What is the Small Bowel?

 

 

Your small intestine or the small bowel is the longest part of your digestive system - about twenty feet long! It connects your stomach to your large intestine (or colon) and folds many times to fit inside your abdomen.

Your small intestine does most of the digesting of the foods you eat. It has three areas called the duodenum, the ileum, and the jejunum.

What are the problems associated with the Small Bowel?

 

  • Amyloidosis

    • A widely scattered multisystem disorder characterized by a deposit of protein-based material within various tissues that affects their functioning.

  • Celiac disease

    • Sensitivity to gluten (a component of wheat). Patients with this disorder show signs of malabsorption and may experience weight loss, gastric distention or diabetes.

  • Dysmotility

    • Disorder where the muscles of the digestive system become impaired leading to changes in the speed, strength or coordination in the stomach, small intestine and colon.

  • Infections

    • Can be present for a number of years, ranging from being acute to chronic. Gastrointestinal infections can be broken up into three main types: intestinal, protozoal, and salmonella.

  • Inflammatory bowel disease(IBD)

    • IBD is a group of disorders where the intestines become inflamed. These disorders affect more than 500,000 Americans and treatments can include dietary adjustments, different medications and surgery.

  • Intestinal Lymphangiectasia

    • Affecting children and young adults, intestinal lymphangiectasia is an abnormality of the tubular system of channels that transports fats from the intestine to the liver and other organs.

  • Intestinal lymphoma

    • A recognized complication of celiac sprue and can occur when the body's ability to fight infectious diseases is compromised or entirely absent.

  • Lactose intolerance

    • Occurs when the body lacks the proper enzymes to break down lactose, a special type of sugar that is found in dairy products. Symptoms such as diarrhea, bloating and gas may occur.

  • A small bowel obstruction, be it functional or mechanical, prevents or slows down the movement of food through your small intestine. It is a potentially dangerous condition that can seriously impact quality of life.

  • Tropical Sprue

    • A malabsorptive disorder characterized by abnormalities in the lining of the small intestine that may result in increased water loss as well as poor absorption of folic acid and salts.

  • Tumors of the small intestine are rare but they either fall into the category of malignant or benign. They are usually single, but may be multiple depending on the syndrome.

  • Whipple's disease

    • A rare condition that prevents the small intestine from properly absorbing nutrients. This disorder can also affect the skin, joints, nervous system and heart.

Signs & Symptoms

 

  • Amyloidosis

    • Weight loss and fatigue

    • Anemia

    • Joint pain

    • Kidney problems

    • Abnormal liver function

  • Dysmotility

 

  • Infections

    • Diarrhea

    • Bleeding

    • Bloating

    • Nausea

    • Vomiting

    • Abdominal pain

 

  • IBD

    • Diarrhea

    • Fever and fatigue

    • Abdominal pain and cramping

    • Blood in your stool

    • Reduced appetite

    • Unintended weight loss

 

  • Intestinal Lymphangiectasia

    • Nausea

    • Vomiting

    • Fatty stools

    • Abdominal pain

    • Swelling of one or both legs

    • Diarrhea

 

  • Intestinal lymphoma

    • Crampy abdominal (belly) pain

    • Blood mixed in the stools

    • Dark/tarry/black stools (from "digested" blood)

    • Weight loss

    • Diarrhea

    • Jaundice

    • Weakness

    • Fatigue

    • Anemia (decreased red blood cell counts)

  • Lactose intolerance

    • Diarrhea

    • Gas

    • Bloating/swelling in the abdomen

    • Abdominal pain/cramping

    • Nausea, vomiting

    • Headaches or migraines

    • Acne

  • Small bowel obstruction

    • Crampy abdominal pain that comes and goes.

    • Loss of appetite.

    • Constipation.

    • Vomiting.

    • Inability to have a bowel movement or pass gas.

    • Swelling of the abdomen.

 

  • Tropical Sprue

    • Abdominal cramps

    • Diarrhea, which may get worse on a high-fat diet

    • Excessive gas

    • Indigestion

    • Irritability

    • Muscle cramps

    • Numbness

    • Paleness

    • Weight loss

  • Tumors of the small intestine

    • Blood in the stool (feces)

    • Dark/black stools.

    • Diarrhea.

    • A lump in the abdomen.

    • Pain or cramps in the abdomen.

    • Unexplained weight loss.

    • Episodes of abdominal pain that may be accompanied by severe nausea or vomiting.

 

  • Whipple's disease

    • Diarrhea

    • Abdominal cramping and pain, which may worsen after meals

    • Weight loss, associated with the malabsorption of nutrients 

    • Inflamed joints, particularly the ankles, knees and wrists

    • Fatigue

    • Weakness

    • Anemia

    • Fever

    • Cough

    • Enlarged lymph nodes

    • Skin darkening (hyperpigmentation) in areas exposed to the sun and in scars

    • Chest pain

    • Enlarged Difficulty walking

    • Visual impairment, including lack of control of eye movements

    • Confusion

    • Memory loss spleen

 

How do you know if it’s something to worry about?

  • The following symptoms may indicate advanced disease and should be signs to seek medical attention:

    • Fatigue

    • Weight loss

    • Iron deficiency anemia

    • Visible blood loss:Blood or a material that looks like coffee grounds may be vomited, or black stools may be passed.

    • Severe nausea and vomiting because of a blockage inthe small bowel by the enlarging cancer: Doctors frequently diagnose small intestine cancer during surgery for unexplained bowel obstruction.

    • Jaundice (yellowish skin): This is a symptom in people with cancerthat involvesthe upper small intestine because of blockage of the bile ducts, which drain the liver, where they enter the small intestine.

How are Small Bowel diseases diagnosed?

  • Amyloidosis               

    • Blood tests and urine tests can be used to look for abnormal proteins that could indicate amyloidosis. The definite diagnosis of amyloidosis is made by detecting the characteristic amyloid protein in a biopsy specimen of involved tissue (such as mouth, rectum, fat, kidney, heart, or liver).

  • Celiac disease

    • Blood tests for gluten autoantibodies (These are IgA based tests accurate only while on a gluten-containing diet)

    1.                         EMA - anti-endomysial

    2.                         TTG - anti-tissue transglutaminase

    3.                         DGP - Deamidated Gliadin Peptide

    • A small bowel biopsy to assess gut damage. For those with suspected dermatitis herpetiformis, skin biopsies will be taken of the skin near the lesion.

    • (NOTE: Diagnostic tests should be performed before restricting gluten, to ensure the most accurate diagnosis.  The gluten-free diet should be implemented only after the biopsy and discussion with the physician.  Follow the gastroenterologist instructions on the length of time and quantity of gluten containing foods to eat prior to the tests.)

  • Dysmotility

    • Blood Tests – Blood tests help to assess the degree of malnutrition, anemia and any salt imbalance. They may also make a specific diagnosis such as diabetes, thyroid problems and systemic disorders such as Lupus.

    • X-ray Studies – barium X-ray studies help to delineate the extent of bowel involvement by demonstrating areas of distended intestines, and by excluding mechanical obstruction. This must be done because treatment of pseudo-obstruction and true obstruction are very different.

    • Motility/Transit Studies – Motility/transit investigations help to define the degree of contractile abnormality as well as propulsive abnormality of the intestines.

    • Biopsies – Biopsy samples of the intestine are obtained at endoscopy or surgery, and may detect the cause of the dysmotility.

  • Infections

    • Blood tests may be ordered looking for different causes of anemia, electrolyte imbalance, and vitamin deficiencies.

    • Breath tests may be considered to measure the byproducts of digestion, especially those that are dependent upon bacteria in the intestine. Interpreting the test results may help make the diagnosis of SIBO without having to perform an endoscopy or biopsy.

    • Upper GI endoscopy allows a gastroenterologist to look at the inside of the upper part of the small intestine and take biopsies or small bits of tissue that can be examined under the microscope. Samples of the fluid from the duodenum and jejunum can be analyzed looking for abnormalities that are associated with SIBO.

  • IBD

    • Tests for anemia or infection. Your doctor may suggest blood tests to check for anemia — a condition in which there aren't enough red blood cells to carry adequate oxygen to your tissues — or to check for signs of infection from bacteria or viruses.

    • Fecal occult blood test. You may need to provide a stool sample so that your doctor can test for hidden blood in your stool.

    • Colonoscopy. This test allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis, which may help confirm a diagnosis. Clusters of inflammatory cells called granulomas, if present, help confirm a diagnosis of Crohn's disease.

    • Flexible sigmoidoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the last section of your colon (sigmoid).

    • Upper endoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the esophagus, stomach and first part of the small intestine (duodenum). While it is rare for these areas to be involved with Crohn's disease, this test may be recommended if you are having nausea and vomiting, difficulty eating or upper abdominal pain.

    • Capsule endoscopy. This test is used to help diagnose Crohn's disease. You swallow a capsule that has a camera in it. The images are transmitted to a computer you wear on your belt, after which the camera exits your body painlessly in your stool. You may still need endoscopy with biopsy to confirm a diagnosis of Crohn's disease.

    • Double-balloon endoscopy. For this test, a longer scope is used to look further into the small bowel where standard endoscopes don't reach. This technique is useful when capsule endoscopy shows abnormalities, but the exact diagnosis is still in question.

    • X-ray. If you have severe symptoms, your doctor may use a standard X-ray of your abdominal area to rule out serious complications, such as a perforated colon.

    • Computerized tomography (CT) scan. You may have a CT scan — a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as at tissues outside the bowel. CT enterography is a special CT scan that provides better images of the small bowel. This test has replaced barium X-rays in many medical centers.

    • Magnetic resonance imaging (MRI). An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. MRI is particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR enterography). Unlike CT, there is no radiation exposure with MRI.

    • Small bowel imaging. This test looks at the part of the small bowel that can't be seen by colonoscopy. After you drink a liquid containing barium, doctors take an X-ray of your small intestine. While this technique may still be used, CT or MRI enterography has largely replaced it.

  • Intestinal Lymphangiectasia

    • Biopsy

    • Sometimes contrast lymphangiography

    • Doctors usually make the diagnosis by removing tissue (biopsy) from the small intestine using an endoscope (a flexible viewing tube equipped with a light source and a camera through which a small clipper can be inserted). The tissue that is removed is then examined under a microscope.

    • Sometimes doctors inject a dye that can be seen on x-rays into lymph vessels in the foot (called contrast lymphangiography). The dye travels to the abdomen and chest and can show the abnormal intestinal lymph vessels.

    • Other blood tests are done to look for complications of the disorder. People may have low levels of protein, cholesterol, and white blood cells in the blood. The low protein levels result in tissue swelling.

  • Intestinal lymphoma

    • The diagnosis is typically made by biopsy at the time of endoscopy. Several endoscopic findings have been reported, including solitary ulcers, thickened gastric folds, mass lesions and nodules. As there may be infiltration of the submucosa, larger biopsy forceps, endoscopic ultrasound guided biopsy, endoscopic submucosal resection, or laparotomy may be required to obtain tissue.

    • Imaging investigations including CT scans or endoscopic ultrasound are useful to stage disease. Hematological parameters are usually checked to assist with staging and to exclude concomitant leukemia. An elevated LDH level may be suggestive of lymphoma.

  • Lactose intolerance

    • Lactose tolerance test. The lactose tolerance test gauges your body's reaction to a liquid that contains high levels of lactose. Two hours after drinking the liquid, you'll undergo blood tests to measure the amount of glucose in your bloodstream. If your glucose level doesn't rise, it means your body isn't properly digesting and absorbing the lactose-filled drink.

    • Hydrogen breath test. This test also requires you to drink a liquid that contains high levels of lactose. Then your doctor measures the amount of hydrogen in your breath at regular intervals. Normally, very little hydrogen is detectable. However, if your body doesn't digest the lactose, it will ferment in the colon, releasing hydrogen and other gases, which are absorbed by your intestines and eventually exhaled. Larger than normal amounts of exhaled hydrogen measured during a breath test indicate that you aren't fully digesting and absorbing lactose.

    • Stool acidity test. For infants and children who can't undergo other tests, a stool acidity test may be used. The fermenting of undigested lactose creates lactic acid and other acids that can be detected in a stool sample.

  • Small bowel obstruction

    • Blood tests

    • X-rays of the abdomen

    • CT scanning

    • Ultrasound

    • Biopsy

  • Tropical Sprue

    • Bone density test

    • Complete blood count

    • Folate level

    • Vitamin B12 level

    • Vitamin D level

    • Enteroscopy: During this test, a thin tube is inserted through your mouth into your gastrointestinal tract. This allows your doctor to see any changes in the small intestine.

  • Tumors of the small intestine

    • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.

    • Blood chemistry studies : A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.

    • Liver function tests : A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by the liver. A higher than normal amount of a substance can be a sign of liver disease that may be caused by small intestine cancer.

    • Endoscopy : A procedure to look at organs and tissues inside the body to check for abnormal areas.

    • Laparotomy : A surgical procedure in which an incision (cut) is made in the wall of the abdomen to check the inside of the abdomen for signs of disease. The size of the incision depends on the reason the laparotomy is being done. Sometimes organs or lymph nodes are removed or tissue samples are taken and checked under a microscope for signs of disease.

    • Biopsy : The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. This may be done during an endoscopy or laparotomy. The sample is checked by a pathologist to see if it contains cancer cells.

    • Upper GI series with small bowel follow-through: A series of x-rays of the esophagus, stomach, and small bowel. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus, stomach, and small bowel. X-rays are taken at different times as the barium travels through the upper GI tract and small bowel.

    • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

    • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

  • Whipple’s disease

    • Physical exam. Your doctor will likely begin with a physical exam, looking for signs and symptoms that suggest the presence of this condition — for example, abdominal tenderness and skin darkening, particularly on sun-exposed parts of your body.

    • Biopsy. An important step in diagnosing Whipple disease is taking a tissue sample (biopsy), usually from the lining of the small intestine. To do this, your doctor typically performs an upper endoscopy. The procedure uses a thin, flexible scope that passes through your mouth, throat, esophagus and stomach to your small intestine. The scope allows your doctor to view your digestive passages and obtain biopsies.During the procedure, tissue samples are removed from several intestinal sites. This tissue is microscopically examined for the presence of disease-causing bacteria and their lesions, and specifically for Tropheryma whipplei bacteria. If biopsies of the small intestine don't confirm the diagnosis, your doctor might biopsy an enlarged lymph node or perform other tests.A DNA-based test known as polymerase chain reaction, which is available at some medical centers, can detect Tropheryma whipplei bacteria in biopsy specimens or spinal fluid samples.

    • Blood tests. Your doctor may also order blood tests, such as a complete blood count. Blood tests can detect certain conditions associated with Whipple disease, particularly anemia, which is a decline in the number of red blood cells, and low concentrations of albumin, a protein in your blood.

 

Treatment Options

  • Amyloidosis

    • Chemotherapy, to stop the growth of abnormal cells that produce amyloid.

    • Peripheral blood stem cell transplant, in which your own stem cells are collected from your blood and stored for a short time while you have high-dose chemotherapy. The stem cells are then returned to your body via a vein. This treatment is most appropriate for people whose disease isn't advanced and whose heart isn't greatly affected.

    • AA amyloidosis. The underlying condition is treated with medication — for example, an anti-inflammatory medication to treat rheumatoid arthritis.

    • Hereditary amyloidosis. Liver transplantation may be an option because the protein that causes this form of amyloidosis is made in the liver.

    • Dialysis-related amyloidosis. Options include changing your mode of dialysis or having a kidney transplant.

  • Celiac disease

    • There is no cure for celiac disease; the only treatment is a gluten-free diet. Celiac disease patients vary in their tolerance of gluten -- some patients can ingest small amounts of gluten without developing symptoms, while others experience massive diarrhea with only minute amounts of gluten. The standard treatment calls for complete avoidance of gluten for life.

  • Dysmotility

    • Diet: Diet manipulation is individually tailored to your needs. Often a small frequent meal plan is advised. In some cases you may be asked follow a liquid diet for a defined period of time.

    • Medicines: There are lots of medicines that your doctor or pharmacist can recommend helping with your symptoms. These may include medicines known as laxatives to help with constipation, prokinetics which may help to speed up the bowel and medication to help control feelings of sickness and nausea.

    • Surgery: urgery is rarely used to treat dysmotility

  •  Infections

    • The treatment for SIBO includes controlling and treating any underlying associated illness. The goal is to control the symptoms of small intestine bacterial overgrowth since it may not be possible to "cure" the disease.

    • Antibiotics are one of the treatments that are helpful in controlling the excess bacteria.

    • While a single course of antibiotics for 1-2 weeks may be sufficient, SIBO has a tendency to relapse, and sometimes-repeated courses of antibiotics may be required. In some people, the antibiotics will be routinely cycled, meaning that they will alternate a 1-2 weeks on the antibiotic with 1-2 weeks off.

    • In addition, underlying vitamin and nutrient deficiencies due to malabsorption should be treated.

  • IBD

    • Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease.

    • Immunosuppressant drugs reduce inflammation, but they target your immune system rather than directly treating inflammation. Instead, they suppress the immune response that releases inflammation-inducing chemicals in the intestinal lining. For some people, a combination of these drugs works better than one drug alone.

    • People with ulcerative colitis who run fevers will likely be given antibiotics to help prevent or control infection. Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn's disease.

    • If diet and lifestyle changes, drug therapy, or other treatments don't relieve your IBD signs and symptoms, your doctor may recommend surgery.

  • Intestinal Lymphangiectasia

    • The administration of water pills (diuretics) may sometimes be helpful.

    • Albumin infusion is sometimes proposed in patients with important serous effusion or uncomfortable lower limb edema.

    • Very occasionally surgical removal of the diseased portion of the intestine may be beneficial if the damage is limited to a local area.

    • In some cases, octreotide is proposed in association with the diet.

    • Compression stocking is used to stabilize in associated lower limb lymphedema.

  • Intestinal lymphoma

    • Chemotherapy

    • Biological therapy

    • Surgery

    • Radiation therapy

  • Lactose intolerance

    • Avoiding large servings of milk and other dairy products

    • Including small servings of dairy products in your regular meals

    • Eating and drinking lactose-reduced ice cream and milk

    • Drinking regular milk after you add a liquid or powder to it to break down the lactose

  • Small bowel obstruction

    • Placing an intravenous (IV) line into a vein in your arm so that fluids can be given

    • Putting a nasogastric tube through your nose and into your stomach to suck out air and fluid and relieve abdominal swelling

    • Placing a thin, flexible tube (catheter) into your bladder to drain urine and collect it for testing

    • If nothing is able to pass through your intestine, you'll usually need surgery to relieve the blockage. The procedure you have will depend on what's causing the obstruction and which part of your intestine is affected. Surgery typically involves removing the obstruction, as well as any section of your intestine that has died or is damaged.Alternatively, your doctor may recommend treating the obstruction with a self-expanding metal stent. The wire mesh tube is inserted into your colon via an endoscope passed through your mouth or colon. It forces open the colon so that the obstruction can clear.

  • Tropical Sprue

    • Useful therapeutic interventions involve antibiotics and replacement of nutrients (eg, folic acid, vitamin B-12, iron), deficient fluid, and sometimes blood. However, despite success reported in other regions, antibiotic therapy for tropical sprue is not useful in patient populations of southern India.

    • Generally, administer a combination of antibiotics and folic acid to patients for 3-6 months. Patients with symptoms persisting longer than 6 months may be administered the combination for as long as a year.

  • Tumors of the small intestine

    • Surgery

    • Chemotherapy

    • Radiation therapy

  • Whipple’s disease

    • The health care provider prescribes antibiotics to destroy the T. whipplei bacteria and treat Whipple disease. Health care providers choose antibiotics that treat the infection in the small intestine and cross the blood-brain barrier—a layer of tissue around the brain.

Prevention

  • Amyloidosis

    • There is no prevention for amyloidosis. However, treating the underlying diseases that are associated with inflammation can prevent the secondary forms of amyloidosis. Genetic counseling can be beneficial in familial amyloidosis.

  • Celiac disease

  • Dysmotility

    • A healthy lifestyle is the best prevention for intestinal motility disorders. A diet rich in fiber, especially insoluble fibers, cannot prevent colon cancer, but it may prevent constipation and impaction, its more severe complication. In addition, because insoluble fibers create a mass effect in the stomach, they may be helpful in weight control, preventing diseases related to obesity (eg, cardiovascular accidents and endocrine disturbances).

  • Infections

    • Since infections is often a secondary illness that occurs because the intestine has in some way been damaged by another disease, it is important to keep chronic diseases properly treated and under control as best as possible.

  • IBD

    • It can be helpful to keep a food diary to keep track of what you're eating, as well as how you feel. If you discover some foods are causing your symptoms to flare, you can try eliminating those foods. These include dairy products, low-fat foods, fiber and other problem foods such as spicy foods, alcohol and caffeine.

    • Stop smoking

    • Limit stess

  • Intestinal Lymphangiectasia

    • Sometimes, children are born with intestinal wall lymph vessels that are improperly formed, which causes blockage of the flow of lymph fluid. These children are typically diagnosed before 3 years of age. Less commonly, the flow of lymph fluid from the digestive tract becomes blocked later in life as a result of such conditions as inflammation of the pancreas (pancreatitis), tumors, or stiffening of the sac that envelops the heart (constrictive pericarditis). It is difficult to predict when someone would be born with this ailment and therefore, prevention is equally as difficult.

  • Intestinal lymphoma

    • Stop tobacco use

    • Diets with low consumption of red meat, high in fruits and vegetables may have a protective effect against many cancers.

  • Lactose intolerance

    • While it cannot be prevented, you can drink milk especially made for people with lactose intolerance or yogurt. Add calcium in your diet by adding sardines, almonds, sardines, broccoli and calcium supplements. You could also drink soy milk fortified with calcium.

  • Small bowel obstruction

    • Follow a low fibre diet

    • Chew all food well. If a food cannot be thoroughly chewed, it should be avoided. Cooking your food well can sometimes make it easier to chew

    • Avoid any food that is tough and/or stringy eg. Tough gristly meat

    • Some people find that in order to avoid symptoms they need to have soft/puree foods and/or nutritious fluids only

  • Tropical Sprue

    • Preventive measures for visitors to tropical areas where the condition exists include steps to reduce the likelihood of gastroenteritis. These may comprise using only bottled water for drinking, brushing teeth, and washing food, and avoiding fruits washed with tap water (or consuming only peeled fruits, such as bananas and oranges). Basic sanitation is necessary to reduce fecal-oral contamination and the impact of environmental enteropathy in the developing world.

  • Tumors of the small intestine

    • Since smoking may increase the risk of this cancer, not starting or quitting smoking may reduce the risk for this disease.

    • People with familial adenomatous polyposis (FAP) can have a very high risk of duodenal cancer. Doctors may suggest that these patients have surgery to remove the duodenum before cancer can develop. The procedure most often used is called a pancreaticoduodenectomy, a major operation that removes the duodenum, part of the pancreas, the gallbladder, the common bile duct, and part of the stomach. This surgery is most often done in patients with FAP who have many polyps in the duodenum and so are at a high risk of getting duodenal cancer.

  • Whipple’s disease

    • There are no current guidelines to prevent Whipple's disease.

SINGLE INCISION LAPAROSCOPIC PANCREAS SURGERIES