Jonathan Green, MD, Ann K Friedrich, MD, Christopher R Schlieve, MD, Kevin Barrata, MD, David Ma, MD, May Min, MD, Krunal Patel, MD, David Stein, BS, David Cave, MD, PhD, Demetrius Litwin, MD, MBA, Mitchell Cahan, MD, MBA. University of Massachusetts Medical School
Introduction: Small bowel lesions (SBL) are rare, representing diagnostic and management challenges due to difficulty in identification and localization. As an advanced endoscopic referral center, we frequently see patients with SBL. The purpose of this study was to evaluate the success of our management and treatment strategies.
Methods: We retrospectively analyzed patients undergoing surgical management for SBL from July 2005- September 2015 at our institution. Based on presenting symptomatology, patients fell into two distinct subgroups: gastrointestinal bleed/anemia (GIBA) or obstruction/pain (OP).
Results: Overall, 112 patients underwent surgery after presenting with either GIBA(n=67) or OP(n=45). Sub-groups were similar except for BMI, which was higher in GIBA (30 vs. 20, p<0.01). All GIBA patients had chronic or acute-on-chronic symptoms compared to 67% in OP (P<0.001). GIBA patients were more often referred from outside hospitals (82% vs. 44%, p<0.001). Video Capsule Endoscopy (VCE) (n=64, 96%) and CT (n=35, 78%) were the most common preoperative imaging modalities for GIBA and OP patients respectively. VCE in GIBA patients (n=43, 67%) and CT in OP patients (18, 51%) most frequently correlated to operative findings. Intraoperatively, visual inspection or palpation of the bowel most successfully identified lesions (GIBA:69%, OP:75%). When performed in GIBA(n=26), Intraoperative Enteroscopy (IE) confirmed lesions or identified lesions in 18(69%) patients. In the GIBA group, 60 (90%) patients underwent small bowel resections. Of these patients, 56 (93%) had laparoscopic-assisted approaches (4 (6.7%) were converted to open for enhanced exposure)) and 4 (6.7%) were initially approached open. In the OP group, 26 (58%) had a small bowel resection. Of these patients, 21(81%) were laparoscopic-assisted (3 (14%) were converted to open enhanced exposure) and 5(19%) were initially approached open. Surgical exploration failed to identify lesions in 7(10%) GIBA patients and 8 (18%)OP patients. In the GIBA group who had resections, 21% (11/60) had recurrent symptoms compared to 21% (4/31) in the OP group.
Conclusion: Successful management and identification of small bowel lesions is governed by presenting symptomatology. Optimal management includes VCE and IE for GIBA and CT scans for OP patients. Comprehensive evaluation may require referral to specialized centers.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80246
Program Number: S121
Presentation Session: MIS – Cool Stuff
Presentation Type: Podium