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Intestinal Resection:
INTESTINAL
RESECTION AND ANASTOMOSIS
GENERAL
INFORMATION
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End-to-end
anastomosis is the gold standard.
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If the luminal diameter post-transection
is anticipated to be unequal, use a
perpendicular incision across the intestine
with the larger luminal diameter and
an oblique incision across the area
with the smaller diameter.
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Make the oblique incision so the antimesenteric
border is shorter than the mesenteric
border.
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With equal luminal diameters, use a
perpendicular incision.
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Intestinal healing is dependent upon
blood supply, mucosal apposition and
amount of surgical trauma.
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Approximating sutures will facilitate
the most rapid intestinal healing.
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Intestinal suture patterns need to include
the tough submucosal layer, so be sure
to incorporate it in your sutures. Omental
wrap or pexy.
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Do not use catgut or multifilament suture
materials when closing intestinal incisions.
MOST
COMMON COMPLICATIONS AND DIFFICULTY
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Dehiscence
and leakage are the most common severe
complication. Use proper technique to
avoid this complication.
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Tissue trauma/maceration from rough
handling with traumatic forceps during
suturing.
Removal of more than 70% to 80% of the
small intestine may result in short
bowel syndrome.
Effect
of intestinal resection on human small
bowel motility
Few data are available on adaptive
changes of human small bowel motility
after intestinal resection. AIM: To
characterise jejunal motility after
extensive and limited distal intestinal
resection. METHODS: Seven patients with
a short bowel syndrome after total ileal
and partial jejunal resection (residual
jejunal segments between 60 and 100
cm) and six patients with limited distal
ileal resection (resected segment between
30 and 70 cm) underwent ambulatory 24
hour jejunal manometry 15 (6-24) months
after the operation. Normal values were
obtained from 50 healthy subjects. Fasting
motility and the motor response to a
600 kcal solid meal were analysed visually
and by a computer program. RESULTS:
Limited ileal resection did not result
in changed jejunal motility. After extensive
distal resection, patients had a significantly
shorter migrating motor complex (MMC)
cycle and a significantly shorter duration
of the postprandial motor response compared
with controls (p < 0.005). Intestinal
resection had no influence on jejunal
contraction frequency and amplitude
and did not lead to any abnormal motor
pattern. CONCLUSION: Extensive distal
resection of the small intestine produces
distinct abnormalities of fasting and
postprandial motility in the intestinal
remnant. The shortening of digestive
motility and the increased frequency
of MMC cycling could contribute to malabsorption
and diarrhoea in the short bowel syndrome.
EXPERTS'
ADVICE
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Gently
reflect mesenteric fat from ends of
bowel to identify bowel wall.
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Place stay sutures at the mesenteric
and anti-mesenteric borders to begin
the closure. This allows proper alignment
and the best apposition and suture
placement at the mesenteric border.
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Place atraumatic forceps (Doyens,
assistant’s fingers, arms of
Allis tissue forceps) at least one
arcuate vessel away from the anastamosis
site to prevent compromise to the
blood supply at the anastamosis.
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The mesenteric border is most likely
to leak. Begin your closure there
and be sure that you incorporate the
submucosa in your sutures.
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Consider using a serosal patch if
delayed healing is expected.
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