Surgical paper VI
Surgical treatment of short bowel syndrome
Study of 2 Cases
Short Bowel Syndrome (SBS) manifests as malnutrition, electrolyte imbalances, and various other complications due to the extensive resection of the small intestine. We present two cases where reverse peristaltic bowel loop anastomosis was performed in the distal small intestine to mitigate the risks of SBS.
Case 1: Male Farmer, 29 Years Old
The patient underwent extensive resection of the lower small intestine due to torsional necrosis, sparing only 3 cm above the ileocecal valve and leaving 80 cm of the jejunum intact. To restore intestinal continuity, the distal 7 cm of the jejunum, along with its mesentery, was inverted and an end-to-end anastomosis was performed. Postoperative observations showed effective reverse peristalsis in the interposed bowel segment. Although the patient experienced frequent bowel movements and mild indigestion, there were no significant nutritional or electrolyte imbalances, negating the need for specialized nutritional interventions. The patient returned to work six months post-surgery and has remained symptom-free for 18 years.
Case 2: Female Peasant, 24 Years Old
The patient presented with segmental enteritis featuring multiple necrotic perforations. A resection of the lower small intestine and a right hemicolectomy were performed, leaving 100 cm of the jejunum. The distal 7 cm of the jejunum was inverted, followed by a jejunum-to-jejunum-to-transverse colon end-to-end anastomosis. The patient successfully recovered from postoperative infection risks. However, she experienced loose stools for three months post-surgery. Nutritional absorption was satisfactory, and she resumed her normal life within a year. X-ray barium examination eight months post-surgery revealed reverse peristalsis at the anastomotic site, with slow barium propulsion. She has remained largely symptom-free for 20 years, except for two instances of abdominal pain.
Both cases highlight the potential of reverse peristaltic bowel loop anastomosis in preventing the onset of SBS. The technique appears to be particularly effective in preserving nutritional absorption and electrolyte balance. It also allows for a reasonable quality of life post-surgery, as evidenced by the patients’ ability to return to work and maintain a normal lifestyle over an extended follow-up period.
Importance of Intestinal Segmentation in SBS
The onset of Short Bowel Syndrome (SBS) is not solely determined by the length of the intestinal segment removed but also by its specific location. The small intestine demonstrates selective nutrient absorption at different segments—iron and calcium are primarily absorbed in the proximal jejunum, whereas bile salts and vitamin B are absorbed in the distal ileum. The duodenum, proximal jejunum, and distal ileum are considered pivotal for intestinal digestion and absorption. Thus, preserving these key segments and the ileocecal valve during resection can often prevent the development of SBS, even if up to 50% of the middle small intestine is removed.
Physiological Adaptations and Complications
The small intestine has a significant functional reserve, making it relatively tolerant to partial resection. However, extensive resection, particularly of functionally crucial segments, can trigger SBS. Initial symptoms often involve substantial fecal fluid loss and electrolyte imbalances. In some cases, increased gastric secretions can lead to peptic ulcers. Over time, the remaining small intestine may undergo compensatory changes, like villi enlargement and mucosal cell proliferation, to enhance absorption. If these compensatory mechanisms are inadequate, SBS may still develop, necessitating surgical interventions like short bowel anastomosis.
Limitations of Non-Operative Measures
Non-surgical treatments are generally supportive and aim to assist patients through the adaptation and compensatory phases. Our study group had ten other cases without specific short bowel anastomosis; three patients died within two months from severe electrolyte and fluid imbalances, despite aggressive fluid and blood transfusion therapies. The remaining seven underwent a challenging recovery period lasting 1-2 years.
Efficiency of Reverse Peristaltic Bowel Loop Anastomosis
Various techniques for short bowel anastomosis exist, but the reverse peristaltic bowel loop anastomosis has proven to be straightforward, effective, and complication-free, even in emergency scenarios. The optimal length for the interposed loop is between 7-14 cm for adults and less than 8 cm (3 cm for neonates) to prevent physiological intestinal obstruction due to reverse peristalsis. The location of the loop should be carefully considered, aiming for the distal side of the remaining small intestine to maximize its functional efficiency.
Preventative Strategies for SBS
In adults, the length of the small intestine can reach up to 7 meters, but the actual in vivo length is often around 3 meters. During resection, it’s generally advised to limit the removal to less than 50% of the intestine. Special attention should be paid to conditions like Peutz-Jegher’s disease, which may require multiple surgeries due to recurrent polyps. In such cases, individual polyp excision should be prioritized over extensive resection. Care should also be taken to preserve the ileocecal valve function and avoid indiscriminate incisions.
In summary, a multifaceted approach, considering the anatomical, physiological, and surgical aspects, is essential in both the treatment and prevention of SBS.
This article was originally published in Transportation Medicine 1991. Vol.5, No.1: 41-40 Changhang Hospital, Li Mingjie