The length of the small intestine in a healthy person is approximately 6 meters. The total surface area of the small intestine mucosa is huge - about 500 m 2 , which is comparable with the area of the tennis court; colon - 4 m 2 - is equal to the area of the table for table tennis. With the removal of a large part of the intestine, its functions are significantly reduced, which leads to intestinal failure and the appearance of short bowel syndrome. Particularly difficult recovery occurs if less than 2 meters of the intestine is preserved.
The main reasons why an extensive bowel resection is performed:
- thrombosis and embolism of the intestinal vessels (30-90%);
- Crohn's disease (50%);
- Gardner's syndrome (20%);
- periarteritis nodosa (15%);
- intestinal tumors (1-16%);
- post-radiation enteritis (10%);
- intestinal angiomatosis (4%).
Intestine anatomy
Food from the stomach enters the small intestine, which consists of three departments, which differ in their functions. Next, a lump of overcooked food - chyme - enters the large intestine, which also consists of three sections. Between them is the ileocecal valve, which acts as a damper. The lower part of the large intestine - the rectum - serves for the accumulation of feces, ends with the anus.
Operation Options
Depending on the localization of the pathology due to which the operation is performed, part or all of the small intestine, part of the colon or rectum can be removed. There are three types of resection.
- Removing part of the small intestine while preserving part of the ileum, ileocecal valve and large intestine. Serious postoperative disorders are rare in these patients.
- Removal of part of the jejunum, the entire ileum and the ileocecal valve with the creation of a compound (anastomosis). Such patients will have steatorrhea, nutritional deficiencies and other disorders. However, over time, the body can adapt to new conditions.
- Resection of the large intestine (colectomy) with the creation of an artificial fistula from the jejunum (jejunostomy) or ileum (ileostomy) of the intestine through the abdominal wall to the outside. Fecal masses will be removed through the created hole, therefore it is called an unnatural anus. In such patients, intestinal adaptation is not observed. It is possible to constantly take saline, glucose, antidiarrheal drugs, in a number of patients - parenteral nutrition.
Features of postoperative disorders depending on the site of resection
Depending on which part of the organ has been removed, certain symptoms prevail.
In the small intestine, all kinds of nutrients are digested, and the vast majority of hydrolyzed substances, vitamins, trace elements and water are absorbed here. Resection of the small intestine leads to:
- deficiency of all types of nutrients in the body during their normal intake in the digestive tract;
- diarrhea due to a sharp decrease in water absorption.
Each section of the small intestine does its job, so the resection of different parts of the intestine is manifested by different symptoms.
Water and nutrients are absorbed mainly in the upper intestine (jejunum). Secrets produced in the digestive tract, bile, and enzymes are absorbed mainly in the lower section (ileum), part of the water is also absorbed here. Therefore:
- Resection of the jejunum is not accompanied by diarrhea, since the remaining ileum takes care of the fluid.
- Removal of the ileum causes severe diarrhea, since the secrets produced in the previous sections of the tract have nowhere to be absorbed, they dilute the chyme, thereby causing frequent watery stools. In addition, in the absence of the ileum, bile and fatty acids are not absorbed, which pass into the large intestine, where they attract water, exacerbating diarrhea.
The ileocecal valve, which closes the passage between the small and large intestines, is of great importance in digestion. Removal of this flap with extensive resection of the small intestine:
- accelerates the passage of chyme, which leads to a decrease in the absorption of electrolytes, nutrients and liquids;
- promotes the penetration of microflora from the large intestine into the small intestine, which leads to the appearance of excessive bacterial growth.
In the large intestine, part of the water and electrolytes are absorbed, feces are formed. The microflora of this part of the body synthesizes B vitamins and vitamin K. Here is the final fermentation of fats to short fatty acids, which are important energy substrates, and also have antimicrobial effects.
Resection of the large intestine leads to the loss of part of the water and minerals, to a lack of vitamins. Feces do not have time to form. Preservation of the colon significantly compensates for malabsorption of carbohydrates and fats, as well as fluid.
The totality of all disorders resulting from intestinal resection is combined under the general name - short bowel syndrome. All arising disorders are caused by:
- violation of digestion;
- malabsorption;
- trophological insufficiency;
- the involvement of other organs in the pathological process.
Recovery after bowel removal
Changes in the body after surgery for intestinal resection go in three stages.
- Postoperative phase - lasts from a week to several months. It is characterized by water diarrhea (up to 6 liters per day), accompanied by a loss of sodium, potassium, chlorides, magnesium, bicarbonates. This causes dehydration and severe electrolyte deficiency, the development of severe metabolic disorders, impaired protein, water, electrolyte and vitamin metabolism.
- Subcompensation phase - lasts for a year after intestinal resection. The digestive system gradually adapts: the frequency of stools decreases, metabolic processes normalize. In this case, the absorption of nutrients is not restored. Therefore, vitamin deficiency and anemia are noted, manifested by general weakness, dermatitis, sensory disturbances (numbness, "goosebumps", tingling), dry skin, and brittle nails. Almost all patients are underweight.
- Adaptation phase - begins about two years after bowel resection. For its beginning, compensatory structural restructuring of the small intestine is necessary. If the intestine adapts, the patient's condition stabilizes. The manifestations of diarrhea will decrease, body weight will be restored. But complications may arise in the form of synthesis of stones in the gall and bladder, the appearance of stomach ulcers. Anemia may persist.
After bowel resection, restoration of functions is possible if the earliest possible:
- normalization of the content of proteins, fats, carbohydrates, vitamins in the body;
- the beginning of stimulation of digestion;
- the beginning of absorption processes;
- restoration of intestinal microbiota.
The most effective way to start the process of adaptation in the intestine is to make it work. Without nutrient intake, the body will not begin to recover. Therefore, it is important to start enteral nutrition as early as possible. The contact of nutrients with enterocytes triggers the synthesis of hormones and enzymes of the intestine and pancreas, which stimulates the processes of adaptation. A large role is played by the nature of nutrition. The diet should be dietary fiber, glutamine, short fatty acids.
Post-operative nutrition principles
In the postoperative period of intestinal resection, in order to preserve the patient's life, measures to prevent complications: dehydration, hypovolemia, hypotension, electrolyte disturbances are paramount. When these conditions are eliminated, 2-3 days after the operation, they begin to establish parenteral (bypassing the digestive tract) nutrition with the introduction of energy substrates. Large volumes of glucose, isotonic solutions of sodium chloride, calcium, potassium, and magnesium salts are administered intravenously.
When the patient's condition is stabilized, diarrhea is taken under control, enteral (using the digestive tract) nutrition is prescribed. After a small bowel resection, food is prescribed for 3-5 days, after an extensive - through a tube in 2-4 weeks. Perhaps increased diarrhea after the start of enteral nutrition. However, you can not stop it, you need to reduce the rate of administration of drugs.
Gradually, when the patient's condition improves, they switch to normal oral (through the mouth) nutrition. Usually prescribed sequentially diet No. 0a, 1a, 1, 1b.
Diet 0a has a low energy value, so the patient lacks nutrients. Protein deficiency is especially dangerous. The processes of catabolism begin to prevail over the processes of synthesis, restorative mechanisms are inhibited, which is fraught with an unfavorable outcome, especially if metabolic processes have already been disturbed before the operation. Therefore, a combined diet with parenteral and enteral administration of nutrients is prescribed. The total calorie content is significantly increased and amounts to 3500 kcal per day.
In the case of good tolerance of the zero diet, after 2-3 days, the patient is prescribed diet No. 1a (another name is 0b). As a rule, the patient remains on this variant of the diet after bowel resection until discharge from the medical institution.
Post-discharge nutrition guidelines
The appointment of the right diet and its strict observance are the most important conditions for recovery.
Two weeks after intestinal resection, the diet is changed from No. 1a to 1 surgical. But within 3-4 weeks it is recommended to wipe all the food. The principle of thermal and mechanical sparing must be observed. Dishes are steamed or boiled, all food is thoroughly crushed to a liquid or gruel-like consistency, the fruits are wiped, they are made of jelly and stewed fruit. Exclude products that enhance rotting and fermentation - canned food, smoked meats, spices.
If such a diet is well tolerated, you can gradually switch to an unprotected version of the surgical diet No. 1. This means a daily reduction in dishes with maximum mechanical and heat treatment. Good tolerance of a new dish indicates the formation of compensatory reactions of the digestive tract, the normalization of its functions, which allows to expand the diet. Such a transition should take at least 2 weeks, and sometimes reach 5-6.
In the non-mashed version of the diet, food can be boiled, after boiling, you can bake a piece. A wider selection of vegetable and fruit purees, compotes is allowed. Meal should be fractional - at least 6 times a day.
The consequences of intestinal resection include an increase in the sensitivity of the digestive tract to certain products. First of all, we are talking about whole milk, as well as fatty foods, including vegetable oil, strong broths, decoctions, fresh vegetables and fruits, sour foods. Milk intolerance is observed in 65% of patients after intestinal resection, food in this case must be changed, there is no need to practice the “training” of the fragile organ with dairy products. Whole milk needs to be replaced with soy or other vegetable milk for several months or even years until lactose intolerance passes.
Diets in the first month after surgery
In the first month after resection, both the small and large intestines are prescribed the same nutrition.
Diet 0a.
Appointed for two to three days. The food is liquid or jelly-like. Calorie intake 750-800 kcal. You can drink about 2 liters of free liquid.
Allowed: weak meat broth without fat, rice broth with butter, strained compote, liquid jelly, rosehip broth with sugar, not more than 50 ml of freshly prepared juice from fruits or berries, diluted 2 times with water. On the third or fourth day, when the condition stabilizes, you can add a soft-boiled egg, butter or cream.
Exclude: heavy food, whole milk and cream, sour cream, vegetable juices, carbonated drinks.
Diet 1a is surgical.
Calorie content is 1500-1600 kcal, liquid - up to 2 l, meals - 6. To already entered dishes add mashed liquid cereals from hercules, rice, buckwheat, cooked in meat broth or in water in half with milk; mucous soups from cereals on vegetable broth; steamed omelette from proteins, steamed mashed potatoes or soufflé from meat or fish (without fascia and fat), cream (up to 100 ml), jelly, non-acidic berry mousse.
Diet 1b is surgical.
It is a more expanded version of the previous diet and serves to prepare the patient's digestive tract for the transition to a good diet. The calorie content of the diet rises to 2300, there are 6 meals. Dishes should not be hot (not more than 50 ° ) and not cold (not less than 20 ° ).
Soups are added in the form of mashed potatoes or cream, steamed dishes from mashed boiled meat, fish or chicken; fresh cottage cheese, mashed with cream to the consistency of thick sour cream, steamed cottage cheese, sour-milk products, baked apples, mashed vegetables and fruits, white crackers. Porridge is boiled in milk, milk can be added to tea.
Diet after resection of the small intestine
For bowel resection, the following list of dishes and products is recommended:
- Yesterday’s wheat bread.
- Soups on a weak broth - meat or fish, with meatballs, noodles or boiled cereals.
- Cutlets or meatballs from beef, veal, rabbit, chicken, turkey. Low-fat fish, steamed or boiled.
- Potatoes and carrots in the form of a separate dish or side dish - boiled and mashed. Exclude cabbage, beets, radishes, turnips, tomatoes, garlic, sorrel, mushrooms.
- Porridge (except for pearl barley and millet) on water with the addition of a third of milk, legumes, pasta.
- Boiled egg or steam omelet from two proteins.
- Allowed in a small amount of milk (only in cereals), sour cream and cream (as an additive to dishes). Fresh cottage cheese, baked or steam curd puddings are allowed. If milk intolerance appears, you will have to refuse the use of milk for a long time (sometimes forever). Dairy products are replaced by soy, which is also a rich source of protein.
- Jelly, mashed compotes, jelly, apples only baked.
- Rosehip broth, tea, black coffee.
To support patients with extensive bowel resection in the postoperative period, nutrient mixtures are often used, which are used as an addition to the diet or basic nutrition. Similar mixtures developed abroad and in our country are widely represented in pharmacies and stores. They can significantly increase the calorie intake, provide plastic and energy needs, while not overloading the enzyme system of the digestive tract.
Diet after colon resection
Special nutrition should be in patients after resection of the large intestine and excretion of unnatural anus. Such patients must observe three main parameters of nutrition:
- the amount of eaten;
- the quality of products that provide either liquefaction or thickening of feces;
- meal time.
The amount of solid food eaten should always be in the same proportion with the drunk liquid. For example, for breakfast, the patient always eats one plate of porridge and drinks one glass of tea. Porridge can be from different cereals, and tea - different degrees of brewing. Lunch, dinner, and other meals should also include a stable amount of solid food and fluid. So it will be possible to control the density of the stool.
If necessary, thickening stool, porridge is cooked thicker, from rice and buckwheat, semolina and pea are excluded. They cancel everything that promotes peristalsis and gas formation: sour dairy products, fresh fruits, coffee with milk, compote from plums.
To liquefy feces, increase the proportion of liquid in the diet, reduce the portion of food, reduce the amount of salt, add prunes, fruits, yogurt, vegetable soups without meat to the diet.
The third condition of a normal stool is eating at certain, fixed once and for all hours.
Patient rehabilitation
After bowel resection, rehabilitation includes physiotherapy and kinesitherapy - treatment with physical activity.
After surgery, patients experience disorders associated with the disease itself, surgery, anesthesia, and lack of movement.For example, pain at the incision site leads to a decrease in inspiration, the patient may not use the diaphragm at all. In addition, bedding and anesthesia cause spasms of the small bronchi, clogging their mucus. Therefore, after the operation, especially if the patient has been in bed for a long time, breathing exercises are necessary, which involve the entire volume of the lungs, allow the lungs to straighten.
In the postoperative period, exercise allows you to:
- to prevent complications - congestive pneumonia, atelectasis, intestinal atony, thrombosis;
- improve the activity of the cardiovascular and respiratory systems;
- improve the emotional state,
- prevent the appearance of adhesions,
- form an elastic, movable scar.
Contraindications to physiotherapy exercises: serious condition, acute cardiovascular failure, peritonitis.
In the absence of contraindications, the exercises begin from the first hours after the operation - breathing exercises, warm-up for fingers, feet and hands, chest massage.
Bed rest should be observed 1-6 days after surgery, depending on the condition of the patient. Assign breathing exercises, light exercises for the abdominal muscles, tasks for diaphragmatic breathing, reduction of the muscles of the perineum (reduction of congestion in the pelvic organs), body turns.
On the 6-12th day, you can engage in lying, sitting and standing.
On days 12-14, the choice of types of physical activity is greatly expanded, gymnastic apparatus, sedentary games can be used, dosed walking is allowed.
A month after the operation, it is necessary to perform general toning exercises, tasks to strengthen the abdominal muscles for the prevention of postoperative hernias. Recommended walking, elements of sports, close tourism, skiing.