Four patients underwent massive small bowel resection. Which pattern of resection carries the worst prognosis for eventual freedom from parenteral nutrition?

• A Extensive jejunal resection with intact ileum, ileocaecal valve, and colon
• B Extensive ileal resection with loss of the ileocaecal valve and colon in discontinuity ✓
• C Limited distal jejunal resection of 50 cm with everything else preserved
• D Extensive jejunal resection with preserved ileum but loss of the ileocaecal valve

Explanation

The ileum has the least adaptive capacity and performs irreplaceable functions: bile salt and vitamin B12 absorption, and slowing transit via the ileocaecal valve. Loss of ileum together with the ileocaecal valve and continuity with colon produces severe watery diarrhoea, bile salt wasting, and shortest survival off parenteral nutrition. The jejunum, by contrast, adapts remarkably well and can assume much of the absorptive load if the ileum, valve, and colon remain in circuit, making option A far better tolerated than its length alone would suggest.

Reference: Schwartz's Principles of Surgery, 11th ed.

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