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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.

    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
      • 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

    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

    1. 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.
    2. MacDuff E, Walsh S and Reid R. Dataset for gastrointestinal stromal tumours (GISTs), The Royal College of Pathologists, London, 2012.
    3. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    4. 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.
    5. Guindi M and Riddell RH (2004). Indeterminate colitis. J Clin Pathol 20074;57(12):1233-1244.
    6. 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.
    7. 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.
    8. 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.

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      Small bowel 1

      Small bowel resection

      Small bowel 2

      Small bowel opened

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      25-Mar-2019
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