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Journal of Gastrointestinal Surgery

, Volume 22, Issue 6, pp 1034–1042 | Cite as

Approach to the Diagnostic Workup and Management of Small Bowel Lesions at a Tertiary Care Center

  • Jonathan Green
  • Christopher R. Schlieve
  • Ann K. Friedrich
  • Kevin Baratta
  • David H. Ma
  • May Min
  • Krunal Patel
  • David Stein
  • David R. Cave
  • Demetrius E. Litwin
  • Mitchell A. CahanEmail author
Original Article

Abstract

Background

Small bowel lesions (SBL) are rare, representing diagnostic and management challenges. The purpose of this cross-sectional study was to evaluate diagnostic modalities used and management practices of patients with SBL at an advanced endoscopic referral center.

Methods

We analyzed patients undergoing surgical management for SBL from 2005 to 2015 at a single tertiary care center. Patients were stratified into gastrointestinal bleed/anemia (GIBA) or obstruction/pain (OP).

Results

One hundred and twelve patients underwent surgery after presenting with either GIBA (n = 67) or OP (n = 45). The mean age of our study population was 61.8 years and 45% were women. Patients with GIBA were more likely to have chronic or acute-on-chronic symptoms (100% vs 67%) and more often referred from outside hospitals (82 vs. 44%) (p < 0.01). The most common preoperative imaging modalities were video capsule endoscopy (VCE) (96%) for GIBA and computer tomography CT (78%) for OP. Findings on VCE and CT were most frequently concordant with operative findings in GIBA (67%) and OP (54%) patients, respectively. Intraoperatively, visual inspection or palpation of the bowel successfully identified lesions in 71% of patients. When performed in GIBA (n = 26), intraoperative enteroscopy (IE) confirmed or identified lesions in 69% of patients. Almost all (90%) GIBA patients underwent small bowel resections; most were laparoscopic-assisted (93%). Among patients with OP, 58% had a small bowel resection and the majority (81%) were laparoscopic-assisted. Surgical exploration failed to identify lesions in 10% of GIBA patients and 24% of OP patients. Among patients who underwent resections, 20% of GIBA patients had recurrent symptoms compared with 13% of OP patients.

Conclusion

Management and identification of SBL 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.

Keywords

Small bowel Minimally-invasive surgery Gastrointestinal bleed 

Notes

Author Contributions

All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

JG: Contributed to study design, data acquisition, data analysis, data interpretation, drafting and revising the manuscript, and final approval of the manuscript

CRS: Contributed to study design, data acquisition, data analysis, data interpretation, drafting and revising the manuscript, and final approval of the manuscript

AF: Contributed to study design, data analysis, drafting and revising the manuscript, and final approval of the manuscript

KB: Contributed to study design, data analysis, drafting and revising the manuscript, and final approval of the manuscript

DHM: Contributed to study design, data acquisition, drafting and revising the manuscript, and final approval of the manuscript

MM: Contributed to study design, data acquisition, drafting and revising the manuscript, and final approval of the manuscript

KP: Contributed to study design, data acquisition, drafting and revising the manuscript, and final approval of the manuscript

DS: Contributed to study design, data acquisition, drafting and revising the manuscript, and final approval of the manuscript

DRC: Contributed to study design, data interpretation, critical revision of the manuscript, and final approval of the manuscript

DEL: Contributed to study design, data interpretation, critical revision of the manuscript, and final approval of the manuscript

MAC: Contributed to study design, data interpretation, critical revision of the manuscript, and final approval of the manuscript

Compliance with Ethical Standards

Grant Support

University of Massachusetts Center for Clinical and Translational Sciences TL1 Training Grant.

Grant # TL1TR001454

National Presentation

Society of American Gastrointestinal and Endoscopic Surgery (SAGES) Annual Meeting on March 24, 2017, in Houston Texas

Author Disclosures

Drs. Green, Schlieve, Friedrich, Baratta, Ma, Min, Patel, Cahan and Cave as well as Mr. Stein, have no conflicts of interest or financial ties to disclose. Dr. Litwin is on the surgical advisory board for Titan Medical.

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Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  • Jonathan Green
    • 1
  • Christopher R. Schlieve
    • 1
  • Ann K. Friedrich
    • 2
  • Kevin Baratta
    • 3
  • David H. Ma
    • 4
  • May Min
    • 5
  • Krunal Patel
    • 6
  • David Stein
    • 4
  • David R. Cave
    • 6
  • Demetrius E. Litwin
    • 1
  • Mitchell A. Cahan
    • 1
    Email author
  1. 1.Department of SurgeryUniversity of Massachusetts Medical SchoolWorcesterUSA
  2. 2.Department of SurgerySaint Mary’s HospitalWaterburyUSA
  3. 3.Department of MedicineSaint Mary’s HospitalWaterburyUSA
  4. 4.University of Massachusetts Medical SchoolWorcesterUSA
  5. 5.Department of MedicineUniversity of Massachusetts Medical SchoolWorcesterUSA
  6. 6.Division of GastroenterologyDepartment of Medicine, University of Massachusetts Medical SchoolWorcesterUSA

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