A case study utilizing an enteral refeeding technique in a premature infant with short bowel syndrome

Chyme reinfusion practices in the neonatal population

INTRODUCTION

Chyme reinfusion therapy (CRT) is a safe and effective method to improve nutritional outcomes and promote intestinal adaptation in patients with stomas. This practice involves refeeding the proximal stoma output, down the distal limb, and mimics a state of intestinal continuity; thereby promoting growth and adaption of the distal bowel. Despite its promise, CRT in neonates is a relatively underutilised practice and can be of significant value in neonates with congenital bowel anomalies or necrotising enterocolitis. We aimed to identify the frequency, methodology and adverse effects associated with CRT in our neonatal population. We aimed to identify the frequency, methodology and adverse events associated with CRT in our neonatal population.

METHODS

A ten-year retrospective cohort study was conducted using database searches at two major paediatric hospitals in New Zealand. All patients with suitable anatomy were identified, and data on CRT methodology and outcomes were recorded.

RESULTS

Of the 49 eligible neonates, 23 (47%) underwent CRT. Indications for CRT included high stoma output, malnutrition with poor weight gain, and routine refeeding prior to stoma reversal. A nasogastric feeding tube was inserted into the distal limb and collected chyme was reinfused via manual bolus or automated syringe driver. The median (IQR) weight gain increased from 13.9 (3.50-22.89) to 24.37 (19.68-29.99) g/day during CRT (p = 0.04). 18 infections requiring medical intervention but unrelated to CRT occurred in 13 patients (56%). Amongst our cohort, there was a high rate of non-infectious events, including peri-stomal skin irritation (60%), stoma prolapse (43%) and stomal bleeding (26%).

CONCLUSION

CRT is an underutilised method of improving nutrition in neonates with intestinal failure. Premature neonates requiring double enterostomy formation are at high risk of infectious and non-infectious complications, but few of these are related to CRT. Standardised protocols providing clear eligibility criteria and detailed methodology for CRT are required to promote uniform utilisation of this practice.

Mucous fistula refeeding in neonates: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Mucous fistula refeeding (MFR) aims to maximise bowel function when an ostomy is active after abdominal surgery, by introducing the proximal ostomy effluent into the distal mucous fistula to maintain intestinal physiology. The aim of the study was to assess the effectiveness and complications of MFR in neonates following abdominal surgery.

DESIGN, SETTING AND INTERVENTIONS

Systematic review and meta-analysis of randomised controlled trials and observational studies. PubMed, Embase, Cochrane and CINAHL were searched until June 2022 for studies including neonates with ostomy receiving MFR compared with neonates with ostomy without MFR.

OUTCOMES

The primary outcome was duration of parenteral nutrition. Secondary outcomes were time to full enteral feeds, rates of cholestasis, peak total serum bilirubin, sepsis, time to reanastomosis and length of hospital stay.

RESULTS

A total of 16 observational studies were included (n=623). Compared with comparator group, neonates who received MFR had fewer days of parenteral nutrition (mean difference 37.17 days, 95% CI -63.91 to -10.4, n=244, 5 studies, GRADE: low). In addition, neonates who received MFR had lower rates of cholestasis, shorter time to reach full feeds and shorter hospital stay.

CONCLUSION

Low certainty of evidence suggests that MFR is associated with shorter duration of parenteral nutrition in neonates following abdominal surgery and stoma creation. Results of ongoing and future randomised trials may help to corroborate these findings.

MUC-FIRE: Study protocol for a randomized multicenter open-label controlled trial to show that MUCous FIstula REfeeding reduces the time from enterostomy closure to full enteral feeds

Background

After enterostomy creation, the distal bowel to the ostomy is excluded from the physiologic passage of stool, nutrient uptake, and growth of this intestinal section. Those infants frequently require long-term parenteral nutrition, continued after enterostomy reversal due to the notable diameter discrepancy of the proximal and distal bowel. Previous studies have shown that mucous fistula refeeding (MFR) results in faster weight gain in infants. The aim of the randomized multicenter open-label controlled MUCous FIstula REfeeding ("MUC-FIRE") trial is to demonstrate that MFR between enterostomy creation and reversal reduces the time to full enteral feeds after enterostomy closure compared to controls, resulting in shorter hospital stay and less adverse effects of parenteral nutrition. Methods/Design: A total of 120 infants will be included in the MUC-FIRE trial. Following enterostomy creation, infants will be randomized to either an intervention or a non-intervention group.In the intervention group, perioperative MFR between enterostomy creation and reversal will be performed. The control group receives standard care without MFR.The primary efficacy endpoint of the study is the time to full enteral feeds. Secondary endpoints include first postoperative bowel movement after stoma reversal, postoperative weight gain, and days of postoperative parenteral nutrition. In addition adverse events will be analyzed.

Discussion

The MUC-FIRE trial will be the first prospective randomized trial to investigate the benefits and disadvantages of MFR in infants. The results of the trial are expected to provide an evidence-based foundation for guidelines in pediatric surgical centers worldwide.

Trial registration

The trial has been registered at clinicaltrials.gov (number: NCT03469609, date of registration: March 19, 2018; last update: January 20, 2023, https://clinicaltrials.gov/ct2/show/NCT03469609?term=NCT03469609&draw=2&rank=1).

Stoma recycling in a surgical neonatal unit: Prevalence, challenges, and review of nursing attitudes

AIM

Recycling has been shown to improve growth, nutrition and facilitate early stoma closure. We aim to review current practice and nursing experience at a tertiary paediatric surgical unit and to evaluate possible areas for improvement.

METHOD

Retrospective study of all neonates who underwent a stoma closure between January 2018 and October 2020, alongside a nursing staff survey on experience and barriers to effective recycling. Data presented as median (range) and number (percentage). P value <0.05 was regarded as significant.

RESULTS

A total of 71 neonates were included; median birthweight 869.5 (500-3600)g and gestation 26 (23-40) for a median of 15.5 (1-51) days. Rates of early stoma closure were similar in both the recycling (RG) and non recycling groups (NRG); 15/29 vs. 21/42, p > 0.999. Thirty-nine neonatal nurses responded to the survey with 36/39 (92%) having prior experience of recycling. Time constraints were the main reason nurses felt it was difficult to achieve effective recycling, with some also being worried about causing damage. Increased training and parental involvement were two potential solutions suggested by nurses to overcome these issues.

CONCLUSION

Despite the known benefits, less than half of our cohort had successful recycling prior to stoma closure. Increased training, development of a uniform policy and involvement of the parents may help to improve the rates of stoma recycling.

LEVEL OF EVIDENCE

Level III (Retrospective Comparative Study).

A review of chyme reinfusion: new tech solutions for age old problems

High-output double enterostomies (DES) and enteroatmospheric fistulae (EAF) are associated with significant morbidity, including infection, malnutrition, and prolonged hospital admissions. Management is complex and has remained a challenging surgical problem for many decades in both adult and paediatric patient populations. Chyme reinfusion (CR) from the proximal to distal DES or EAF limb is a potential therapeutic solution which has been shown to be safe and beneficial; however, early methods have involved the manual handling of chyme, which is labour intensive and poorly tolerated by both patients and staff. Over the past four decades, there has been growing interest in the application and development of medical device technology to improve the effectiveness and user-friendliness of CR. New Zealand (NZ) has been at the forefront of innovation in this field, with exciting translational research projects in both adults and neonates (funded and enabled by the NZ MedTech CORE). This narrative review provides a summary of the evolution of CR technology globally, synthesises the extant clinical evidence and highlights future directions.

A Review on Safety and Outcomes of Mucous Fistula Refeeding in Neonates

INTRODUCTION

 The utility of mucous fistula refeeding (MFR) in neonates with short bowel syndrome is widely debated. Our purpose is to review MFR and outline methods, reported complications, and clinical outcomes (survival, weight gain, dependence on parenteral nutrition [PN], and time to enteral autonomy).

MATERIALS AND METHODS

 We performed a MEDLINE literature search and reference review from January 1980 to May 2020 for terms ("mucous fistula re-feeding" or "enteral re-feeding") and neonates. We included studies that utilized conventional MFR in the neonatal period. Non-English language articles were excluded.

RESULTS

 We identified 11 relevant articles. Internationally, there was no consensus on methods of MFR. A total of 197 neonates underwent MFR. Within a single study, four neonates developed major complications; however, the procedure was well tolerated without major complications in 10 of the 11 studies. A mortality of nine patients during MFR highlights the burden of disease within the study population; however, of these, only one was directly attributable to MFR. Minor complications were seldom quantified. Three studies demonstrated a higher rate of weight gain and shorter PN support versus controls. Neonates who underwent MFR had lower chance of anastomotic leak and quicker progression to full feed after reversal versus controls. The influence of microorganisms in MFR was only investigated in one study.

CONCLUSION

 Current evidence suggests benefits of MFR; however, an international consensus is yet to be reached on the optimal method. A large prospective study investigating the influence of MFR on the enteric system is required.

Chyme recycling in the management of small bowel double enterostomy in pediatric and neonatal populations: A systematic review

BACKGROUND & AIMS

Intestinal failure (IF) in neonatal and pediatric patients is associated with substantial morbidity. Management of IF includes the formation of a double enterostomy (DES) of the small bowel. Parenteral nutrition (PN) is frequently required, which is expensive. Recycling chyme from the proximal DES limb distally is an alternative therapy, but standardized data on this intervention is lacking. This review systematically evaluated the existing literature on chyme recycling (CR) in neonatal and pediatric populations.

METHODS

Medical databases were systematically searched for articles reporting CR in neonatal and pediatric populations. Articles documenting CR indications, methods, clinical outcomes, benefits and adverse events (AEs) were reviewed. A narrative synthesis was performed on the extracted data.

RESULTS

This review identified 20 full-text articles, in which 289 patients received CR, most commonly following necrotizing enterocolitis (n = 117 patients). The most common motivators for CR were proximally located DES (n = 7 articles) and to support nutrition and growth (n = 7 articles). Proximal DES output collection was predominantly manual (n = 11 articles), whereas distal CR was mostly automated (n = 12 articles), using customized peristaltic or syringe infusion pumps. Clinical benefits encompassed PN reduction (n = 19 patients) or cessation (n = 122 patients), weight gain, normalization of fluid balance, improvement in liver function tests and distal gut maturation. Technical problems commonly included tube dislodgement, leakage and effluent reflux (n = 9 articles). AEs included intestinal perforation (n = 3 patients) and haemorrhage (n = 1 patient).

CONCLUSIONS

From the limited available data, CR is demonstrated as an effective therapeutic intervention for small bowel DES in pediatric and neonatal patients. However, standardized methods that improve the delivery of and minimise AEs associated with the intervention are needed.

Safety and efficacy of mucous fistula refeeding in low-birth-weight infants with enterostomies

PURPOSE

To investigate the safety and efficacy of mucous fistula refeeding (MFR) in low-birth-weight infants.

METHODS

Between December 2006 and December 2018, medical records of low-birth-weight infants who underwent small bowel enterostomy formation in the neonatal period and subsequent stoma closure at our institution were retrospectively reviewed. Patients were assigned to "refeeding" (RF) and "non-refeeding" (NRF) groups, which were compared for patient characteristics and clinical outcomes. We also cultured the proximal stoma output over time in the RF group and reviewed changes in the flora to evaluate the safety of refeeding.

RESULTS

In the RF group, compared with that before refeeding, there was significantly more rapid weight gain after refeeding (17.7 vs 10.6 g/day; P = 0.002). Median total time of parenteral nutrition (PN) was 25 and 87 days in the RF and NRF groups, respectively (P = 0.001). The number of patients who developed PN-associated liver disease (PNALD) was smaller in the RF group (P = 0.12). No complications of MFR were noted and no pathogenic bacteria were cultured.

CONCLUSION

MFR was able to diminish the need for PN, which potentially decreased the incidence of PNALD, and was safe as there were no complications of the refeeding process.

Safety of mucous fistula refeeding in neonates with functional short bowel syndrome: A retrospective review

PURPOSE

Mucous fistula (MF) refeeding of proximal stoma effluent in neonates after small bowel resection can promote nutrient absorption and prevent atrophy of the unused distal bowel. This study aimed to assess the safety of this practice in neonates.

METHODS

A retrospective chart review of all patients admitted to the neonatal intensive care unit (NICU) between 2009 and 2015 who underwent a laparotomy with creation of an enterostomy and mucous fistula was performed. Patients were included if they were refed proximal stoma effluent into the MF.

RESULTS

Thirty-one patients were identified that were refed. There were no major complications (perforation, stricture, death) related to refeeding. Patients were refed for an average of 41 days (± 22), with patients gaining an average of 25.7 g/day (± 10.1) while being refed. Total parental nutrition (TPN) was administered for an average of 55 days (± 31.4) between resection and reanastomosis, with only 7 (23%) developing cholestasis and 15 (48%) reaching full feeds in this time. Mean time to full feeds after reanastomosis was 36 days (± 58.6) with two patients having anastomotic leaks.

CONCLUSION

MF refeeding is a safe technique that has the potential to contribute to significant weight gain and a decreased dependence on total parenteral nutrition.

LEVEL OF EVIDENCE

II.

Reinfusion of Succus Entericus Into the Mucous Fistula Decreases Dependence on Parenteral Nutrition in Neonates

Background. Neonates who undergo surgery and have an ostomy with a creation of a mucous fistula are at nutritional risk, especially if the ostomy placement is proximal and the remaining bowel is not being used. Total parenteral nutrition (TPN) is used to maintain the neonatal nutritional status, but long-term use is associated with increased morbidities. The concept of reinfusing succus entericus into the mucous fistula to decrease the neonate’s dependence on TPN has been limited to case reports. Methods. This is a retrospective cohort study documenting the effectiveness of reinfusing succus entericus into the mucous fistula for neonates admitted to the neonatal intensive care unit (NICU). The authors’ primary hypothesis was that neonates who had succus entericus reinfused into the mucous fistula had decreased dependence on TPN. Results. Of the premature infants receiving mucous fistula feedings, 65% had TPN discontinued, whereas 67% of the term infants had TPN discontinued. The type of ostomy affected the neonate’s ability to be weaned off TPN. In all, 80% of the neonates with ileostomies were able to have TPN discontinued as compared with only 38% of the neonates with jejunostomies. Conclusions. The reinfusion of succus entericus into the mucous fistula decreases the neonate’s dependence on TPN and may prevent the progression of TPN-related morbidities from long-term use. Reinfusion of succus entericus into the mucous fistula may be a beneficial practice for neonates with ostomy placements.

Management of short bowel syndrome in postoperative very low birth weight infants

Short bowel syndrome is a potentially devastating morbidity for the very low birth weight infant and family with a high risk for mortality. Prevention of injury to the intestine is the ideal, but, if and when the problem arises, it is important to have a systematic approach to manage nutrition, use pharmaceutical strategies and tools to maximize the outcome potential. Safely maximizing parenteral nutrition support by providing adequate macronutrients and micronutrients while minimizing its hepatotoxic effects is the initial postoperative strategy. As the infant stabilizes and starts to recover from that initial injury and/or surgery, a slow and closely monitored enteral nutrition approach should be initiated. Enteral feeds can be complemented with medications and supplements emerging as valuable clinical tools. Engaging a multidisciplinary team of neonatologists, gastroenterologists, pharmacists, skilled clinical nutrition support staff including registered dietitians and nutrition support nurses will facilitate optimizing each and every infant's long term result. Promoting intestinal rehabilitation and adaptation through evidence-based practice where it is found, and ongoing pursuit of research in this rare and devastating disease, is paramount in achieving optimal outcomes.

Beneficial effects of mucous fistula refeeding in necrotizing enterocolitis neonates with enterostomies

BACKGROUND

Necrotizing enterocolitis in premature neonates often results in bowel resection and stoma formation. One way to promote bowel adaptation before stoma closure is to introduce proximal loop effluents into the mucous fistula. In this study, we reviewed our experience with distal loop refeeding with respect to control group.

METHODS

All patients with necrotizing enterocolitis between 2000 and 2014 necessitating initial diverting enterostomies and subsequent stoma closure in a tertiary referral center were included. Medical records were retrospectively reviewed. Demographic data, surgical procedures, and postoperative outcomes were analyzed.

RESULTS

92 patients were identified, with 77 patients receiving mucous fistula refeeding. The refeeding group showed less bowel ends size discrepancy (25 vs 53%, p=0.034) and less postoperative anastomotic leakage (3 vs 20%, p=0.029). Fewer refeeding group patients developed parenteral nutrition related cholestasis (42 vs 73%, p=0.045) and required shorter parenteral nutrition support (47 vs 135days, p=0.002). The mean peak bilirubin level was higher in the non-refeeding group (155 vs 275μmol/L, p<0.001). No major complication was associated with refeeding.

CONCLUSIONS

Mucous fistula refeeding is safe and can decrease risk of anastomotic complication and parental nutrition related cholestasis. It provides both diagnostic and therapeutic value preoperatively and its use should be advocated. Level III Treatment Study in a Case Control Manner.

Mucous fistula refeeding decreases parenteral nutrition exposure in postsurgical premature neonates

BACKGROUND/PURPOSE

Premature neonates can develop intraabdominal conditions requiring emergent bowel resection and enterostomy. Parenteral nutrition (PN) is often required, but results in cholestasis. Mucous fistula refeeding allows for functional restoration of continuity. We sought to determine the effect of refeeding on nutrition intake, PN dependence, and PN associated hepatotoxicity while evaluating the safety of this practice.

METHODS

A retrospective review of neonates who underwent bowel resection and small bowel enterostomy with or without mucous fistula over 2years was undertaken. Patients who underwent mucous fistula refeeding (RF) were compared to those who did not (OST). Primary outcomes included days from surgery to discontinuation of PN and goal enteral feeds, and total days on PN. Secondary outcomes were related to PN hepatotoxicity.

RESULTS

Thirteen RF and eleven OST were identified. There were no significant differences among markers of critical illness (p>0.20). In the interoperative period, RF patients reached goal enteral feeds earlier than OST patients (median 28 versus 43days; p=0.03) and were able to have PN discontinued earlier (median 25 versus 41days; p=0.04). Following anastomosis, the magnitude of effect was more pronounced, with RF patients reaching goal enteral feeds earlier than OST patients (median 7.5 versus 20days; p≤0.001) and having PN discontinued sooner (30.5 versus 48days; p=0.001).

CONCLUSIONS

RF neonates reached goal feeds and were able to be weaned from PN sooner than OST patients. A prospective multicenter trial of refeeding is needed to define the benefits and potential side effects of refeeding in a larger patient population in varied care environments.

Enteral refeeding is useful for promoting growth in neonates with enterostomy before stoma closure

BACKGROUND

Enterostomy may lead to fluid and electrolyte imbalance, or impaired absorption of nutrition followed by impairment of growth. This study aimed to clarify the effectiveness of enteral refeeding (ER) in premature and full-term neonates.

METHODS

A retrospective database of all consecutive neonates who had enterostomy during 2000-2014 in a regional center was analyzed. Thirteen patients with ER (ER group) and 14 patients without ER (control group) were included. Detailed clinical data were evaluated with reference to the increment in body weight during ER.

RESULTS

The ER group had a significantly higher rate in weight gain compared with the control group (P=0.0012), despite the gestational age (<37weeks: P=0.0012, ≥37weeks: P=0.029). ER starting at a lower body weight was also associated with a higher weight gain (P=0.0002). Moreover, univariate and multivariate analyses showed that only the ER procedure (P<0.0001) and birth weight (P=0.049) were significantly independent predictors of good weight gain.

CONCLUSIONS

Using ER, low-birth-weight infants may have benefits, such as better acceleration of growth, than normal-birth-weight infants. We do not hesitate to perform ER, even in low-birth-weight neonates or those with low body weight, when starting ER.

Glycerin suppositories used prophylactically in premature infants (SUPP) trial: a study protocol for a pilot randomized controlled trial

BACKGROUND

Feeding is a significant challenge for premature infants in the neonatal intensive care unit (NICU). These patients are often treated with glycerin suppositories to stimulate the passage of meconium and prevent feeding intolerance. Unfortunately, the evidence for this practice is inconclusive.

METHODS/DESIGN

This protocol is for an external pilot study that will assess the feasibility of a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. Participants are premature infants treated in a level 3 NICU with a gestational age 24 to 32 weeks and/or birth weight of 500 to 1500 g. Thirty participants will be recruited as part of this external pilot study. Participants will be randomized to glycerin suppository (250 mg) or placebo starting 48 to 72 h after birth and continuing once daily until meconium evacuation is complete or for a maximum of 12 days. The placebo consists of a 250-mg glycerin suppository placed in the diaper rather than the rectum. Study treatments are administered by the charge nurse on duty who is not otherwise involved in patient care. All other clinicians and research personnel will remain blinded. Outcomes for the pilot study are percentage of eligible participants randomized, percentage of infants reaching full enteral feeds, cost, and treatment-related adverse events (rectal bleeding, rectal perforation, and anal fissure).

DISCUSSION

This external pilot study will assess the feasibility of a multicenter randomized controlled trial of glycerin suppositories in premature infants. The subsequent multicenter trial will have sufficient power to determine whether this treatment strategy is associated with decreased time to full enteral feeds.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02153606.

Glycerin enemas and suppositories in premature infants: a meta-analysis

BACKGROUND AND OBJECTIVE

Premature infants are often given glycerin enemas or suppositories to facilitate meconium evacuation and transition to enteral feeding. The purpose of this study was to assess the available evidence for this treatment strategy.

METHODS

We conducted a systematic search of Medline, Embase, Central, and trial registries for randomized controlled trials of premature infants treated with glycerin enemas or suppositories. Data were extracted in duplicate and meta-analyzed using a random effects model.

RESULTS

We identified 185 premature infants treated prophylactically with glycerin enemas in one trial (n = 81) and suppositories in two other trials (n = 104). All infants were less than 32 weeks gestation and had no congenital malformations. Treatment was associated with earlier initiation of stooling in one trial (2 vs 4 days, P = .02) and a trend towards earlier meconium evacuation in another (6.5 vs 9 days, P = .11). Meta-analysis demonstrated no effect on transition to enteral feeding (0.7 days faster, P = .43) or mortality (P = 0.50). There were no reports of rectal bleeding or perforation but there was a trend towards increased risk of necrotizing enterocolitis with glycerin enemas or suppositories (risk ratio = 2.72, P = .13). These three trials are underpowered and affected by one or more major methodological issues. As a result, the quality of evidence is low to very low. Three other trials are underway.

CONCLUSIONS

The evidence for the use glycerin enemas or suppositories in premature infants in inconclusive. Meta-analyzed data suggest that treatment may be associated with increased risk of necrotizing enterocolitis. Careful monitoring of ongoing trials is required.

Mucous fistula refeeding in neonates with enterostomies

BACKGROUND/PURPOSE

Neonates with intestinal pathology may require staged surgery with creation of an enterostomy and mucous fistula (MF). Refeeding (MFR) of ostomy output may minimize fluid and electrolyte losses and reduce dependence on parenteral nutrition (PN), though a paucity of evidence exists to support this practice. The purpose of this study was to assess the outcomes of infants undergoing MFR and document associated complications.

METHODS

With REB approval, infants with intestinal failure undergoing MFR between January 2000 and December 2012 were identified. A chart review was conducted and relevant data were collected. Descriptive statistics were used.

RESULTS

Twenty-three neonates underwent MFR. Mean gestational age and birth weight were 35weeks and 2416grams. Pathologies included intestinal atresia (n=12), necrotizing enterocolitis (n=5), meconium ileus (n=4), and other (n=6). Seven patients were able to wean from PN. Four patients had complications: 3 had perforation of the MF, 1 had bleeding. Four patients died, with one death directly attributable to MFR.

CONCLUSIONS

In this cohort MF refeeding was associated with significant complications and ongoing PN dependence. With advances in intestinal rehabilitation and PN, the benefit of MF refeeding must be weighed against the potential complications.

Refeeding enteroclysis as an alternative to parenteral nutrition for enteric fistula

AIM

Refeeding enteroclysis is one method of giving artificial nutritional support to patients with enterocutaneous fistula. This study compares the results of this technique with parenteral nutrition or nutrition given via a proximal stoma.

METHOD

All patients admitted to our intestinal failure unit with a proximal enteric fistula and managed with refeeding enteroclysis over a 4-year period were included and compared with a matched group of patients managed without using this technique.

RESULTS

Twenty patients (15 men) with a proximal enteric fistula received chyme refeeding down the distal limb of the fistula. This was established at a mean of 14 days after admission to the unit and total parenteral nutrition could be weaned off by 20 days. The mean output from the proximal limb was 1800 ml and the mean volume refed down the distal limb was 1220 ml per day. Additional enteric feed was given to 12 patients. No patient was given pharmacological agents to delay gastrointestinal transit or additional intravenous water and electrolyte for most of the time after refeeding was established. There were no complications or deaths related to chyme refeeding.

CONCLUSION

Refeeding enteroclysis is feasible in selected patients with a proximal enteric fistula or stoma. Adequate nutrition, water and electrolyte balance can be achieved without resorting to parenteral infusions.

Recycling of bowel content: the importance of the right timing

INTRODUCTION

Extracorporeal stool transport (recycling of chyme discharged from the proximal stoma end to the distal end of a high jejunostomy or ileostomy) is thought to be beneficial in preventing malabsoprtion, sodium loss, cholestasis and atrophy of the distal intestine until restoration of the intestinal continuity becomes possible. However little is known about its adverse effects. Our aim was to investigate the microbiological safety of recycling.

MATERIAL AND METHOD

Native samples were taken from the proximal stoma in 5 premature neonates who underwent an ileostomy or a jejunostomy due to necrotising enterocolitis, for qualitative culture. The first sample was drawn immediately after the change of the stoma bag, further samples were sent from the stoma bag at 30, 60, 90, 120, 150, and 180min later. The samples were inoculated by calibrated (10 μl) loops onto blood agar (5% sheep blood), eosin-methylene blue agar and anaerobic blood agar, respectively (Oxoid). The aerobic plates were incubated for 18-20 h at 5% CO2, whereas the anaerobic plates were incubated for 24-48 h in an anaerobic chamber (Concept 400). The bacterial strains were identified to species level by specific biochemical reactions, RapID-ANA II system (Oxoid) and ID32E, Rapid ID 32 Strep ATB automatic system cards (bioMérieux).

RESULTS

The number of colony forming unit (CFU) of Gram-negative bacteria (mainly E. coli) exponentially increased after 30 min and reached 10(5)/ml after 120 min. Gram-positive strains (primarily E. faecalis) were detected after 60 min and CFU increased to 10(5)/ml after 120 min. The number of anaerobic (principally Bacteroides fragilis) CFU started to increase after 120 min. In two cases coagulase negative Staphylococcus strains were isolated the earliest in the chyme. The average of total CFU approached 10(5)/ml after 90 min and exceeded 10(5)/ml after 120 min.

CONCLUSION

The chyme in the stoma bag is colonized by commensal facultative pathogenic enteral/colonic as well as skin flora species after 120 min. Recycling of stoma bag content may be dangerous after 90 min.

Nutritional management of infants with short bowel syndrome

The prevalence of short bowel syndrome appears to be increasing because of more aggressive surgical and medical approaches to the management of neonatal intraabdominal catastrophies. Hence, a large cohort of neonates with intestinal failure occupies neonatal intensive care units, requiring chronic total parenteral nutrition (TPN) in hopes that the residual bowel will adapt, thereby permitting weaning of TPN. Alternatively, when there is no hope for adaptation, these infants are maintained on TPN in hopes that they will grow to a size and state of general health satisfactory for either isolated intestinal transplant when liver function is preserved or combined liver-intestinal transplantation when the liver is irreparably damaged. Thus, it is imperative to provide enough parenteral nutrition to facilitate growth while minimizing TPN constituents predisposing to liver damage. Liver disease associated with intestinal failure (IFALD) seems to occur due to a variety of host factors combined with deleterious components of TPN. Host factors include an immature bile secretory mechanism, bile stasis due to fasting, and repeated septic episodes resulting in endotoxemia. Many constituents of TPN are associated with liver damage. Excessive glucose may result in fatty liver and/or hepatic fibrosis, excessive protein may lead to reduced bile flow, and phytosterols present in intravenous lipid may produce direct oxidant damage to the liver or may impede cholesterol synthesis and subsequent bile acid synthesis. Parenteral strategies employed to minimize TPN damage include reducing glucose infusion rates, reducing parenteral protein load, and reducing parenteral lipid load. Furthermore, preliminary studies suggest that fish oil-based lipid solutions may have a salutary effect on IFALD. Ultimately, provision of enteral nutrition is imperative for preventing or reversing IFALD as well as facilitating bowel adaptation. While studies of trophic hormones are ongoing, the most reliable current method to facilitate adaptation is to provide enteral nutrition. Continuous enteral feeding remains the mainstay of enteral nutrition support.

What is the evidence on the practice of mucous fistula refeeding in neonates with short bowel syndrome?

A systematic review of literature was performed on the practice of mucous fistula refeeding in neonates with short bowel syndrome. No randomised controlled studies were identified. Case series reports of 30 infants showed improved weight gain (from -2.36 +/- 1.24 to 21.06 +/- 3.02 g/d) and reduced need for total parenteral nutrition. Randomised controlled trials are required to establish the benefits of mucous fistula refeeding in this condition.