Does a Colorectal Surgeon Remove Small Bowel Fecaliths?
Yes, colorectal surgeons routinely remove small bowel fecaliths when surgical intervention is required, as this falls within their scope of managing small bowel pathology and intestinal obstructions.
Surgical Management Authority
Colorectal surgeons are the appropriate specialists to manage small bowel fecaliths requiring operative intervention. The ECCO guidelines explicitly recommend that IBD surgery, including small bowel procedures, should be performed by experienced colorectal surgeons who are core members of the multidisciplinary team 1. While these guidelines focus on inflammatory bowel disease, they establish that colorectal surgeons have expertise in small bowel surgery beyond just colonic procedures 1.
When Surgical Removal is Indicated
Small bowel fecaliths causing obstruction require surgical management when:
- Conservative management fails after 24-48 hours of fasting, fluid replacement, gastrointestinal decompression, and antibiotics 2
- Complete obstruction is present with inability to pass the fecalith spontaneously 2, 3
- Perforation or peritonitis develops, which requires immediate surgical intervention 1, 4
- Hemodynamic instability or septic shock occurs, mandating urgent operative exploration 4
The evidence shows that delayed surgical intervention beyond 24 hours when conservative management fails increases complication rates and hospital stays 4.
Surgical Technique
The standard approach for small bowel fecalith removal involves:
- Laparoscopic or open exploratory surgery to locate the obstructing fecalith 2
- Enterotomy with primary closure for simple fecalith extraction when the bowel is healthy 2, 3
- Segmental resection with primary anastomosis if the bowel wall is compromised or unhealthy 1, 4
- Resection with ileostomy creation in critically ill patients or when severe inflammation creates friable tissue that precludes safe anastomosis 1, 4
Case reports demonstrate successful laparoscopic removal of small bowel fecaliths through enterotomy, with uneventful recovery and discharge by postoperative day 7 2.
Multidisciplinary Context
Colorectal surgeons should work within a structured multidisciplinary team with gastroenterologists for optimal patient outcomes 1. The ECCO guidelines emphasize that there should be joint decision-making before and after surgery involving the gastroenterologist, colorectal surgeon, and patient 1. This is particularly important when fecaliths occur in the context of underlying conditions like Crohn's disease, where medical optimization may be needed 1.
Critical Pitfalls to Avoid
- Do not delay surgery beyond 24 hours if conservative management fails, as this significantly increases morbidity 4
- Do not attempt conservative management in immunocompromised patients regardless of the clinical presentation 4
- Obtain detailed dietary history when encountering intestinal obstruction without prior surgical history, particularly regarding consumption of persimmons or other foods that can cause phytobezoars 2
- Ensure complete bowel assessment during surgery to identify any additional pathology, strictures, or skip lesions that may be present 1
The evidence clearly establishes that colorectal surgeons have both the training and authority to manage small bowel fecaliths surgically, with outcomes dependent on timely intervention and appropriate surgical technique selection based on bowel viability 1, 4, 2.