Chapter 19. Small Bowel Resection

• Tumor.
• Ischemia or incarceration.
• Trauma or perforation.
• Fistula.
• Ulcer or bleeding.
• Obstruction.
• Stricture or Crohn's disease.

Absolute

• Poor blood supply to bowel ends (ie, radiation-injured bowel).
• Unclear bowel viability after a revascularization procedure.
  • Both ends of the small bowel may be brought up to skin level as temporary ostomies if the distal small bowel is involved. A proximal small bowel ostomy will create a high-output fistula that is difficult to manage.
  • Alternatively, both ends can be stapled closed and a plan made for a second-look laparotomy in 24–48 hours.
  • In extreme situations (eg, acute mesenteric ischemia with gangrene extending from the ligament of Treitz to mid colon), the likelihood of survival is very small. This is an absolute contraindication to attempted resection and anastomosis.
• Inadequate tumor margins.
  • If a tumor is unresectable, and small bowel obstruction is likely to occur, a side-to-side anastomosis in uninvolved bowel proximal and distal to the obstruction may be performed as a bypass procedure, leaving the tumor in situ.

Relative

• Peritoneal sepsis.
• Hemodynamically precarious patient.
• Extensive Crohn's disease.
  • Stricturoplasty should be considered to minimize the need for extensive resection and risk of short gut syndrome; 90 cm is the approximate shortest length of small bowel that might still support a viable oral nutrition program.

• The patient should be supine.
• The abdomen is usually entered through a midline incision.

• Epidural analgesia can decrease the amount of postoperative pain and ileus.
• The nasogastric tube should be left in place until resolution of postoperative ileus with nasogastric output < 200 mL per 8-hour shift. Diet should be advanced slowly after the passage of flatus.
• Perioperative antibiotics can be discontinued postoperatively if there has been no intraoperative contamination.
• Parenteral nutrition should be considered if the patient was malnourished preoperatively, if delayed resumption of oral intake is anticipated, or if prolonged postoperative ileus is expected.

• Wound infection.
• Prolonged ileus.
• Mechanical obstruction.
• Anastomotic bleeding.
• Anastomotic leak.
• Enterocutaneous fistula.