1. Dr.M.Farhad

2. History The first reported small bowel was reported to have taken place in 1727 by Ramdohr. –Removed 2 feet of gangrenous intestine By 1836 at least 10 more procedures had been performed by French, German, and English surgeons –5 cured, 2 with artificial anus, 2 died Became a recognized surgical procedure in 1875 by Kuster.

3. Malignant neoplasm: Histologic types: Tumor type Cell of origin Frequency Predominant Site adenocarcinoma Epithelial cell 35 – 50% Duodenum carcinoid Enterochromaffin cell 20 – 40% Ileum lymphomalymphocyte 10 – 15% Ileum GIST (gastrointestinal stromal tumors) ? Interstitial cell of Cajal 10 – 15% -

4. Malignant neoplasm: 1. Adenocarcinoma: Most common CA of small bowel Most common in duodenum and proximal jejunum Half involve the ampulla of Vater.

5. Film from a small bowel follow through demonstrating an “apple-core” appearance caused by a metastatic lesion to the small intestine from a scirrhous gastric cancer.

6. S.I. ADENOCARCINOMA

7. Malignant neoplasm: 2. Carcinoid: From enterochromaffin cells or Kultchitsky cells Arise from foregut, midgut & hindgut Appendix (46%) > Ileum (28%) > Rectum (17%)

8. Malignant neoplasm: 2. Carcinoid: Aggressive behavior than the appendiceal carcinoid. appendix – 3% metastasize; Ileum – 35% metastasize Appendix – solitary; Ileum – 30% multiple 25-50% w/ carcinoid tumor with liver metastasis develops carcinoid syndrome. Secretes serotonin, bradykinin and substance P 1.Diarrhea 2.Flushing 3.Hypotension 4.tachycardia 5.fibrosis of endocardium and valves of the right heart.

9. S.I. CARCINIOD

10. CT scan demonstrates a soft tissue mass containing coarse central calcifications (short arrow) in the right lower quadrant. This carcinoid tumor is producing a characteristic desmoplastic response with spiculation of the adjacent mesenteric fat (long arrow).

11. Malignant neoplasm: 3. Lymphomas: Most common intestinal neoplasm in children under 10y/o. In adult = 10-15% of small bowel malignant tumors Most common presentation 1.intestinal obstruction 2.Perforation (10%)

12. Malignant neoplasm: 3. Lymphomas: Criteria of primary lymphomas of the small bowel: 1.Absence of peripheral lymphadenopathy 2.Normal chest x-ray w/o evidence of mediastinal LN enlargement. 3.Normal WBC count and differential 4.At operation, the bowel lesion must predominate and the only nodes are associated w/ the bowel lesion 5.Absence of disease in the liver and sple

13. Malignant neoplasm: 4. GISTs: (gastrointestinal stromal tumors) Most common mesenchymal tumors arising in the small bowel 70% arises from the stomach followed by the small bowel 15% of small bowel malignancies Formerly classified as: 1. Leiomyomas 2. Leiomyosarcomas 3. Smooth muscle tumors of small bowel Associated w/ overt hemorrhage Has its expression of the receptor tyrosine kinase KIT (CD117). There is pathological KIT signal transduction

14. GIST

15. SARCOMA

16. Capsule endoscopy view of an ulcerated mass in a patient who presented with gastrointestinal bleeding. Four ulcerated, bleeding masses were found throughout the small bowel; these were confirmed at surgery and found to be sarcomas

17. Small bowel follow through study shows multiple rounded, nodular filling defects in the wall of the small bowel (arrows). Multiple small bowel tumors may be seen in metastatic disease or in polyposis syndromes; the most common cause of small bowel metastases is melanoma.

18. Treatment: II. Malignant lesions: 1.Adenocarcinoma: Wide local resection w/ it’s mesentery to achieve regional lymphadenectomy Chemotherapy has no proven efficacy in the adjuvant or palliative treatment of small- intestinal adenoCA. 2.Small intestinal lymphoma: For localized: segmental resection w/ adjacent mesentery If w/ diffused involvement: -->chemotherapy rather than surgery, is primary therapy

19. Treatment: 3.Carcinoid: Segmental intestinal resection & regional lymphadenectomy. −< 1cm rarely has LN metastases −> 3cm 75 to 90% LN metastases 30% are multiple, hence entire small bowel shd be examined prior to surgery.

20. Treatment: 3.Carcinoid: Is w/ metastatic lesions---> debulking, associated w/ long-term survival & amelioration of symptoms of carcinoid syndrome Chemotherapy: ---> 30 -50% response 1. Doxorubicin 2. 5-fluorouracil 3. Streptozocin Octreotide: - most effective for management of symptoms of carcinoid syndrome

21. Allen Oldfather Whipple (1881-1963) Pancreatico- duodenectomy (PD) was first performed by Kausch in 1908, and popularized by Whipple in the 1930s (who performed 37 procedures). —Whipple AO, Parsons WB, —Whipple AO, Parsons WB, Mullins CR. Mullins CR. Treatment of Carcinoma of the Ampulla of Vater. Ann Surg 1935; 102: 763-769. Treatment of Carcinoma of the Ampulla of Vater. Ann Surg 1935; 102: 763-769.

22. The operation' classical 'Whipple involves an 'en-bloc' resection of the pancreatic head, together with the distal stomach and omentum, the duodenum and upper jejunum, and the distal biliary tree including the gall bladder Classic Whipple Resection— Pancreatico- duodenectomy

23. Reconstruction after Classic Whipple Resection

24. Modified Whipple operation —PPPD A more limited duodenectomy with preservation of the stomach and antropyloric region is preferred by some experts and the pylorus preserving pancreatico-duodenectomy (PPPD) involves a lesser lymphadenectomy

25. PPPD Pylorus- preserving pancreatico- duodenectom y

26. (a) pancreaticogastrostomy (b) end-to-end pancreaticojejunostomy (c) end-to-side pancreaticojejunostomy

27. Classic Whipple V.S. PPPD PPPD—protects against gastric dumping, marginal ulceration, and bile reflux gastritis. Significant reduction of the operation time, the intraoperative blood loss and the consequent need for blood substitution. But sufficiently radical to treat pancreatic cancer? Similar or even better postoperative morbidity and mortality result was debated.

28. Principle Indications for PD (1) Ductal adenocarcinoma of the pancreatic head (2) Cholangiocarcinoma of the distal biliary tree (3) Periampullary adenocarcinoma and ampullary carcinoid (4) Primary duodenal adenocarcinoma, duodenal GIST and duodenal lymphoma (5) Chronic pancreatitis with associated mass lesion of uncertain aetiology

29. Laparoscopic Advantages –Quicker recovery time –Faster return to eating solid foods –Less pain –Fewer scars –Lower risk of infection –Fewer post-operative complications

30. Surgical Risks Damage to nearby organs in the body Wound infections Wound breaking open Bulging tissue through the incision, called an incisional hernia Short bowel syndrome (when a large amount of the small intestine needs to be removed) The ends of your intestines that are sewn together may come open. This is called anastomosis. This may be life threatening. –Anastamotic leak Scar tissue may form in your belly and cause blockage of your intestines. Problems with your ileostomy Inadvertant enterotomy Anastomotic stricture Hemorrhage

31. Operating Room Layout Patient begins in supine position Move patient into positions later to allow gravity to shift unwanted organs out of the way. Two screens to allow surgeons on both sides of patient to see Anthesiologist positioned behind patient’s head and scrub nurse positioned near the feet (not shown)

32. Port Placements One 10 mm trocar placed in umbilical incision for camera Two 5 mm trocars placed in abdomen to triangulate on area to be resected. Trocar placed in abdomen via the Opti-view This can be seen on the left going through the layers of the abdomen.

33. Key Steps Step 1: Move along bowel using atraumatic bowel graspers to find the source of the desired bowel for excision. Note from surgeon  be sure to grab the fat near the bowel and not the bowel itself this will reduce the risk of tearing. Bowel may have attachments so be sure to mobilize the bowel. This is important because the small bowel will be extracted from the abdomen.

34. Key Steps Step 2: –After finding desired small bowel, use the harmonic scalpel to dissect mesentery and ligate the arteries of the Superior Mesenteric Artery –If bleeding occurs suction may be used to remove interfering blood. Caution: The Harmonic Scalpel is very hot. Be sure not to damage internal structures by touching them with the tip after cutting.

35. Key Steps Step 3: –Once vasculature has been minimized to desired area, remove the camera and trocar and lengthen the umbilical incision. –This lengthening will allow for the small intestine to be removed from the abdominal cavity. A hand port may be used during this step of the procedure. If a hand port is used, the umbilical incision will be lengthened, the port placed, and then the intestine will be pulled from the abdomen.

36. Key Steps Step 4: –Locate desired portion of bowel and using mosquito clamps, clamp around the edge of the area to be removed. –Cut in between the two clamps. –This procedure will be done on both sides of the intestine to be removed.

37. Key Steps Step 5: –Perform a side-to-side anastamosis by aligning the two healthy small bowel segments side-by- side with the openings next to one another. The GIA endostapler may now be inserted into the openings and applied. This will anastamose the intestine leaving one opening at the end.

38. Key Steps Step 6: –Close the opening of the anastamosis. –Be sure to place other sutures around the anastamosis in order to reinforce the intestine.

39. Key Steps Step 7: –Return bowel to abdomen through the umbilical incision. If desired, place On-Q Painbuster in patient. Step 8: Close incisions left over from trocars and umbilical incision.

40. Post-Operative Care Hospitalization for 3-7 days. Ingestion of liquids is allowed by the second day. Slowly thicken liquid over time until solid foods may be ingested Pain and wound management The longer the length of bowel removed the longer the hospital stay and the longer one will be unable to eat solid foods.