 Small Bowel
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Complications of bowel resection and their management
Complication Characteristics
Pain and redness in incision Open the incision and check if the midline
Wound infection
227
Management
fascia is intact
Bedside irrigation and
debridement+packing in a “wet-to-dry”
fashion
If cellulitis or purulent
drainage→antibiotics
Present 5–7days postoperative
Anastomotic leak
Enterocutaneous stula
Small bowel obstruction Small bowel obstruction due to adhesions Patient with persistent or recurrent
Presentation: Tachycardia, peritonitis,
prolonged ileus, abdominal pain, fever
Fever, leukocytosis, and wound erythema
Sepsis is common and is the most common
cause of death
High output stula→increased risk of
metabolic derangements
Patients with enteroenteric and
enterocolonic stulae may have diarrhea
Resuscitation (IVF)+antibiotics
Stable→CT with PO and IV contrast
Unstable→surgical intervention
See table above
SBO→laparoscopic adhesiolysis
Research
Reference
Sajid MS, Siddiqui MR, Baig MK.Single layer
versus double layer suture anastomosis of the
gastrointestinal tract. Cochrane Database Syst Rev.
2012; 1:CD005477
Suturing or stapling in gastrointestinal surgery: a
prospective randomized study. West of Scotland and
Highland Anastomosis Study Group. Br J Surg
1991;78:337
Handsewn single- and double-layer anastomoses: There
was no signicant difference in anastomotic failure,
morbidity, and mortality rates. Single-layer anastomosis
was faster, but only by a mean difference of 11min
Handsewn and stapled anastomoses: The incidence of
clinical leaks was similar between the two groups, while
the incidence of radiological leaks was higher in the
sutured group. Other patient outcomes were comparable
Findings
Colon
c of riolan
Super
HazimHakmi, HassanHashmi, ToyookiSonoda,
andMatthewSymer
Anatomy
Anatomy
Arterial supply:
Ileocolic, right and middle colic arteries
(branches of SMA) supply the ascending
and proximal 2/3 of transverse colon.
• Left colic, sigmoid and superior rectal
arteries (branches of IMA) supply distal
1/3 of transverse, descending colon,
sigmoid, and upper part of rectum.
• Watershed areas: Splenic exure “Grifth
point” (SMA and IMA junction)
Recto-sigmoid junction “Sudeck point”
(junction of last sigmoidal and superior
rectal artery)
Middle colic
artery
Right colic
artery
IIeocolic
artery
ior rectal
artery
Marginal artery
of Drummond
Internal iliac
artery
Middle rectal artery
Inferior rectal artery
Ar
Superior
mesenteric
artery
Inferior
mesenteric
artery
Left
colic artery
Sigmoid
arteries
8
H. Hakmi (*) · H. Hashmi
General Surgery Residency, NYU Long Island
School of Medicine, NYU Langone—Long Island
Hospital, Mineola, NY, USA
e-mail: hazim.hakmi@nyulangone.org
M. Symer
Department of Surgery, NYU Long Island School of
Medicine, NYU Langone—Long Island Hospital,
Mineola, NY, USA
e-mail: matthew.symer@nyulangone.org
T. Sonoda
Division of Colon and Rectal Surgery, Department of
Surgery, NYU Long Island School of Medicine, NYU
Langone—Long Island Hospital, Mineola, NY, USA
e-mail: toyooki.sonoda@nyulangone.org
© 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_8
229
230
Inter
ry
Male Female
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Anatomy
A large collateral vessel known as the
marginal artery forms a circular arcade at
the mesenteric border and connects all the
colon branches
• Arc of Riolan connects SMA to IMA
along with marginal arteries providing
collateral supply
• Variants in collateral supply are common
Venous drainage:
• Venous drainage follows arterial anatomy.
SMV joins splenic vein to form portal
vein. IMV joins splenic vein and variant
joins portal vein or SMV
Ureters:
• Passes anterior to psoas muscle and enters
posterior aspect of bladder
• Runs posterior to gonadal vessels
• Antior to iliac vessels close to iliac
bifurication
• Left ureter more commonly injured during
IMA division or from adhesions
• Identied by observing peristalsis under
cecum or sigmoid colon
Ureter
nal iliac
artery
External
iliac artery
Vas
deferens
Bladder
Uterus
H. Hakmi et al.
Ureter
Common
iliac arte
Rectum
Uterine
artery
Appendix:
• Lies 60% in RLQ, 30% in pelvis and 10%
is retro-cecal
Lower Gastrointestinal Bleeding
Lower GI bleeding
Anatomy Bleeding originating beyond the ligament of Treitz
Types of lower GI
bleeding
Common causes and
pathophysiology
Hematochezia: Bleeding per rectum, either bright red, clots, or burgundy stools
Melena: Passage of black, tarry stools
Diverticulosis: Site of vasa recta penetrating bowel wall with no muscular layer
support➔outpouching➔erosion causes brisk arterial bleeding
Angiodysplasia: Constipation➔new AVM and vasodilation➔incompetent
precapillary valves➔slow venous blood loss➔melena and iron deciency anemia
Ischemic colitis
Hemorrhoids
Polyps and neoplasms
Inammatory bowel disease
Radiation proctitis
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