What are the indications, treatment, and management options for small intestine removal?

Small Intestine Removal: Indications, Treatment, and Management

Small intestine removal should only be performed when absolutely necessary to preserve life, with surgical strategies focused on minimizing intestinal resection and managing complications to optimize patient survival and quality of life. 1

Indications for Small Intestine Removal

• Vascular events: Superior mesenteric artery thrombosis leading to intestinal ischemia and necrosis is a common indication for small bowel resection 1, 2
• Crohn's disease: Severe cases with complications such as strictures, fistulas, or perforation may require resection 1, 3
• Radiation damage: Radiation enteritis causing irreversible intestinal damage 1
• Trauma: Severe abdominal trauma with intestinal injury 2
• Neoplasms: Intra-abdominal tumors involving the small intestine 2
• Intestinal dysmotility: In rare cases, severe chronic small intestinal dysmotility may require surgical intervention, though this is generally avoided when possible 1

Surgical Management Principles

Preservation of Intestinal Length

• Strictureplasty: For Crohn's disease strictures, this technique relieves obstruction without removing intestine 4
• Minimal resection: Only removing clearly non-viable tissue to preserve maximum intestinal length 4, 3
• Serosal patching: Alternative to resection for treating perforations or strictures 4
• Intestinal tapering: Improves function of dilated segments without requiring resection 4

Surgical Approaches

• Laparoscopic techniques: Minimally invasive approaches when appropriate for less tissue trauma and faster recovery 5
• Bypass operations: For intestinal dysmotility, bypass procedures (gastro-enterostomy, duodeno-jejunostomy, jejuno-enterostomy) may be performed to reduce symptoms like vomiting in dilated gut 1
• Anastomosis options: After resection, options include jejunocolic anastomosis (jejunum-colon), preserving terminal ileum and colon (jejunum-ileum), or formation of a stoma (jejunostomy) 1
• Duodenocolostomy: In cases of total enterectomy, this approach helps manage foregut secretions 2

Surgical Considerations

• Multidisciplinary approach: Surgical decisions should be made by an experienced multidisciplinary team 1
• Avoid vagotomy: During gastric surgery, vagotomy must be avoided as it further retards gastrointestinal transit 1
• Optimize nutrition: Nutritional status should be optimized before any surgical procedure when possible 1
• Sepsis management: In cases with intra-abdominal infection, resolving sepsis is the priority before proceeding with definitive surgery 3

Post-Surgical Management

Nutritional Support

• Parenteral nutrition: Home parenteral nutrition (HPN) is essential for patients with severe intestinal failure 1
• Enteral nutrition: When possible, enteral feeding should be attempted 1
• Feeding options:
  • Oral supplements/dietary adjustments for mild intestinal failure 1
  • Gastric feeding if oral route unsuccessful and patient not vomiting 1
  • Jejunal feeding via nasojejunal tube, PEG-J, or direct jejunostomy if gastric feeding fails 1

Managing Complications

• Catheter-related sepsis: A significant risk with HPN (approximately 0.5 per 1000 catheter days) 1
• Fluid and electrolyte imbalances: Particularly problematic in patients with jejunostomy 1
• Diarrhea/steatorrhea: Common in jejunum-colon patients 1
• Malnutrition: Weight loss and undernutrition may develop over months following surgery 1

Intestinal Transplantation

• Primary indications: Intestinal transplantation should be reserved for patients with complications related to parenteral nutrition, including 1:
  • IF-associated liver disease
  • Central vein thrombosis with reduced venous access
  • Recurrent catheter-related bloodstream infections
• Multivisceral transplantation: May be considered if other organs are damaged 1
• Timing: Patients with irreversible intestinal failure expected to die prematurely on parenteral nutrition should be referred for consideration of intestinal transplantation 1
• Evaluation: All patients considered for transplantation should be reviewed by an experienced multidisciplinary team with expertise in intestinal failure and transplantation 1

Psychosocial Support

• Psychological support: From nurses, physicians, and psychologists is important for these complex patients 1
• Monitoring for psychopathology: Vigilance for anxiety, depression, somatization disorder, personality disorders, substance misuse, and disordered eating 1
• Quality of life considerations: Even with successful nutritional support, quality of life may remain suboptimal if symptoms like vomiting, diarrhea, or abdominal pain persist 1

Outcomes

• Prognosis: Varies based on underlying condition, extent of resection, and complications 1
• Adaptation: Intestinal adaptation occurs over time through hypertrophy, hyperplasia, and nutrient transporter changes 6
• Survival: For patients with chronic intestinal dysmotility on HPN, over half will be alive at 10 years 1
• Rehabilitation: While about 70% of patients with Crohn's disease or ischemic bowel conditions are fully rehabilitated after the first year on HPN, only about one-third of those with chronic intestinal dysmotility achieve similar rehabilitation 1