Four Radical Bowel-Sparing Procedures for the Treatment of Small Bowel Tumors: A Retrospective Cohort Study From a Prospective Clinical Trial.

BACKGROUND: Bowel tumor surgery lacks standardized lymphadenectomy levels comparable to D1/D3 concepts in colorectal surgery. Wedge bowel resections compromise nodal staging, whereas extensive resection increases the risk of short bowel syndrome. Preoperative 3D-vascular reconstruction enables tailored lymphadenectomy while preserving bowel length. PURPOSE: To introduce and evaluate four radical bowel-sparing procedures for small bowel tumors, based on preoperative identification of tumor-feeding arteries and standardized D3-volume lymphadenectomy. METHODS: Consecutive patients from the prospective trial "Surgery with Extended Mesenterectomy for Small Bowel Tumors" were analyzed. Patients underwent preoperative 3D vascular reconstruction to identify tumor-feeding arteries. Four procedures were defined by the tumor feeding vessel and tumor location: duodenojejunal resection, jejunal resection, ileal resection, and right colectomy/ileocaecal resection. Lymph node harvest, D3 positivity, bowel length, and short-term outcomes were analyzed. RESULTS: Eighty-six patients were included. Tumor-feeding arteries were jejunal arteries in 15 patients, the terminal ileal artery in 50, and the ileocolic artery in 21. Duodenojejunal resection was performed in 5 patients, jejunal resection in 10, ileal resection in 34, ileocaecal resection in 6, and right colectomy in 31. Median specimen length was 31.5cm. Median lymph node harvest was 31, and median D3-lymph node harvest was 12. Positive nodes were found in 71 patients, with D3 positivity in 33. Vascular injuries occurred in 20 patients. 11 patients were reoperated. There was no 30- or 90-day mortality. CONCLUSIONS: Artery-based partitioning of the small bowel into four radical bowel-sparing procedures enables standardized D3-volume lymphadenectomy with comparable nodal yield, limited bowel resection, acceptable morbidity, and no short-term mortality.