Small bowel
Background
Resection of small bowel may be necessary in inflammatory (Crohn’s disease) or ischaemic (due to a volvulus) conditions.
Resection for tumour is rare, carcinoid tumours being the most common, but a range of malignancies similar to the large bowel can occur (adenoma, adenocarcinoma, lymphoma and gastrointestinal stromal tumour).1-5
Resection of small bowel may occur as part of another procedure to remove tumour in adjoining tissues (e.g. stomach, pancreas or large bowel).
Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.
- No
- Non-routine fixation (not formalin), describe.
- Yes
- Special studies required, describe.
- Ensure samples are taken prior to fixation.
- Not performed
- Performed, describe type and result
- Frozen section
- Imprints
- Other, describe
See general information for more detail on specimen handling procedures.
Inspect the specimen and dictate a macroscopic description.
External Inspection
Orientate and identify anatomical features of the specimen; both cut ends (proximal and distal margins), apical vessels and possible Meckel’s diverticulum.
Orientate and identify the anatomical features of the specimen.
Record additional orientation or designation provided by operating clinician:
- Absent
- Present
- Method of designation (e.g. suture, incision)
- Feature denoted
Photograph the intact specimen if required.
Describe the following features of the specimen:1,2
Procedure
Describe as stated by the clinician.
- Segmental resection (more than one may apply)
- Duodenum
- Jejunum
- Ileum
- Not specified
Specimen integrity
- Intact
- Opened or disrupted, describe
Anatomical components (more than one may apply) and dimensions (mm)
Describe and measure the anatomical components present.
- Small bowel
- Length
- Range of luminal diameters
- Mesentery, in three dimensions
- Omentum, in three dimensions
- Other, describe and measure in three dimensions
Dissection
The lumen of specimens should be gently rinsed.
After sufficient fixation, paint the relevant surgical margins with ink and record the colours applied.
Open longitudinally along the antimesenteric border.
After opening, the specimen may require longer fixation in larger quantity of formalin.
Internal Inspection
Describe the internal appearance including the following items:1,2
Discernible lesion
- Absent
- Present, number; if more than one lesion, designate and describe each lesion separately
- If large number of lesions, record number and range of maximum diameters
Lesion site
- Duodenum
- Jejunum
- Ileum
- Mesentery
- Other organ, describe
- Not known
Lesion size (mm)
Distance to margins (mm)
- Distance of lesion to the nearest cut longitudinal margin, specify margin if known
- Distance of lesion to the mesenteric margin if mesentery is involved
Tumour description
Luminal obstruction
- Absent
- Present
- Proportion (%) of lumen occluded
Serosal involvement
- Absent
- Suspicious
- Present
Carcinoid tumours are solid, yellow, intramural or submucosal lesions, at times distorting the muscularis and obstructing the lumen.3,4
Non-tumour description
Mucosa
- Ischaemia/infarction (blue/black or haemorrhagic in appearance)
- Adhesions
- Thickening
- Ulceration
- Cobblestone appearance
- Fistula
- Anastomosis
- Intact
- Disrupted, describe surrounding tissue
- Erythematous
- Fibrous exudate
- Other, specify
Serosa/mesentery
- Adhesions
- Erythematous
- Fibrous exudate
- Perforation
- Abscess/diverticulum (identified after sectioning)
- Fat wrapping
- Meckel’s diverticulum
- Absent
- Present
- Measure length and diameter (mm)
- Other, describe
Retrieved from resection specimen
- Describe site(s)
- Number retrieved
Separately submitted
- For each container, record specimen number and designation
- Collective size of tissue in three dimensions (mm)
- Number of grossly identified lymph nodes submitted
- Maximum diameter of each (mm)
Photograph the dissected specimen.
Note photographs taken, diagrams recorded and markings used for identification.
Processing
Serially section the specimen in the transverse plane and submit sections for processing as follows:
Submit representative sections of:
- Tumour demonstrating deepest point penetration
- Interface with normal mucosa
- Non-neoplastic tissue
- Mesenteric/apical vessels, transverse sections
- Proximal and distal margins, perpendicular sections
Submit all lymph nodes.
Submit representative sections of:
- Lesion demonstrating most severely affected area and/or perforation or abscess
- Interface with normal mucosa
- Non-lesional tissue
- Mesenteric vessels, transverse sections
- Proximal and distal margins, shave or longitudinal sections
Submit representative lymph nodes.
Section bowel at 3-5mm intervals transversely and submit representative sections of:
- Bowel at 10 to 50mm intervals of whole length of specimen
- Mesenteric vessels, transverse sections
- Proximal and distal margins, shave or longitudinal sections
Submit representative lymph nodes.
There is conflicting evidence as to the value of sections from margins but the presence of active Crohn’s disease at the margins may influence patient treatment.1,6-8
Record details of each cassette.
An illustrated block key similar to the one below may be useful.
Block allocation key
Cassette id
|
Site
|
No. of pieces
|
A
|
Proximal/closer margin (if indicated) a longitudinal section to the surgical margin may give a more accurate measurement if the lesion is <10mm from the margin
|
|
B
|
Distal margin (if indicated)
|
|
C
|
Apical/vascular mesenteric margin
|
|
D-G
|
Representative sections of the lesion including deepest point of invasion and serosa (if tumour) and interface with normal mucosa (x4)
|
|
H+
|
Lymph nodes
|
|
Acknowledgements
Dr Ian Brown for his contribution in reviewing and editing this protocol.
References
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Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
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Fazio VW, Marchetti F, Church M, Goldblum JR, Lavery C, Hull TL, Milsom JW, Strong SA, Oakley JR and Secic M. Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial.
Ann Surg 1996;224(4):563-571; discussion 571-573.
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Wolff BG, Beart RW, Jr., Frydenberg HB, Weiland LH, Agrez MV and Ilstrup DM. The importance of disease-free margins in resections for Crohn's disease.
Dis Colon Rectum 1983;26(4):239-243.