What is the treatment for a small bowel that needs to be slit and dilated to connect with the larger bowel?

Surgical Management of Dilated Small Bowel Requiring Connection to Large Bowel

For dilated small bowel requiring connection to the large bowel, strictureplasty is the preferred surgical technique for strictures <10 cm to preserve bowel length, while resection with primary anastomosis is indicated for longer strictures, ischemic bowel, or when malignancy cannot be excluded. 1

Primary Decision Algorithm

When Strictureplasty is Indicated

• Strictureplasty should be performed for small bowel strictures shorter than 10 cm, particularly when there are multiple strictures or a critical need to preserve gut length (e.g., patients at risk for short bowel syndrome). 1
• The conventional Heineke-Mikulicz technique is used for strictures up to 10 cm in length. 1
• For intermediate length strictures (10-25 cm), modified techniques such as the Finney procedure should be employed. 1
• For longer strictures, an enteroenterostomy (Michelassi procedure) is the appropriate technique. 1
• If multiple strictures are clustered close together in one segment and adequate healthy bowel remains elsewhere, a single resection is preferable to multiple strictureplasties. 1

When Resection with Anastomosis is Required

• Surgery with resection is warranted for small bowel obstruction with potential impending perforation, long or multiple strictures not amenable to strictureplasty, strictures not endoscopically accessible, or when medical/endoscopic treatment fails. 1
• Resection is mandatory when there is concern for concomitant malignancy—any colorectal stricture must be assessed with endoscopic biopsies to exclude malignancy. 1
• Bowel ischemia or necrosis requires immediate resection with anastomosis in hemodynamically stable patients. 1

Management of Chronically Dilated Bowel

When Tapering Without Resection is Appropriate

• For dilated bowel segments in patients with short bowel syndrome or at risk for it, intestinal lengthening and tapering procedures (LILT or STEP) should be performed to restore normal caliber without losing absorptive surface area. 1
• Simple tapering enteroplasty (removing a strip along the anti-mesenteric border) can be used when bowel length is clearly not a concern. 1
• The Spiral Intestinal Lengthening and Tailoring (SILT) procedure offers minimal mesenteric handling and can increase bowel length by 56% while reducing diameter by 50%. 2, 3
• 50-60% of patients undergoing autologous gastrointestinal reconstructive surgery (LILT/STEP) may eventually wean off parenteral nutrition. 1

Critical Principle for Short Bowel Patients

• The principle of primum non nocere applies even more to patients with short bowel syndrome, who can ill-afford any inadvertent loss of further bowel length from ill-considered surgery. 1
• Any bowel resection should be carefully planned, as further loss of bowel length can be catastrophic. 4

Surgical Approach Selection

Laparoscopic vs Open Approach

• A laparoscopic approach with adhesiolysis and bowel resection is recommended if appropriate expertise exists in hemodynamically stable patients, with care taken to avoid iatrogenic bowel injury. 1
• Laparoscopic evaluation reliably identifies bowel requiring resection—no patients requiring bowel resection are missed using this method, with only 8% of completed laparoscopic cases requiring resection versus 64% of converted cases. 5
• Open approach is mandatory in hemodynamically unstable patients or those with free perforation and generalized peritonitis. 1
• Laparoscopic management reduces length of stay (7.7 days) compared to converted (11.0 days) or open procedures (11.4 days). 5

Anastomotic Considerations

When to Create vs Avoid Anastomosis

• If there is hemodynamic stability and only localized contamination, an anastomosis may be considered, but other factors including nutritional status and degree of inflammation must be evaluated. 1
• A laparoscopic approach with resection, lavage and stoma is suggested in hemodynamically stable patients with perforation and peritonitis to avoid complications associated with anastomotic leak. 1
• Colorectal anastomosis should be avoided in patients with suspected or confirmed COVID-19 or other high-risk scenarios due to high risk of complications. 1

Common Pitfalls to Avoid

• Do not perform limited resection if the dilated/diseased segment extends beyond what is being removed—for example, limited sigmoid resection with concomitant megacolon has an 82% recurrence rate versus 0% with adequate subtotal colectomy. 4
• Do not delay restoration of intestinal continuity in short bowel patients—recruitment of available distal bowel should be accomplished as soon as safely possible to improve function and reduce parenteral nutrition dependency. 1
• The presence of active inflammation at a stricture site does not prevent successful strictureplasty and should not be considered a contraindication. 1
• Contraindications to strictureplasty include presence of fistulae, fistula-associated abscesses, or possible carcinoma. 1