Small Bowel Cancer Surgery

When surgery is possible

Surgery is recommended when there are no distant metastases and the tumor can be removed completely together with the lymph nodes. Before surgery the doctor decides which tests are needed. Depending on the situation, they include:

• CT or MR enterography — shows the tumor, narrowing, and the state of the mesentery and lymph nodes;
• balloon enteroscopy with biopsy — confirms the diagnosis and allows the site to be marked for the surgeon;
• contrast-enhanced CT of the chest, abdomen and pelvis — to assess spread;
• tumor markers CEA and CA 19-9 and testing of the tumor for microsatellite instability (MSI/dMMR).

This page is about small bowel adenocarcinoma. For neuroendocrine tumors the extent and preparation are different — see the page “Neuroendocrine Tumor Surgery”. The disease itself, its symptoms and tests are described on the page “Small Bowel Cancer”.

If the tumor has caused obstruction

Often the diagnosis is made only during surgery for obstruction. Surgery is then urgent, but whenever possible it follows the same oncologic extent: the mesentery and lymph nodes are removed together with the tumor, not just the narrowed segment.

If you have already had surgery for obstruction, you need the histopathology report and the operative report: to find out whether the mesentery with lymph nodes was removed and whether the margins are clear. Next comes CT to assess spread and a tumor board decision on chemotherapy or, less often, re-operation. A surgeon’s second opinion is suitable for this.

If surgery is not possible right now

With distant metastases, chemotherapy becomes the basis of treatment; for tumors with microsatellite instability immunotherapy may be effective. If the tumor causes obstruction or bleeding, a palliative procedure is performed — removal of a segment of bowel or a bypass anastomosis to relieve the obstruction.

When metastases shrink after treatment or there are only a few, the tumor board may consider removing the primary tumor and the metastases.

How the operation is performed

The segment of small bowel with the tumor is removed with a margin of healthy tissue on both sides, together with a wedge of mesentery containing the vessels and lymph nodes. For accurate staging it is important to examine an adequate number of lymph nodes. The ends of the bowel are joined to restore continuity. During surgery the entire small bowel and the peritoneum are examined.

If the tumor is in the last part of the ileum, near the junction with the large bowel, the first part of the large bowel is usually removed as well — an ileocecal resection or a right hemicolectomy, depending on the distance to the valve and the lymphatic drainage. Duodenal tumors require a different extent of surgery.

When the tumor location and extent of resection allow it, the operation is performed laparoscopically — through a few small incisions. More about this approach is on the page “Laparoscopic Surgery”.

Hospital stay, recovery and further treatment

Recovery follows the enhanced recovery (ERAS) protocol: early mobilization, early eating, controlled pain relief. The length of the hospital stay depends on the extent of surgery and the approach. After removal of a short segment of small bowel, digestion usually recovers, and a strict diet is mostly not needed afterwards.

After removal of the last part of the ileum, absorption of vitamin B12 and bile acids may be impaired; B12 levels are then monitored and bowel habits are managed if needed. With lymph node involvement adjuvant chemotherapy is recommended, and in stage II it is discussed based on risk factors; the regimen is set by the oncologist.

In the first years CT and tumor markers are done regularly, every few months, and later less often; the schedule is set by the doctor. If tumor testing shows microsatellite instability or there have been bowel or endometrial tumors at a young age in the family, genetic counseling is recommended.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The main ones are:

• anastomotic leak — when the join in the bowel does not heal;
• temporary slowing of bowel function after surgery;
• bleeding during or after surgery;
• infection and general surgical complications, including thrombosis.

The likelihood of each depends on the extent of surgery, whether there was obstruction, and general condition. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost depends on the extent of surgery, the approach, the number of days in the hospital and the tests. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

What documents are needed and how to book

• CT or MR enterography or CT discs with the reports, capsule endoscopy recordings if performed;
• the enteroscopy report and histopathology report, tissue blocks and slides;
• the operative report and discharge summary, if the patient has already had surgery for obstruction;
• CEA and CA 19-9 tumor markers, complete blood count;
• information about bowel diseases and cancer in the family.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.