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Mesenteric Ischemia

Mesenteric ischemia represents insufficient perfusion of the mesentery to meet the metabolic demands of the splanchnic system. Understanding the etiology and presentation of the different forms of mesenteric ischemia is pivotal to the prompt diagnosis and treatment of this often life-threatening condition, with mortality rates that can range from 24% to 94%. This chapter will separate the forms of mesenteric ischemia based on the acuity of…

Anatomy and Physiology of the Mesenteric Circulation

The focus of this chapter is limited to describing the embryology, anatomy, and physiology of the mesenteric circulation. The terms mesenteric circulation and splanchnic circulation are sometimes used interchangeably; however, they have distinct meanings. The mesenteric circulation refers specifically to the vasculature of the intestines, whereas the splanchnic circulation provides blood flow to the entire abdominal portion of the digestive system that includes the hepatobiliary system,…

Suturing, Stapling, and Tissue Adhesion

Surgical procedures typically involve excision, resection, or transection to address a pathologic situation. Subsequent reconstruction, which includes maneuvers to secure a restoration of function, often allows the choice of a variety of methods. Surgical and general medical principles, safeguards, and prophylactic measures require planning, vigilance, and support across the health care spectrum to facilitate a completely successful result. Preoperative planning should be anticipatory, perioperative monitoring appropriate,…

Ileostomy

Ileostomy is an intestinal stoma fashioned from the distal small intestine. Although the creation of an ileostomy can be the smallest part of a larger surgery, the stoma can have the most significant physical and psychosocial effect on a patient. Despite an eventual return to a prior quality of life and activity level, body image and sexual function do not change over time. A well-constructed ileostomy…

Surgical Conditions of the Small Intestine in Infants and Children

In infants and children, small intestinal disorders encompass a wide spectrum of congenital and acquired conditions distinct from those seen in adults. Congenital lesions, such as rotational anomalies, duodenal or jejunoileal atresia, meconium ileus, omphalomesenteric remnants, and duplication cysts, are more likely to present in infancy, if not prenatally. Acquired pediatric small intestinal diseases include necrotizing enterocolitis (NEC) and intussusception. Malrotation Intestinal malrotation represents one of…

Gastrointestinal Lymphomas

The incidence of non-Hodgkin lymphoma (NHL) increased significantly in the United States and worldwide in the last two decades of the 20th century; most of this increase has been attributed to the HIV epidemic. The incidence of NHL appeared to reach a plateau around the turn of the 21st century, both in the human immunodeficiency virus (HIV)-infected and the non–HIV-infected population, and according to some reports…

Gastrointestinal Stromal Tumors

Epidemiology Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal, or nonepithelial, neoplasms of the gastrointestinal (GI) tract. GISTs may be found anywhere in the GI tract, from the esophagus to the internal anal sphincter. The most common GI location is the stomach (56%), as reported in a 2015 review of multiple population-based studies, followed by the small intestine (32%), colon and rectum (6%), and esophagus…

Gastrointestinal Carcinoid Tumors

In 1867 Theodor Langhans reported the first description of a carcinoid tumor in a 50-year-old woman with a mushroom-shaped small bowel tumor that contained nesting glandular structures within a fibrous stroma. Otto Lubarsch subsequently described autopsy findings of two patients with ileal tumors in 1888, making the astute observation that they were unlikely to be carcinomas. Soon thereafter, William Ransom described the first case of carcinoid…

Short Bowel Syndrome

The “normal” length of an adult human's small intestine has been estimated between 20 and 22 feet, or 609 and 670 cm. Past estimates of normal small intestine length have been between 300 and 800 cm, and this variability is based on measurements from surgical, radiologic, or autopsy measurements. Short bowel syndrome (SBS) occurs when there is less than 200 cm of small intestine remaining. The minimal length of…

Radiation Enteritis

The first record of radiation enteritis was described in 1897 and involved transient symptoms of pain and diarrhea that correlated with radiation exposure. The symptoms did not return after a lead shield was used during the experiments. Fifty to 70% of patients with malignancy undergo radiation therapy. Symptoms of acute radiation enteritis (ARE) are reported in a majority of patients. The incidence of chronic radiation enteritis…

Small Bowel Diverticula

Small bowel diverticular disease occurs in 0.3% to 20% of the population and is much less common than large bowel diverticular disease, which is present in 15% to 40% of adults. Of those with small bowel diverticula, only 4% will develop symptoms. Despite these relatively low statistics, it is nevertheless important for the general surgeon to have a firm understanding of small bowel diverticular disease when…

Gastric, Duodenal, and Small Intestinal Fistulas

A fistula is an abnormal communication between two epithelialized surfaces. Over the past half century, the mortality associated with gastrointestinal fistulas has decreased from 40% to 60% to approximately 15% to 20% of patients. This improvement in prognosis is attributable to advances in fluid and electrolyte/acid-base knowledge and therapy, blood administration, critical care, antibiotic regimens, and nutritional management. Formerly, malnutrition and electrolyte imbalance were the major…

Crohn Disease and Its Surgical Management

Crohn disease is an incurable, chronic disease of unknown etiology, which along with ulcerative colitis comprises inflammatory bowel disease (IBD). Crohn disease is characterized by transmural inflammation that can involve any part of the gastrointestinal tract, from mouth to anus, and presentations of the disease vary widely. Although there is no cure for Crohn disease at this time, great advances in medicine and surgery have aided…

Internal Hernias: Congenital and Acquired

Intestinal obstruction is a commonly encountered surgical condition. The diagnosis is made with a history of nausea, vomiting, abdominal pain, signs of abdominal distention and tenderness, and imaging displaying dilated bowel with air-fluid levels. Adhesive disease is the etiology of approximately 50% to 75% of small bowel obstructions, with Crohn obstruction, neoplasm, and abdominal wall hernia completing the differential diagnosis in most cases. Internal hernias, defined…

Volvulus of the Stomach and Small Bowel

The term volvulus derives from the Latin word volvere, meaning to turn or roll. Clinically, volvulus refers to a greater than 180-degree twisting of a hollow organ about its mesentery, resulting in luminal obstruction, impaired venous return, and eventually ischemia and perforation. Although much less common than volvulus of the cecum and sigmoid colon, small bowel volvulus (SBV) and gastric volvulus (GV) are clinical problems that,…

Small Bowel Obstruction

Descriptions of patients with small bowel obstruction (SBO) date back to the earliest medical literature. It was not until the 19th century and the advent of anesthesia and antisepsis, however, that surgery became a recognized and effective treatment. At the same time, physiologic studies of fluid shifts, electrolyte imbalances, intravenous resuscitation, and antibiotics allowed even safer surgical approaches to patients with obstruction. Despite advances in treatment,…

Anatomy and Physiology of the Small Intestine

The small intestine is the longest organ in the gastrointestinal (GI) tract. It is responsible for the absorption of nutrients, maintaining water and electrolyte balance, providing an immunologic barrier, and endocrine secretion. Embryology During the fourth week of gestation, the flat embryonic endoderm folds and fuses in the midline to create the gut tube. The tube consists of the foregut, midgut, and hindgut. The midgut, which…

Reoperations on the Stomach and Duodenum

Operations on the stomach and duodenum are performed for six primary reasons: neoplasia, gastroesophageal reflux disease (GERD), obesity, peptic ulcer disease, trauma, and congenital defects. Any operation done for these reasons, whether laparoscopic or open, can result in long-term complications requiring reoperation. This chapter describes how these complications can be avoided by attention to the details of the first operation and how they are managed by…

Adenocarcinoma of the Small Intestine

Although the small intestine is an infrequent site of gastrointestinal (GI) cancer, the incidence of small intestinal cancer has increased considerably in the past several decades, primarily due to an increase in adenocarcinoma and particularly small bowel neuroendocrine tumors; together, these cancers account for two-thirds of all small bowel malignancies. In 2016, an estimated 10,090 Americans will be diagnosed with small intestinal cancer, about one-third of…

Anatomy and Physiology of the Duodenum

Although spanning only 20 to 30 cm, from the pylorus to the ligament of Treitz, the duodenum is the “gate” that controls the passage of food from the stomach to the jejunum. The name is derived from the Latin phrase intestinum duodenum digitorum , or “intestine of twelve digits.” This Latin phrase may have derived from the writings of the Greek physician Herophilus (334–280 bc ). Although…