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

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Absolute

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  • 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.

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Relative

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  • 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.

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Expected Benefits

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  • Relief of obstruction.
  • Control of gastrointestinal hemorrhage.
  • Treatment of gastrointestinal ischemia, necrosis, or perforation.

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Potential Risks

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  • Common complications include:
    • Surgical site infection (either deep or superficial).
    • Bleeding.
    • Systemic complications of major surgery, including pneumonia, venous thromboembolism, and cardiovascular events.
  • Small bowel obstruction, stricture, and need for further surgery are also potential risks of small bowel resection.
  • Patients with extensive intra-abdominal sepsis or who are in a malnourished state are at increased risk for anastomotic leak and enteric fistula.

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  • Self-retaining retractors are useful to help provide adequate exposure and access.
  • Gastrointestinal anastomosis (GIA) stapler or thoracoabdominal (TA) stapler, or both (depending on surgeon's preference for anastomotic technique).

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Preoperative Evaluation

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  • CT scan.
  • Small bowel follow-through versus small bowel enteroclysis.
  • As indicated for bleeding:
    • Esophagogastroduodenoscopy, push enteroscopy, or double balloon enteroscopy.
    • Capsule endoscopy.
    • Nuclear scan.
    • Angiography.

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At the Time of the Procedure

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  • Nutritional status should be optimized preoperatively if possible.
  • Treatment of systemic illness.
  • Intravenous perioperative antibiotics.
  • Nasogastric tube, in cases of obstruction.

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

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Hand-Sewn Anastomosis

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  • The abdomen is entered via a standard midline incision.
  • A thorough four-quadrant examination should be performed, with lysis only of those adhesions necessary to gain access to the area of pathology.
  • Figure 19–1: After the margins of resection have been determined (dotted line), electrocautery is used to score the mesentery to encompass ...

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