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Small bowel

Background

Resection of small bowel may be necessary in inflammatory (Crohn’s disease) or ischaemic (due to a volvulus) conditions.

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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.

Fresh tissue received

No
- Non-routine fixation (not formalin), describe.

Yes
- Special studies required, describe.
- Ensure samples are taken prior to fixation.

Intraoperative consultation

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.

Orientation markers

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.

Options

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
- Mucosa
- Submucosa
- Serosa
Mesentery
Other organ, describe
Not known

Lesion size (mm)

In three dimensions

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

More detail

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

Lymph nodes

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:

Tumour apparent

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.

Non-tumour lesion

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.

No tumour or focal lesions

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

Feakins R, Campbell F, Mears L, Moffat C, Scott N and Allen D. Tissue pathways for gastrointestinal and pancreatobiliary pathology, The Royal College of Pathologists, London, 2009.
MacDuff E, Walsh S and Reid R. Dataset for gastrointestinal stromal tumours (GISTs), The Royal College of Pathologists, London, 2012.
Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
Klöppel G, Rindi G, Anlauf M, Perren A and Komminoth P. Site-specific biology and pathology of gastroenteropancreatic neuroendocrine tumors. Virchows Arch 2007;451 Suppl 1(1):S9-27.
Guindi M and Riddell RH (2004). Indeterminate colitis. J Clin Pathol 20074;57(12):1233-1244.
Howat A, Boyd K, Jeffrey M, Lessells A, Shepherd NA and McCluggage G. Histopathology and cytopathology of limited or no clinical value, The Royal College of Pathologists, London, 2005.
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.
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.

Dictation Template