Small intestine resection: causes, features of the operation and conduct, preparation for surgery, contraindications, consequences, rehabilitation

Small intestine resection is an operation in which part of the intestinal tube is cut out and the remaining ends are sutured. The indications must be serious, since this is an intracavitary intervention, with the use of general anesthesia. If you follow all the doctor's recommendations, you will be able to avoid the negative consequences of resection of the small intestine.

Small intestine structure

In the small intestine, 3 anatomical sections are distinguished, its length is about 6 m:

1. The duodenum is located just behind the stomach, about 25-30 cm long. Located in a horseshoe shape, it covers the head of the pancreas. This is where pancreatic enzymes and bile are secreted. This area is often affected by ulcerative processes, since acidic contents get here from the stomach. As the ulcer progresses, it leads to bleeding, perforation of the organ wall,
   peritonitis.
2. The jejunum is located in the upper left part of the abdomen and the umbilical region, its length is 0.9-1.8 m. It forms 5-6 loops, located mainly horizontally.
3. The ileum occupies the lower and right abdomen. It ends in the right iliac region, where it passes into the large intestine. The Bauginia valve prevents the contents of the large intestine from being thrown into the small intestine.

The lower the level of the small intestine, the thicker the wall and the wider the lumen of the organ. Above, predominantly secretory processes and the splitting of food into small components take place, below the resulting simple substances are actively absorbed.

Reasons for resection

Any disease that leads to necrosis of a portion of the intestinal wall may require resection of the small intestine. The most common reasons are:

1. Abdominal trauma with intestinal injury. With a point wound, the wound is sutured; if more than 2/3 of the intestinal diameter is damaged, resection is performed.
2. Clusters of helminths.
3. Intestinal obstruction. Occurs with fecal stones, intestinal atony, volvulus, short or long mesentery. In this case, the movement of intestinal contents is disrupted, it stagnates, leads to abdominal pain, constipation, and intoxication.
4. Meckel's diverticulum. Protrusion of the intestinal wall in the form of a bag. Inflammation of the diverticulum can cause necrosis of the adjacent small intestine.
5. Tumors. Benign lesions are excised within healthy tissues. In malignant tumors, the volume of intervention is usually greater. The affected area of ​​the intestine, the adjacent healthy area, regional lymph nodes in the mesentery are removed. Some precancerous conditions, such as polyps, are also treated by resection of the small intestine.
6. Intestinal bleedingwhich cannot be stopped by conservative methods.
7. Intestinal ulcers, Crohn's disease. Often complicated by perforation, peritonitis, stricture (narrowing). This requires surgical treatment with resection of part of the intestine.
8. Thrombosis of mesenteric vessels with intestinal necrosis.

Preparation for small bowel resection

As part of the preoperative examination, the following are prescribed:

• general analysis of blood, urine;
• blood biochemistry;
• X-ray of the abdomen;
• Ultrasound of dense abdominal organs;
• ECG.

According to the indications, contrast fluoroscopy, analysis of feces are performed.

A few days before the resection of the small intestine, foods with a lot of fiber are excluded from food - raw vegetables, cabbage, legumes. Do not eat soft fresh bread, milk. Before the operation, it is recommended not to eat for 12 hours, to take Espumisan to reduce the amount of gas and feces. The night before, according to indications, an intestinal cleansing is carried out.

For 5-7 days, stop taking medications that affect blood clotting, vitamins, food additives. Any medications taken, cases of allergies, concomitant diseases must be reported to the doctor in advance.

In urgent operations, preparation is reduced to checking the basic analyzes and ECG.

Anesthesia

Anesthesia during resection of the small intestine - general or conductive anesthesia. At the first, the drug is injected into the bloodstream or gas inhalation is used. In the second, the drug is injected into the spinal canal at a level below the second lumbar vertebra. There is no longer a spinal cord, but only nerve processes, which are also called the cauda equina, are located.

Additionally, the anesthetic is injected between the sheets of the peritoneum after the incision of the anterior abdominal wall.

Local anesthesia is rarely used, since the volume of intervention is large, and there are many receptors in the peritoneum. The best result can be achieved with a complete shutdown of consciousness.

Operation technique

Depending on the localization of the pathology, the site of the incision is selected. More often this is the anterior midline of the abdomen. Only tendons are located here, muscles are not injured, and the scar after surgery is less noticeable.

After opening the abdominal cavity, the condition of the intestine is assessed. Necrotized tissues look like flabby areas of the intestine of gray, black or dark blue color. They are removed.

In this case, it is imperative to take into account that the contents of the intestine do not get into the abdominal cavity, since it contains many microbes and will lead to peritonitis. With tumors, 10 cm recede from the borders of the lesion in both directions. With necrosis, 30-40 cm recede towards the beginning of the intestine, 15-20 cm towards the end. The vessels feeding the affected area of ​​the intestinal tube are ligated.

2 soft clamps are applied to the intestine and all the walls of the organ are cut between them. Sterile wipes are placed under the incision site. Do the same on the other side of the pathological focus. Bleeding vessels are ligated or coagulated. Next, you need to align the 2 ends of the tube. There are several techniques for doing this.

Classic surgery with end-to-end anastomosis

The ends of the intestine are brought together using two guide sutures with silk threads at the level of the mesenteric edge and on the opposite side. All walls of the organ are sutured with catgut thread continuously.

Then a second row of stitches is applied. It captures only the muscle and serous layer, without piercing the mucous membrane. Such a suture more reliably than a single-row suture protects against leakage of intestinal contents and eversion of the mucous membrane.

Small intestine resection with side-to-side anastomosis

If the diameter of the two bowel segments is very different, a side-to-side anastomosis is performed. To do this, after crushing the intestine with a clamp, a silk ligature is applied to the site of the future incision.

After cutting off, a purse-string suture is performed, and then the edge of the tube is screwed into the lumen of the organ. This is how the intestine stump is formed on both sides. Then the sides of the intestine are aligned. The walls are cut and sewn with a double-row seam.

An end-to-side anastomosis can be used to connect the small intestine to the large intestine and, if necessary, to the stomach.

The operation of resection of the small intestine is completed - the hole in the mesentery is sutured and the anterior abdominal wall is sutured in layers.

Postoperative period

Tissues grow together in about 2-3 weeks. At this time, it is necessary to observe a gentle regimen, dietary food after resection of the small intestine.

Eliminate coarse food so as not to stimulate the peristalsis of the small intestine. Prescribed mainly cereals, soups. All products are heat treated - boiled or steamed.

At this time, it is not recommended to have diarrhea or constipation. Eliminate foods that stimulate the formation of gases:

• legumes;
• cabbage;
• fresh baked goods;
• drinks with gas.

Also, do not lift heavy objects so that the seam on the abdomen heals well. In some cases, it is recommended to wear a bandage to relieve stress on the anterior abdominal wall.

It is useful to move, walk, as it helps the intestines.

Consequences and complications of small intestine resection

Complications in the early postoperative period include:

• incompetence of the seams - the intestinal contents enter the peritoneal cavity;
• bleeding.

This requires a second operation.

Later, at the site of the anastomosis, a narrowing of the lumen of the gastrointestinal tract may develop with difficulty in passing food through this area.

One of the consequences of resection of large volumes of the small intestine is short bowel syndrome. In this case, the length of the intestine is reduced so much that food does not have time to digest properly while it passes through the gastrointestinal tract. Many nutrients are not absorbed, but are excreted from the body without being absorbed.

Gastroenterologists are involved in the treatment of this condition. Easily digestible mixtures are prescribed so that there is no deficiency of vitamins, proteins, microelements. The loss of vitamin B12, fats, bile acids, electrolytes affects the body most of all.

The secretion of liquid intestinal secretion occurs mainly in the initial parts of the intestine - the jejunum. Up to 8 liters of liquid are released per day. It is absorbed in the final sections, that is, in the iliac part and up to 2 liters already in the large intestine.

Hence, the differences in symptoms during resection of the jejunum and ileum are clear. Severe diarrhea with a large loss of water and electrolytes is characteristic of conditions after resection of the distal ileum. In this case, the secretion is not disturbed, and absorption is significantly limited due to the shortening of the length of the intestinal tract.

For normal bowel function, an important role is played by the preservation of the ileocecal valve at the transition from the thin to the thick one. This slows down the movement of the contents, which means it improves its digestion due to a longer contact with enzymes. It also prevents the spread of microflora from the large intestine to the small intestine.

After resection of the small intestine, part of its function is taken over by the large intestine. Here water absorption is enhanced, dietary fiber is broken down, fats and carbohydrates are absorbed.

Stages of recovery of the small intestine after resection:

1. Acute postoperative period. Diarrhea 5-6 liters per day with loss of electrolytes, proteins, vitamins. Treatment - the introduction of fluids and electrolytes to maintain balance (K, Ca, Cl, Na, Mg, glucose) intravenously and with food. With a lack of proteins, albumin, dextrans, and freshly frozen plasma are administered.
2. Subcompensation - up to 1 year after surgery. Anemia, dermatitis, paresthesias, weight loss. But profuse diarrhea is gradually compensated.
3. Adaptation - after 2 years. Possible gallstones and urinary stones, anemia, stomach ulcers.

By severity:

• Mild - weight loss up to 5 kg, recurrent diarrhea, abdominal pain, flatulence.
• Moderate - weight loss 5-10 kg, diarrhea 5-6 times a day, anemia. Enteral nutrition is required to compensate.
• Severe - more than 10 kg, abnormalities in the work of all organs, osteoporosis, weakness, edema, anemia. In addition to enteral nutrition, parenteral administration of electrolytes, amino acids, fatty acids, vitamins is added to the treatment.

Common complications of small bowel resection are:

1. Gallstones (30% of all resections), especially if the intestine after resection is less than 120 cm, and there is no ileocecal junction. This is due to the regular loss of bile acids, which do not have time to be absorbed back into the blood in the distal gastrointestinal tract. In this case, the ratio between cholesterol and bile acids is disrupted, due to which cholesterol precipitates. It becomes a substrate for stone formation. A decrease in digestive mediators, which are produced in the cells of the intestinal wall, also plays a role - bile stagnation occurs.
2. Excess hydrochloric acid in the stomach due to a violation of the release of regulatory factors. The risk of ulcers in the stomach and the initial part of the small intestine increases. This is more typical for resection of the jejunum. Also, the activity of pancreatic lipase decreases, the efficiency of the already poor digestion of food decreases.
3. Kidney stones - 25%.
4. Osteoporosis - 45%, more in women.
5. Excessive bacterial growth.
6. Acidosis with a predominance of lactic acid. Leads to brain damage, speech, balance, attention and sleep disorders. This is due to the ingress of large amounts of lactate into the bloodstream when bacteria overgrow in the intestines. Lactate attracts water into the lumen of the gastrointestinal tract, which increases diarrhea.

It is necessary to take into account the remaining length of the intestine when prescribing antibiotics, since the microflora is easily disturbed, the absorption of the drug into the blood changes.

Adaptation mechanisms

Resection of even half of the jejunum is easier to tolerate than resection of a third of the ileum. Over time, within 1 to 2 years, the digestive system adjusts to new working conditions:

1. The number of enterocytes (cells of the intestinal wall) and their production of enzymes increase.
2. The passage of food is slowed down for longer contact with enzymes and absorption through the intestinal wall.
3. Crypts deepen, the number of villi increases. This increases the area of ​​contact between food and the intestinal wall, improves parietal digestion.
4. The production of digestive enzymes in the pancreas and bile in the liver increases.

The younger and healthier a person is, the more compensation the body achieves after resection of the small intestine. Severe concomitant pathology, old age, parenteral nutrition for a long time reduce the compensatory capabilities of the body.

Conditions for good adaptation:

1. The remaining intestine is at least 1 m.
2. Preservation of the bauhinia shutter.
3. The length of the jejunum is more than 20 cm.

Treatment of the consequences of resection of the small intestine

Shown early tube feeding with the inclusion of dietary fiber, short-chain fatty acids, glutamine. Enteral mixtures are prescribed from 4-5 days after the operation of small intestine resection. At first, it is administered slowly by drip. If the diarrhea does not worsen, it is administered in portions. With poor tolerance, slow down the rate, but do not cancel their introduction.

In the future, they switch to regular meals. They increase the protein content in the diet, from fats they give preference to those for the digestion of which bile acids are not needed.

These are triglycerides, in which fatty acids have a short chain. For example, coconut oil. Glutamine, pectins, dietary fiber are added. Supplementary feeding is continued for about six months after the operation.

Also appoint:

1. Loperamide. To stop diarrhea. Sometimes it is required to take after each meal, a maximum of 6 tablets per day. Adsorbents - white clay, smecta bilignin, cholestyramine - bind excess bile and organic acids in the lumen of the intestinal tract.
2. Enzyme preparations - panzinorm, creon. Improves food digestion.
3. Sandostatin. Regulates the digestion process. Reduces the activity of secretory processes.
4. Proton pump inhibitors and H2-histamine blockers. To reduce the synthesis of acid in the stomach and prevent the formation of ulcers. First, it is administered intravenously, then taken orally. They inhibit gastric and intestinal secretion.
5. Antibiotics and probiotics for increased bacterial growth - rifaximin, metronidazole, tetracyclines. At the same time, the intake of carbohydrates from food is reduced.
6. B12, intravenous or oral iron preparations - with vitamin deficiency.
7. Calcium gluconate - prevention of osteoporosis.
8. Ursosan - prevention of cholesterol stone formation.

Sometimes re-intervention is required after resection of the small intestine, if it is not possible to establish the processes of food digestion. A valve is artificially formed, the intestines are narrowed, part of the intestinal tube is unfolded (cut out and sewn in the opposite direction). This delays the movement of intestinal contents. An organ site is transplanted.

Power features

Food is taken fractionally, often. Less fat - up to 60 g per day. More vegetables, fruits, dairy products, cheeses. Drink liquid between meals, you can drink Rehydron - it contains electrolytes.

Once every 3 months, take a course of treatment with vitamin B12.

To replenish proteins, mixtures of amino acids, lipids - fat emulsions are parenterally administered. Sometimes glucose, glucosteril, complex preparations are prescribed.

Surgical treatment, such as resection of the small intestine, saves lives, but it is important to perform all stages of the operation with high quality. To restore bowel function, it is necessary to follow medical recommendations on nutrition, receive medications, and monitor analyzes.

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Sources:

• https://urgent.com.ua/ru-issue-article-286
• https://sinref.ru