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Home , Appendix (anatomy), Blind loop syndrome, Fecalith, Fistula, Strictureplasty

GIGI SurgerySurgery (Small(Small IntestineIntestine && )Appendix) SmallSmall IntestineIntestine

ObstructionObstruction Historically,Historically, nonoperativenonoperative managementmanagement ruledruled Reduction of Laxatives Ingestion of heavy metals Leeches LateLate 1800s1800s whenwhen antisepsisantisepsis andand asepticaseptic surgicalsurgical techniquetechnique developeddeveloped surgicalsurgical interventionintervention becamebecame safersafer SmallSmall IntestineIntestine -- ObstructionObstruction

UnderstandingUnderstanding thethe pathophysiologypathophysiology ofof SBOSBO withwith thethe useuse ofof thethe followingfollowing hashas greatlygreatly reducedreduced mortalitymortality ofof ptspts withwith mechanicalmechanical SBOSBO IsotonicIsotonic fluidfluid resuscitationresuscitation IntestinalIntestinal tubetube decompressiondecompression AntibioticsAntibiotics SBOSBO

EtiologyEtiology ObstructionObstruction arisingarising fromfrom extraluminalextraluminal causescauses (adhesions,(adhesions, hernias,hernias, carcinomas,carcinomas, andand )abscesses) ObstructionObstruction intrinsicintrinsic toto thethe bowelbowel wallwall (primary(primary tumors)tumors) IntraluminalIntraluminal obstructionobstruction (,(gallstones, enteroliths,enteroliths, FB,FB, )bezoars) SBOSBO

AtAt turnturn ofof 2020th century,century, herniashernias accountedaccounted forfor >50%>50% ofof mechanicalmechanical SBOSBO NowNow withwith electiveelective herniahernia repairs,repairs, itit isis thethe 33rd mostmost commoncommon causecause ofof SBOSBO ADHESIONSADHESIONS areare byby farfar thethe MCCMCC ofof SBO!SBO! SBOSBO

AdhesionsAdhesions MainlyMainly afterafter pelvicpelvic operationsoperations (gynecologic(gynecologic procedures,procedures, ,appendectomy, andand colorectalcolorectal resection)resection) MoreMore thanthan 60%60% ofof allall causescauses ofof bowelbowel obstructionobstruction inin thethe U.S.U.S. LikelyLikely duedue toto thethe increasedincreased mobilitymobility ofof thethe bowelbowel inin thethe pelvispelvis asas comparedcompared toto thethe moremore tetheredtethered statestate inin thethe upperupper abdomenabdomen SBOSBO

MalignantMalignant tumorstumors 20%20% ofof casescases MajorityMajority areare metastaticmetastatic lesionslesions secondarysecondary toto peritonealperitoneal implantsimplants thatthat havehave spreadspread fromfrom anan intraintra--abdominalabdominal primaryprimary tumortumor suchsuch asas ovarian,ovarian, pancreatic,pancreatic, gastric,gastric, oror coloniccolonic PrimaryPrimary coloniccolonic cancerscancers (cecal(cecal oror ascendingascending colon)colon) maymay causecause extrinsicextrinsic compressioncompression PrimaryPrimary SBSB tumorstumors areare extremelyextremely rarerare SBOSBO

HerniasHernias 10%10% ofof casescases (3(3rd MCC)MCC) VentralVentral oror inguinalinguinal InternalInternal herniashernias –– usuallyusually relatedrelated toto priorprior abdominalabdominal surgerysurgery SBOSBO

CrohnCrohn’’ss diseasedisease 44th MCCMCC (approximately(approximately 5%)5%) ObstructionObstruction resultsresults fromfrom acuteacute inflammationinflammation andand edemaedema thatthat sometimessometimes resolvesresolves withwith conservativeconservative managementmanagement LongstandingLongstanding CrohnCrohn’’ss diseasedisease cancan leadlead toto stricturesstrictures thatthat maymay requirerequire resectionresection andand reanastomosisreanastomosis versusversus strictureplastystrictureplasty SBOSBO

PathophysiologyPathophysiology Early in an obstruction, intestinal motility and contractile activity increase to propel luminal contents past the obstructing point Early on this increase in peristalsis is present both proximal and distal to the point of obstruction Later in the course, the intestine becomes fatigued and dilates With dilation, water and electrolytes accumulate both intraluminally and within the bowel wall SBOSBO

PathophysiologyPathophysiology Massive 3rd-space fluid loss dehydration and hypovolemia Can lead to hypotension, shock, IAP, ↓venous return, elevation of the diaphragm, ↓ ventilation Proximal obstruction Dehydration + hypochloremia + hypokalemia + metabolic alkalosis + Distal obstruction Less dramatic electrolyte abnormalities Dehydration + oliguria + azotemia + hemoconcentration SBOSBO

PathophysiologyPathophysiology AsAs thethe intraluminalintraluminal pressurepressure ↑↑,, thethe mucosalmucosal bloodblood flowflow ↓↓ ConcernConcern forfor bowelbowel perforationperforation andand peritonitisperitonitis InIn absenceabsence ofof obstruction,obstruction, jejunumjejunum && ileumileum virtuallyvirtually sterile;sterile; however,however, withwith obstruction,obstruction, microfloramicroflora changeschanges E. coli, S. faecalis, Klebsiella (up to 109-1010/ml) SBOSBO –– ClinicalClinical ManifestationsManifestations

SymptomsSymptoms Colicky Vomiting Have patient describe bilious, nonbilious, or feculent Failure to pass flatus/ (obstipation) Develops later Pts may report early on due to increased peristalsis Abdominal distention SBOSBO –– ClinicalClinical ManifestationsManifestations

PhysicalPhysical ExamExam +/- tachycardia +/- hypotension suggestive of severe dehydration Fever (possible strangulation) Distended Rushes/tinkles Localized tenderness, rebound, guarding concern for and strangulated bowel ALWAYS check for incarcerated inguinal hernias!!! Rectal exam – perform hemoccult SBOSBO –– ClinicalClinical ManifestationsManifestations

XX--RayRay AASAAS usuallyusually confirmconfirm H&PH&P 60%60% accurateaccurate UprightUpright multiplemultiple AFLAFL SBOSBO –– ClinicalClinical ManifestationsManifestations

CompleteComplete bowelbowel obstructionobstruction secondarysecondary toto largelarge radiopaqueradiopaque gallstonegallstone SBOSBO –– ClinicalClinical ManifestationsManifestations

CTCT scanscan BeneficialBeneficial whenwhen diagnosisdiagnosis uncertainuncertain SensitiveSensitive forfor diagnosingdiagnosing completecomplete oror HGHG SBOSBO andand forfor determiningdetermining locationlocation andand etiologyetiology LessLess sensitivesensitive inin PSBOPSBO HelpfulHelpful forfor extrinsicextrinsic causescauses SBOSBO –– ClinicalClinical ManifestationsManifestations SBOSBO –– ClinicalClinical ManifestationsManifestations

Barium/Enteroclysis Enteroclysis – oral insertion of tube into to instill air and barium directly into Definitive study in pts in whom diagnosis of LG intermittent SBO is clinically uncertain Disadvantages of enteroclysis NGT Slow transit of contrast in pts with SBO Expertise required SBOSBO –– ClinicalClinical ManifestationsManifestations

U/SU/S PregnantPregnant ptspts MRIMRI NoNo betterbetter thanthan CTCT SBOSBO –– ClinicalClinical ManifestationsManifestations

LabLab workwork NotNot helpfulhelpful inin diagnosisdiagnosis EssentialEssential inin assessingassessing degreedegree ofof dehydrationdehydration PtsPts withwith SBOSBO needneed serialserial electrolyteelectrolyte checkschecks toto assessassess effectivenesseffectiveness ofof resuscitationresuscitation FollowFollow HctHct secondarysecondary toto resuscitationresuscitation onon hemoconcentrationhemoconcentration associatedassociated withwith SBOSBO LeukocytosisLeukocytosis maymay bebe associatedassociated withwith strangulationstrangulation SimpleSimple vs.vs. StrangulatingStrangulating SBOSBO

StrangulatingStrangulating SBOSBO usuallyusually involvesinvolves closedclosed--looploop obstructionobstruction AssociatedAssociated withwith increasedincreased morbidity/mortalitymorbidity/mortality ““ClassicClassic signssigns”” Tachycardia Fever Leukocytosis Constant noncramping abdominal pain SimpleSimple vs.vs. StrangulatingStrangulating SBOSBO

CTCT usefuluseful onlyonly inin latelate stagesstages ofof irreversibleirreversible ischemiaischemia LDH,LDH, amylase,amylase, alkalk phos,phos, ammoniaammonia levelslevels notnot beneficialbeneficial LactateLactate andand CPKCPK limitedlimited successsuccess BOTTOMLINE:BOTTOMLINE: Bowel ischemia and strangulation cannot be reliably diagnosed or excluded preoperatively in all cases by any known clinical parameter. SBOSBO –– TreatmentTreatment

FluidFluid ResuscitationResuscitation LRLR –– IVFIVF ofof choicechoice UOPUOP monitoringmonitoring viavia foleyfoley AfterAfter potassiumpotassium andand chloridechloride levelslevels normalizenormalize andand UOPUOP adequate,adequate, IVFIVF cancan bebe changedchanged toto maintenancemaintenance withwith KClKCl replacementreplacement DueDue toto oftenoften largelarge fluidfluid requirements,requirements, centralcentral venousvenous assessmentassessment maymay bebe necessarynecessary SBOSBO –– TreatmentTreatment

BroadBroad--spectrumspectrum antibioticsantibiotics ProphylacticallyProphylactically givengiven duedue toto somesome reportedreported datadata onon bacterialbacterial translocationtranslocation AlsoAlso givengiven asas prophylaxisprophylaxis forfor possiblepossible resectionresection oror inadvertentinadvertent enterotomyenterotomy atat timetime ofof surgerysurgery SBOSBO –– TreatmentTreatment

NGTNGT EmptiesEmpties stomachstomach NoNo benefitbenefit givengiven fromfrom longerlonger intestinalintestinal tubestubes PSBOPSBO cancan bebe managedmanaged conservativelyconservatively (IVF(IVF && NGT)NGT) inin 6060--85%85% ofof patientspatients SBOSBO –– OperativeOperative ManagementManagement

CompleteComplete bowelbowel obstructionobstruction OROR 1212--24hr24hr delaydelay ofof surgerysurgery isis safesafe butbut incidenceincidence ofof strangulationstrangulation andand otherother complicationscomplications increasesincreases significantlysignificantly afterafter thisthis periodperiod ““sunsun shouldshould nevernever setset onon aa SBOSBO”” SBOSBO –– SurgicalSurgical ManagementManagement

LOA Manual reduction of herniated segment of bowel and defect repair Malignancy with metastasis - simple bypass of obstructing lesion appropriate Crohn’s – resection or strictureplasty IAA – percutaneous drainage XRT – if chronic, may require resection versus bypass If ? intestinal viability, fluoriscein versus second look SBOSBO –– SurgicalSurgical ManagementManagement

LaparoscopyLaparoscopy –– acceptedaccepted inin thethe followingfollowing clinicalclinical scenariosscenarios 1. MildMild abdominalabdominal distentiondistention allowingallowing adequateadequate visualizationvisualization 2. ProximalProximal obstructionobstruction 3. PartialPartial obstructionobstruction 4. AnticipatedAnticipated singlesingle--bandband obstructionobstruction IleusIleus

Intestinal distention and CAUSESCAUSES OFOF ILEUSILEUS slowing or absence of Post laparotomy passage of luminal contents without Metabolic and electrolyte demonstrable mechanical derangements obstruction Drugs

May continue to pass Intra-abdominal flatus and diarrhea Retroperitoneal hemorrhage or Treatment is supportive inflammation with NGT, IVF, and correction of electrolytes Systemic CrohnCrohn’’ss DiseaseDisease –– BuzzBuzz WordsWords

TransmuralTransmural inflammatoryinflammatory diseasedisease AbdominalAbdominal pain,pain, diarrhea,diarrhea, weightweight lossloss ComplicatedComplicated byby SBOSBO oror localizedlocalized perforationperforation withwith fistulafistula formationformation OccursOccurs inin SISI andand coloncolon DiscontinuousDiscontinuous andand segmentalsegmental RectalRectal sparingsparing characteristiccharacteristic inin ptspts withwith coloniccolonic diseasedisease PerianalPerianal involvementinvolvement –– multiplemultiple chronicchronic perianalperianal fistulasfistulas CrohnCrohn’’ss DiseaseDisease –– BuzzBuzz WordsWords

““skipskip areasareas”” ““fatfat wrappingwrapping”” AphthousAphthous ulcerulcer CobblestoneCobblestone appearanceappearance –– linearlinear ulcersulcers thatthat coalescecoalesce producingproducing transversetransverse sinusessinuses withwith islandsislands ofof normalnormal mucosamucosa inin betweenbetween CrohnCrohn’’ss DiseaseDisease –– BuzzBuzz WordsWords

YoungYoung adultadult (20(20--30s)30s) MCCMCC symptomsymptom == intermittentintermittent colickycolicky lowerlower abdominalabdominal painpain NextNext MCCMCC symptomsymptom == diarrheadiarrhea (85%(85% pts)pts) MainMain intestinalintestinal complicationscomplications == obstruction,obstruction, ,fistulas, andand perforationperforation CancerCancer riskrisk RelativeRelative riskrisk SBSB 100x100x greatergreater ()(ileum) ColorectalColorectal riskrisk alsoalso greatgreat CrohnCrohn’’ss DiseaseDisease –– BuzzBuzz WordsWords

ExtraintestinalExtraintestinal ManifestationsManifestations lesions Erythema nodosum Pyoderma gangrenosum Arthritis Arthralgias Uveitis Iritis Pericholangitis Aphthous stomatitis CrohnCrohn’’ss DiseaseDisease CrohnCrohn’’ss SurgicalSurgical TreatmentTreatment

MedicalMedical managementmanagement forfor acuteacute exacerbationsexacerbations SurgicalSurgical treatmenttreatment limitedlimited toto Intestinal obstruction Intestinal perforation with formation or Free perforation GIB Urologic complications Cancer Perianal MakeMake nono attemptattempt toto resectresect moremore bowelbowel eveneven thoughthough grosslygrossly evidentevident diseasedisease maymay bebe apparentapparent StrictureplastyStrictureplasty SBSB NeoplasmsNeoplasms

RareRare despitedespite thethe factfact thatthat SBSB isis 80%80% ofof thethe totaltotal lengthlength ofof thethe GIGI tracttract andand 90%90% ofof mucosalmucosal surfacesurface areaarea 5%5% ofof GIGI neoplasms,neoplasms, 11--2%2% ofof malignantmalignant tumorstumors PossiblePossible reasonsreasons raterate soso lowlow Rapid transit of luminal contents High turnover rate of SB epithelial cells minimizing carcinogenic exposure Alkalinity of SI contents High level IgA Low bacterial count SBSB NeoplasmsNeoplasms

HighestHighest cancercancer ratesrates –– MaoriMaori ofof NewNew ZealandZealand andand nativenative HawaiiansHawaiians LowLow inin India,India, Romania,Romania, andand EasternEastern EuropeEurope IncreasingIncreasing incidenceincidence likelylikely duedue toto spreadspread ofof AIDSAIDS andand lymphomaslymphomas whichwhich occuroccur inin thethe immunocompromisedimmunocompromised hosthost BenignBenign –– leiomyomasleiomyomas andand adenomas;adenomas; moremore commoncommon inin distaldistal SBSB AdenocarcinomaAdenocarcinoma andand carcinoidcarcinoid tumorstumors areare thethe mostmost commoncommon malignantmalignant neoplasmneoplasm GeneticGenetic mutationsmutations –– KK--rasras WorkWork--upup

UpperUpper GIGI seriesseries w/w/ SBFTSBFT 5050--70%70% accurateaccurate diagnosisdiagnosis EnteroclysisEnteroclysis DiagnosticDiagnostic accuracyaccuracy 90%90% FlexibleFlexible endoscopyendoscopy DuodenalDuodenal lesionslesions andand ilealileal lesionslesions CTCT A/PA/P DuodenalDuodenal lesionslesions andand ilealileal lesionslesions

BenignBenign NeoplasmsNeoplasms

AdenomasAdenomas mostmost commoncommon inin autopsyautopsy seriesseries GISTGIST mostmost commoncommon benignbenign lesionlesion producingproducing symptomssymptoms SymptomsSymptoms –– vaguevague andand nonspecificnonspecific Most asymptomatic Dyspepsia Anorexia Malaise Dull abdominal pain SBSB tumorstumors areare thethe MCCMCC ofof intussusceptionintussusception inin adults!adults! BenignBenign NeoplasmsNeoplasms

Treatment – segmental resection and primary Pathology Leiomyomas (GIST) – MC symptomatic benign neoplasm of SB Adenomas – 15%; most asymptomatic (20% duodenum, 30% , 50% ileum) True Villous – rare, mostly found in duodenum, may be associated with FAP, malignant potential 35-55%, Segmental resection preferred, however, in duodenum polypectomy may be performed if histologically benign Brunner gland – benign hyperplastic lesions from Brunner glands of proximal duodenum Simple excision secondary to no malignant potential BenignBenign NeoplasmsNeoplasms PathologyPathology Lipomas (GIST) Mostly found in ileum Elderly men <1/3 symptomatic Symptomatic lesions should be excised; no malignant potential Hamartomas (Peutz-Jeghers syndrome) Entire jejunum and ileum; 50% pts have colorectal involvement while 25% have gastric lesions Adenomatous changes reported in 3-6% of hamartomas Extra colonic cancers (50-90% patients) SI, , , ovary, , , breast SI most frequent site (RR 520) Surgical resection – should be limited to segment of bowel producing complications Cure not possible and extensive resection contraindicated BenignBenign NeoplasmsNeoplasms

PathologyPathology HemangiomasHemangiomas Jejunum most common 3-4% benign SB tumors Multiple in 60% of pts May be part of Rendu-Osler-Weber disease, Turner’s syndrome Most common symptom = GIB Angiography and 99mTc-RBC scan most useful Surgical resection of involved segment only MalignantMalignant NeoplasmsNeoplasms

MostMost commoncommon inin orderorder ofof frequencyfrequency AdenocarcinomasAdenocarcinomas CarcinoidCarcinoid tumorstumors MalignantMalignant GISTsGISTs LymphomasLymphomas MalignantMalignant NeoplasmsNeoplasms

HowHow dodo theythey present?present? Pain Weight loss Obstruction (15-35% pts) Due to infiltration and adhesions as opposed to intussusception caused by SB benign lesions Diarrhea with tenesmus Mucus Palpable mass (10-20% pts) Perforations (10% pts) Lymphomas and sarcomas MalignantMalignant NeoplasmsNeoplasms

PathologyPathology 50% malignant tumors of SB Peak incidence 70s, slight male predominance Duodenum and proximal jejunum Crohn’s pts younger age and in ileum GISTs 20% malignant tumors of SB Peak incidence 50-60s, slight male predominance Jejunum and ileum Direct extension and hematogenous spread >5cm at time of diagnosis in 80% pts Arise in muscularis propria and grow extramurally MalignantMalignant NeoplasmsNeoplasms MalignantMalignant NeoplasmsNeoplasms

PathologyPathology Lymphomas 5% all lymphomas 7-25% malignant tumors of SB (most common intestinal neoplasm in children <10) Ileum Increased risk in those immunocompromised and with celiac disease Usually large MalignantMalignant NeoplasmsNeoplasms

TreatmentTreatment GISTs Segmental bowel resections If invasion into other segments present, resection may confer improved survival Adenocarcinomas/Lymphomas Wide resection + regional LN May require Whipple for duodenal lesions Surgery often not curative Palliative procedures versus bypass are often performed MalignantMalignant NeoplasmsNeoplasms

PrognosisPrognosis 55--yryr survivalsurvival afterafter surgerysurgery onlyonly 25%25% AdenocarcinomaAdenocarcinoma hashas poorestpoorest prognosis,prognosis, withwith overalloverall survivalsurvival raterate 1515--20%20% GISTsGISTs Overall survival 7-56% CarcinoidCarcinoid TumorsTumors

Arise from enterochromaffin cells (Kulchitsky cells) found in the crypts of Lieberkühn (a.k.a. argentaffin cells) , bronchi, GI tract GI tract most common site SB – 5th decade Classified by embryologic site of origin and secretory product Foregut (respiratory tract, ) Low levels of serotonin ACTH (jejunum, ileum, R colon, stomach, and proximal duodenum) serotonin Hindgut (distal colon and ) Rarely produce serotonin Somatostatin and peptide YY CarcinoidCarcinoid TumorsTumors

CanCan secretesecrete corticotropin,corticotropin, histamine,histamine, dopamine,dopamine, eurotensin,eurotensin, prostaglandins,prostaglandins, kinins,kinins, gastrin,gastrin, somatostatin,somatostatin, pancreaticpancreatic polypeptide,polypeptide, calcitonin,calcitonin, neuronneuron--specificspecific enolaseenolase WithinWithin GIGI tracttract AppendixAppendix mostmost commoncommon sitesite SISI 22nd mostmost commoncommon Occur within 2 ft of ileum CarcinoidCarcinoid TumorsTumors

PrimaryPrimary importanceimportance ofof carcinoidcarcinoid tumorstumors isis malignantmalignant potentialpotential ofof tumorstumors themselvesthemselves CarcinoidCarcinoid syndromesyndrome EpisodicEpisodic attacksattacks ofof cutaneouscutaneous flushingflushing BronchospasmBronchospasm DiarrheaDiarrhea VasomotorVasomotor collapsecollapse CarcinoidCarcinoid TumorsTumors

7070--80%80% asymptomaticasymptomatic 90%90% carcinoidscarcinoids == appendixappendix 45%,45%, ileumileum 28%,28%, rectumrectum 16%16% 3%3% appendicealappendiceal carcinoidscarcinoids metastasizemetastasize 35%35% ilealileal carcinoidscarcinoids metastasizemetastasize 75%75% GIGI carcinoidscarcinoids <1cm<1cm (2%(2% metastasize)metastasize) TumorsTumors 11--22 cmcm (50%(50% metastasize)metastasize) TumorsTumors >2cm>2cm (80(80--90%90% metastasize)metastasize) CarcinoidCarcinoid TumorsTumors

PathologyPathology YellowYellow onon cutcut surfacesurface SlowSlow growinggrowing 2020--30%30% multicentricmulticentric SynchronousSynchronous adenocarcinomaadenocarcinoma (most(most commonlycommonly largelarge intestine)intestine) inin 1010--20%20% patientspatients withwith carcinoidcarcinoid tumorstumors AssociatedAssociated withwith MENMEN II inin 10%10% casescases CarcinoidCarcinoid TumorsTumors

DiagnosisDiagnosis ElevatedElevated urinaryurinary levelslevels ofof 55-- hydroxyindoleacetichydroxyindoleacetic acidacid PlasmaPlasma chromograninchromogranin AA elevatedelevated inin >80%>80% ptspts withwith carcinoidcarcinoid tumorstumors AdministrationAdministration ofof pentagastrinpentagastrin safestsafest andand mostmost reliablereliable andand mostmost frequentlyfrequently usedused provocativeprovocative testtest (not(not usuallyusually neededneeded anymore)anymore) CarcinoidCarcinoid TumorsTumors XR Barium may exhibit filling defects as result of kinking/fibrosis of SB Angiography and U/S can reveal mesenteric and hepatic involvement CT detects hepatic and LN metastasis and extent of bowel wall and mesenteric involvement Somatostatin receptor scintigraphy using 111In- labeled pentetreotide Scintigraphic localization study shows higher reported sensitivity than conventional imaging techniques in delineating and localizing tumors SBSB CarcinoidCarcinoid TreatmentTreatment

Treatment based on tumor size and site and presence or absence of metastatic disease Primary tumors <1cm without evidence of regional LN involvement segmental intestinal resection Primary tumors >1cm, multiple tumors, or + regional LN metastasis wide excision of bowel and is required Primary tumors of TI R hemicolectomy Small duodenal tumors local excision (larger duodenal tumors may require Whipple) MUST ALWAYS EXPLORE ABDOMEN FOR MULTICENTRIC LESIONS! SBSB CarcinoidCarcinoid TreatmentTreatment

AnesthesiaAnesthesia alertalert MayMay precipitateprecipitate carcinoidcarcinoid crisiscrisis (hypotension,(hypotension, bronchospasm,bronchospasm, flushing,flushing, tachycardia)tachycardia) TreatmentTreatment IVIV octreotideoctreotide bolusbolus 5050--100100 µµcg,cg, continuedcontinued withwith infusioninfusion ofof 5050 µµcg/hrcg/hr SBSB CarcinoidCarcinoid TreatmentTreatment

SurgerySurgery STILLSTILL indicatedindicated inin ptspts withwith carcinoidcarcinoid tumorstumors andand widespreadwidespread metastasismetastasis DefiniteDefinite rolerole ofof surgicalsurgical debulkingdebulking inin contrastcontrast toto metastasismetastasis fromfrom otherother tumorstumors MayMay involveinvolve hepatichepatic resection,resection, hepatichepatic arteryartery ligationligation ,, oror percutaneouspercutaneous embolization,embolization, hepatichepatic arteryartery occlusionocclusion withwith chemotherapychemotherapy CarcinoidCarcinoid PrognosisPrognosis

BestBest prognosisprognosis ofof allall SBSB tumorstumors ResectionResection ofof carcinoidcarcinoid tumortumor localizedlocalized approachesapproaches 100%100% 65%65% 55--yryr survivalsurvival inin patientspatients withwith regionalregional diseasedisease 2525--35%35% 55--yryr survivalsurvival inin patientspatients withwith distantdistant metastasismetastasis MetastaticMetastatic NeoplasmsNeoplasms

MuchMuch moremore commoncommon thanthan primaryprimary neoplasmsneoplasms CutaneousCutaneous melanomamelanoma isis thethe mostmost commoncommon extraabdominalextraabdominal sourcesource toto involveinvolve SBSB SymptomsSymptoms includeinclude anorexia,anorexia, weightweight loss,loss, anemia,anemia, bleeding,bleeding, PSBOPSBO SBSB DiverticularDiverticular DiseaseDisease

TrueTrue oror falsefalse TrueTrue –– usuallyusually congenitalcongenital andand containcontain allall layerslayers ofof intestinalintestinal wallwall FalseFalse –– usuallyusually acquiredacquired andand containcontain mucosamucosa andand submucosasubmucosa protrudingprotruding throughthrough defectdefect inin musclemuscle coatcoat DuodenalDuodenal locationlocation mostmost commoncommon forfor acquiredacquired diverticuladiverticula MeckelMeckel’’ss diverticulumdiverticulum mostmost commoncommon truetrue diverticulumdiverticulum ofof SBSB DuodenalDuodenal DiverticulaDiverticula

DuodenumDuodenum secondsecond mostmost commoncommon locationlocation afterafter coloncolon FoundFound twicetwice asas oftenoften inin womenwomen RareRare inin ptspts <40<40 yoyo ⅔⅔ -- ¾¾ duodenalduodenal diverticuladiverticula foundfound inin periampullaryperiampullary regionregion DuodenalDuodenal DiverticulaDiverticula

Clinical Manifestations Most asymptomatic <5% require surgery Major complications Obstruction of biliary ducts cholangitis Obstruction of pancreatic ducts Hemorrhage Perforation “blind loop” syndrome – stasis of intestinal contents within distended DuodenalDuodenal DiverticulaDiverticula

TreatmentTreatment SymptomaticSymptomatic duodenalduodenal diverticulumdiverticulum Diverticulectomy via Kocher maneuver exposing duodenum Identification of the ampulla is essential For diverticula embedded deep within the head of the pancreas, duodenotomy performed with invagination of the diverticulum into the lumen followed by excision and closure Perforated diverticulum may require procedures similar to that of trauma to the duodenal wall

JejunalJejunal andand IlealIleal DiverticulaDiverticula

0.10.1--1.4%1.4% incidenceincidence JejunalJejunal moremore commoncommon andand largerlarger FalseFalse diverticuladiverticula OlderOlder ageage MultipleMultiple ProtrudeProtrude fromfrom mesentericmesenteric borderborder (often(often escapesescapes surgicalsurgical exploration)exploration) CauseCause possiblypossibly motormotor dysfunctiondysfunction ofof smoothsmooth musclemuscle oror myentericmyenteric plexusplexus JejunalJejunal andand IlealIleal DiverticulaDiverticula

ClinicalClinical ManifestationsManifestations Majority asymptomatic Acute complications are rare GIB Obstruction – may lead to deconjugation of bowel salts and uptake of B12 by leading to and TreatmentTreatment Intestinal resection and end-to-end anastomosis for obstruction, bleeding, and perforation JejunalJejunal andand IlealIleal DiverticulaDiverticula

Omphalomesenteric remnant persisting as fibrous cord from ileum to umbilicus MeckelMeckel’’ss DiverticulumDiverticulum

MostMost commoncommon congenitalcongenital anomalyanomaly ofof thethe SISI (2%(2% population)population) AntimesentericAntimesenteric borderborder ofof thethe ileumileum 4545--60cm60cm proximalproximal toto thethe ileocecalileocecal valvevalve DueDue toto incompleteincomplete closureclosure ofof thethe vitellinevitelline (omphalomesenteric)(omphalomesenteric) ductduct Male=FemaleMale=Female CellsCells lininglining vitellinevitelline ductduct pluripotent;pluripotent; therefore,therefore, heterotopicheterotopic tissuetissue oftenoften withinwithin MeckelMeckel’’ss (most(most commoncommon isis gastricgastric –– 50%)50%) MeckelMeckel’’ss DiverticulumDiverticulum

ClinicalClinical ManifestationsManifestations MajorityMajority benignbenign andand incidentallyincidentally discovereddiscovered GIBGIB mostmost commoncommon clinicalclinical presentationpresentation UsualUsual sourcesource ofof bleedingbleeding isis chronicchronic acidacid-- inducedinduced ulcerulcer inin ileumileum adjacentadjacent toto MeckelMeckel’’ss thatthat containscontains gastricgastric mucosamucosa IntestinalIntestinal obstructionobstruction isis anotheranother commoncommon presentingpresenting symptomsymptom (,(volvulus, intussusception,intussusception, LittreLittre’’ss )hernia) MeckelMeckel’’ss DiverticulumDiverticulum

ClinicalClinical ManifestationsManifestations IntussusceptionIntussusception –– diverticulumdiverticulum invaginatesinvaginates andand thenthen isis propelledpropelled forwardforward byby peristalsisperistalsis Ileoileal or ileocolic Possible palpable mass DiverticulitisDiverticulitis –– 1010--20%20% symptomaticsymptomatic presentationspresentations MeckelMeckel’’ss WorkWork--upup

XR,XR, CT,CT, U/SU/S rarelyrarely helpfulhelpful MeckelMeckel’’ss scanscan 85% sensitive, 95% specific, 90% accurate in pediatric population Not reliable for adults secondary to reduced ectopic within diverticulum MeckelMeckel’’ss DiverticulumDiverticulum

TreatmentTreatment Symptomatic prompt surgical intervention with resection of diverticulum or segment of ileum with diverticulum Segmental intestinal resection required for bleeding because bleeding site usually in ileum adjacent to diverticulum Hand-sewn technique or stapling across base in diagonal or transverse line safe and feasible option Incidental Meckel’s found in children should be resected; however, in adults treatment controversial MeckelMeckel’’ss DiverticulumDiverticulum

Common presentation of a Meckel diverticulum projecting from the antimesenteric border of the ileum. SBSB UlcerationsUlcerations

NSAIDNSAID useuse andand complicationscomplications responsibleresponsible forfor atat leastleast 4%4% ofof allall SBSB resectionsresections TreatmentTreatment ofof complicationscomplications fromfrom SBSB ulcerationsulcerations isis segmentalsegmental resectionresection withwith reanastomosisreanastomosis ForeignForeign BodyBody IngestionIngestion

Majority treated with observation Can follow radiopaque objects with serial XR Cathartics contraindicated! Development of abdominal pain, tenderness, fever, or leukocytosis OR for laparotomy Also to OR for obstruction SBSB FistulasFistulas

ECEC fistulasfistulas mostmost commonlycommonly iatrogeniciatrogenic (surgical(surgical mishap)mishap) AlsoAlso secondarysecondary toto erosionerosion (suction(suction ,catheters, adjacentadjacent abscesses,abscesses, oror trauma)trauma) ContributingContributing factorsfactors cancan bebe priorprior XRT,XRT, intestinalintestinal obstruction,obstruction, IBD,IBD, mesentericmesenteric vascularvascular disease,disease, intraintra--abdabd sepsissepsis << 2%2% occuroccur spontaneouslyspontaneously andand ifif soso usuallyusually duedue toto CrohnCrohn’’ss diseasedisease SBSB FistulasFistulas

ECEC fistulafistula diagnosisdiagnosis usuallyusually obviousobvious TypicallyTypically postoppostop febrilefebrile ptpt withwith erythematouserythematous woundwound thatthat onceonce woundwound opened,opened, purulentpurulent oror bloodybloody dischargedischarge foundfound followedfollowed byby leakageleakage ofof entericenteric contentscontents immediatelyimmediately oror withinwithin 11--22 daysdays ClassifiedClassified accordingaccording toto theirtheir locationlocation andand volumevolume whichwhich dictatedictate treatmenttreatment SBSB FistulasFistulas

MoreMore proximalproximal thethe FACTORS PREENTING SPONTANEOUS fistula,fistula, thethe moremore FISTULA CLOSURE High output seriousserious thethe problemproblem High output Severe disruption of intestinal continuity (>50% withwith greatergreater fluidfluid && bowel circumference) electrolyteelectrolyte lossloss Active IBD of bowel segment High output fistulas Cancer drain >500cc per 24h Radiation Distal Obstruction Undrained abscess cavity FB in fistula tract Fistula tract <2.5cm in length Epithelialization of fistula tract SBSB FistulaFistula

TreatmentTreatment SuccessfulSuccessful managementmanagement dependentdependent onon establishingestablishing controlledcontrolled drainagedrainage Control of fistulous output most easily done by intubation of fistula tract with drain Must protect skin around fistulous opening using stomahesive appliances with zinc oxide or similar products TPN can be used to replace nutritional losses when necessary SBSB FistulasFistulas

TreatmentTreatment LongLong--actingacting octreotideoctreotide hashas beenbeen usedused withwith successfulsuccessful decreasedecrease inin volumevolume ofof outputoutput inin proximalproximal fistulasfistulas whether it improves rate of closure remains in debate SomeSome advocateadvocate upup toto 33 monthsmonths forfor spontaneousspontaneous closureclosure (however(however aboutabout 90%90% SBSB fistulasfistulas closeclose withinwithin 11 month)month) Therefore current recommendations suggest 4-6 weeks conservative management and optimization of nutritional status prior to surgical intervention if fistula fails to close SBSB FistulasFistulas

SurgicalSurgical ManagementManagement Most easily accomplished by entering prior abdominal wound Preferred approach is fistula tract excision and segmental resection of involved segment of intestine with reanastomosis Simple closure of the fistula after removing the tract almost ALWAYS results in recurrence If unexpected abscess found and anastomosis unsafe, both ends should be exteriorized SBSB FistulasFistulas -- BOTTOMLINEBOTTOMLINE

MostMost commonlycommonly resultsresults fromfrom previousprevious surgicalsurgical procedureprocedure ImagingImaging mustmust bebe performedperformed toto definedefine location,location, possiblepossible abscessabscess (usually(usually byby fistulogram)fistulogram) MustMust controlcontrol sepsis,sepsis, fluidfluid && electrolytes,electrolytes, skinskin protection,protection, andand malnutritionmalnutrition AfterAfter 66 weeks,weeks, ifif nono closureclosure OR!OR! PneumatosisPneumatosis IntestinalisIntestinalis

Multiple gas-filled cysts of GI tract Most common in jejunum Males = Females In neonates, associated with NEC Most promising theories on etiology consist of mechanical, mucosal damage, bacterial, and pulmonary PneumatosisPneumatosis IntestinalisIntestinalis

CystsCysts areare thinthin--walledwalled SymptomsSymptoms andand whenwhen rupturerupture nonspecificnonspecific butbut whenwhen pneumoperitoneumpneumoperitoneum presentpresent RepresentsRepresents oneone ofof thethe Diarrhea fewfew casescases ofof sterilesterile Abdominal pain pneumoperitoneumpneumoperitoneum Abdominal distention Should be considered N/V in pt with free air but Weight loss no evidence of no evidence of Mucus in stool peritonitis PneumatosisPneumatosis IntestinalisIntestinalis

PneumatosisPneumatosis intestinalisintestinalis isis benignbenign causecause ofof !pneumoperitoneum! NoNo treatmenttreatment necessarynecessary unlessunless rarerare complicationcomplication intervenesintervenes RectalRectal bleedingbleeding CystCyst--inducedinduced volvulusvolvulus TensionTension pneumoperitoneumpneumoperitoneum SurgicalSurgical interventionintervention shouldshould bebe decideddecided basedbased onon clinicalclinical coursecourse ofof thethe patientpatient SMASMA SyndromeSyndrome

VascularVascular compressioncompression ofof thethe duodenumduodenum oror WilkieWilkie’’ss syndromesyndrome Characterized by compression of 3rd portion of duodenum by SMA as it passes over this portion of the duodenum SymptomsSymptoms N/V Abdominal distention Weight loss Post-prandial epigastric pain SMASMA SyndromeSyndrome

AssociationAssociation withwith MostMost commoncommon inin Peptic ulcer youngyoung athleticathletic womenwomen Anorexia nervosa PredisposingPredisposing factorsfactors After proctocolectomy Significant weight loss and J-pouch anastomosis Supine immobilization AVM resection of Scoliosis cervical cord Body cast placement Orthopedic procedures (spinal) SMASMA SyndromeSyndrome

DiagnosisDiagnosis mademade byby bariumbarium UGIUGI Abrupt or near-total cessation of flow of barium from duodenum to jejunum SMASMA SyndromeSyndrome

TreatmentTreatment ConservativeConservative measuresmeasures triedtried initiallyinitially OperativeOperative treatmenttreatment ofof choicechoice isis duodenojejunostomyduodenojejunostomy AppendixAppendix

Diagnosis Physical Believe it or not should be Diminished bowel sounds primarily based on H&P! Direct tenderness with (CT scan not to be done muscle spasm in RLQ; BEFORE pt seen) spasm increases with development of rebound Lab and imaging are Lab and imaging are Temperature mildly adjuncts to the H&P! elevated (higher if History perforation) Onset of generalized REMEMBER variable abdominal pain followed location of tip of the by anorexia and nausea appendix from last week! Pain then intensifies in Rovsing’s sign epigastrum migrating toward umbilicus and Obturator sign finally localized in RLQ Rectal to indicate Emesis may occur during presence of a mass migration AppendixAppendix Imaging AAS Pneumoperitoneum usually = diagnosis other than Findings can include , localized , loss of peritoneal fat stripe U/S Often used as initial study in pts with equivocal diagnosis Sensitivity >85%, specificity >90% Highly operator dependent Sonographic criteria Noncompressible appendix 7mm or greater AP diameter Presence of appendicolith Interruption of continuity of echogenic Periappendiceal fluid or mass AppendixAppendix

CTCT A/PA/P ReservedReserved forfor ptspts withwith equivocalequivocal H&PH&P andand lablab findingsfindings GreatestGreatest whenwhen efforteffort mademade toto visualizevisualize appendixappendix POPO && IVIV contrastcontrast AppendixAppendix

DiagnosticDiagnostic CTCT findingsfindings Periappendiceal inflammation Appendix distended or thickened to >5-7mm Wall circumferentially thickened (“halo”) AppendicitisAppendicitis

LabLab workwork WBCWBC 1212--1818 LeftLeft shiftshift CRPCRP nonspecificnonspecific UAUA –– maymay showshow mildmild pyuriapyuria withwith appendicitisappendicitis duedue toto proximityproximity ofof ureterureter toto appendixappendix DiagnosingDiagnosing AppendicitisAppendicitis

What conditions will fool you? School-age children (no lab findings, peritonitis) Omental infarction (no pain migration) Adolescent/young males Crohn’s disease/UC Epididymitis (+ epididymis tenderness) Adolescent/young females PID (lower abdominal pain that is bilateral and worse with pelvic exam) Ovarian cysts and torsion (no migration) UTI (UA) Elderly Malignancies of GI and Diverticulitis Perforated ulcers

AppendicitisAppendicitis && thethe SurgeonSurgeon

IVFIVF resuscitationresuscitation priorprior toto surgerysurgery AcuteAcute UrgentUrgent appendectomyappendectomy ProphylacticProphylactic antibioticsantibiotics shouldshould bebe administeredadministered preoppreop (single(single dose)dose) –– CefoxitinCefoxitin oror cefotetancefotetan NegativeNegative appyappy raterate historicallyhistorically hashas beenbeen acceptableacceptable atat 20%,20%, withwith diagnosticdiagnostic modalitiesmodalities availableavailable inin 20052005 shouldshould bebe lowerlower ☺☺ AppendicitisAppendicitis && thethe SurgeonSurgeon

Transverse incision (Davis- Rockey) Oblique incision (McArthur- McBurney) Paramedian incision OpenOpen AppendectomyAppendectomy LaparoscopicLaparoscopic AppendectomyAppendectomy

UsuallyUsually donedone withwith 33 portsports (one(one umbilicalumbilical andand positionposition ofof otherother 22 varyvary dependingdepending onon thethe surgeon)surgeon) AppendixAppendix cancan bebe removedremoved usingusing endoloopsendoloops oror anan endoscopicendoscopic staplerstapler AppendicealAppendiceal stumpstump isis notnot buriedburied FasciaFascia atat 10mm10mm portport sitessites closedclosed D/CD/C homehome usuallyusually lessless thanthan 24h24h postoppostop LaparoscopicLaparoscopic AppendectomyAppendectomy PerforatedPerforated AppendicitisAppendicitis

AntibioticAntibiotic therapytherapy durationduration controversialcontroversial (7(7--10d10d versusversus untiluntil afebrileafebrile withwith normalnormal WBC)WBC) IntraoperativeIntraoperative Appendix:Appendix: WhatWhat dodo youyou do?do?

ManyMany surgeonssurgeons advocateadvocate thatthat thethe appendixappendix shouldshould bebe removedremoved sincesince thethe complicationcomplication raterate isis quitequite lowlow inin thisthis settingsetting (including(including authorsauthors ofof Sabiston)Sabiston) IntervalInterval AppendectomyAppendectomy

ControversialControversial RiskRisk ofof recurrentrecurrent appendicitisappendicitis mustmust bebe balancedbalanced againstagainst riskrisk ofof intervalinterval appendectomyappendectomy YoungerYounger thethe patient,patient, higherhigher lifetimelifetime riskrisk ofof recurrentrecurrent appendicitisappendicitis andand lowerlower operativeoperative riskrisk AppendicitisAppendicitis inin PregnancyPregnancy

Appendicitis and cholecystitis most common causes of abdominal pain during pregnancy After 5th month of gestation, appendiceal position shifted superiorly above iliac crest and appendix tip rotated medially by gravid uterus AppendicitisAppendicitis inin PregnancyPregnancy

WBC usually not helpful as it is commonly elevated in pregnancy Symptoms usually not of diagnostic value secondary to pregnancy U/S can be helpful Suspicion should lead to EARLY surgical intervention in ALL trimesters Negative laparotomy results in minimal fetal loss whereas delay in diagnosis and perforation may lead to high incidence of fetal death and relatively high incidence of maternal death Laparoscopic approach may be used

NeoplasmsNeoplasms Carcinoids most common appendiceal neoplasm Appendiceal neoplasms extremely rare Adenocarcinomas <0.5% of all GI neoplasms Mucinous (55%) Most common presentation is that of acute appendicitis Survival rate better with R hemicolectomy versus appendectomy alone Second primary was located in 35% patients R hemicolectomy indicated for Invasive Tumors close to Mucin-producing tumors Invasion of lymphatics, serosa, or mesoappendix Cellular pleomorphism with high mitotic rate Appendectomy indicated in ALL patients with Krukenberg tumors when another primary site cannot be identified at time of surgery