When Histology Is Unknown: Surgical Decision-Making in Small Bowel Tumors-From Preoperative Imaging to Intraoperative...

Small-bowel tumors are a heterogeneous and relatively uncommon group of neoplasms whose definitive diagnosis frequently cannot be established before surgery. Their common jejunal or ileal location limits conventional endoscopic access, and stenosing, predominantly extraluminal, or complicated presentations may render preoperative biopsy impossible. In such situations, the surgeon may have to decide the extent of resection and the need for lymphadenectomy without a histological diagnosis, even though the optimal strategy differs substantially among adenocarcinoma, gastrointestinal stromal tumor (GIST), small-bowel neuroendocrine tumor (SBNET), lymphoma, and desmoid-type fibromatosis. This narrative review integrates clinical presentation, preoperative computed tomography (CT) features, and intraoperative macroscopic findings to support a presumptive diagnosis and guide surgical decision-making when histology is unavailable. The evidence was synthesized along the decision pathway preoperative imaging → diagnostic suspicion → intraoperative appearance → surgical decision → definitive histopathology. Histology-specific CT associations are relatively well documented, whereas the independent ability of intraoperative macroscopic impression to predict histology remains limited. We propose a pragmatic, histology-oriented decision framework that prioritizes clinical urgency, disease extent and resectability, the feasibility of preoperative tissue sampling, and the potential impact of histology on the surgical procedure. The framework is conceptual and requires prospective validation; its aim is not to replace histopathological examination but to reduce the risk of both oncologically inadequate and unnecessarily extensive resections.