Nonneoplastic Conditions

Small intestinal resection in non-neoplastic conditions is essentially similar to that for neoplastic disease in that the affected length of intestine is resected, with continuity being restored by a hand-sewn end-to-end anastomosis. Some specific conditions are discussed below:

Crohn's disease: small bowel resection is usually reserved for those individuals for whom medical treatment has failed or who are suffering complications, e.g., obstruction (due to strictures), peri-intestinal abscess, fistula formation or perforation. Essentially, the extent of resection is limited to the macroscopically involved intestine as extensive resection does not reduce the risk of recurrent lesions and may lead to short bowel syndrome if subsequent resections are necessary.

If there are multiple areas of stricturing these need not be resected in order to preserve intestinal length. Instead, a "widening procedure" called a stricturoplasty may be employed. In this procedure the strictured region is incised longitudinally, the walls retracted and the incision then sutured transversely (Figure 4.3).

Infarction: at laparotomy the infarcted intestine will appear dusky and should be resected until there is active bleeding from the ends that are going to form the anastomosis. A primary anastomosis may be fashioned or in cases of extensive intraperitoneal leakage or uncertain intestinal viability, an ileostomy (or jejunostomy) and distal mucus fistula can be fashioned. Essentially, an ileostomy (or jejunostomy) is produced by bringing the cut opened end of the intestine out

Small intesti mesenU,,

Figure 4.2. Resection of tumour in small intestine.

through an opening in the abdominal wall where it is sutured in place. A special ileostomy bag is then fitted to collect the effluent.

Meckel's diverticulum: they are usually only resected if symptomatic or found incidentally during another procedure. Essentially, the diverticulum is excised with the opening in the intestinal wall closed in a transverse fashion to avoid luminal narrowing. If the diverticulum is large or broad based a limited ileal resection may be required.

Intussusception: barium enema can be used both as a diagnostic procedure, and if the reservoir of barium is elevated 1 metre above the abdomen, hydrostatic reduction under radiological screening can be attempted. Reduction is signified when barium flows freely to the proximal loops of ileum. If hydrostatic reduction fails, or there is evidence of perforation/peritonitis, operative management is indicated. In this, reduction may be facilitated by squeezing the distal colon and pushing the intussuscepted intestine proximally. If this is unsuccessful then resection of the affected segment should be carried out.

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