Auto Text: “Insert Crohns Ileocecectomy”

These specimens can be from any part of the small or large intestine, with ileo-cecectomies being most common. Often the specimen encompasses a previous surgical anastomosis, as this is the most common site for recurrence of Crohn’s disease. The loops of bowel are commonly adherent, sometimes with communicating fistulous tracts, although these are often difficult to demonstrate. A gross description of the degree of involvement of the proximal and distal resection margins is of particular interest to the surgeon.

Triage

1. Identify which portions of small intestine and/or colon have been resected, and whether a previous surgical anastomosis is present
2. If the specimen is particularly interesting, photograph
3. Measure length, wall thickness, and inner circumference of all potential segments as follows:
   • Terminal ileum
   • Proximal cecum/ascending colon
   • Bowel proximal and distal to anastomotic site
   • Circumference of any dilated or strictured portion of the specimen and length of the dilated or strictured portion
   • Distance from any lesion to the closest resection margin
   • Length and diameter of the appendix
4. Wrap in gauze and fix for at least 30 minutes prior to grossing to facilitate acquisition of adequate mucosa on submitted sections.

Gross

1. Remove the specimen from formalin and orient it correctly.
2. Check the requisition and prior biopsy history.  If there is dysplasia or carcinoma, then treat the specimen as for neoplastic disease.
3. Longitudinal sections of the proximal and distal margins.
4. Appendiceal tip and cross sections from center and base.
5. Take sections of any small bowel or colonic lesions fistula tract openings, strictures, polyps, dense adhesions, or masses.
6. Take sequential representative sections of the bowel every 10 cm from distal to proximal, to include areas of transition between normal, quiescent, and actively inflamed areas, and especially to document “skip areas” of normal mucosa next to or between involved areas.  Inspect the colon carefully for slightly raised and/or granular/velvety lesions (possible dysplasia).  If identified, section extensively.
7. Document serosal inflammatory masses.
8. If cancer or dysplasia is identified, then a complete lymph node search should be conducted.  Otherwise, a cassette worth of several lymph nodes is sufficient.