Continuous reinfusion of succus entericus associated with fistuloclysis in the management of a complex jejunal fistula on the abdominal wall

Self-administered succus entericus reinfusion before ileostomy closure improves short-term outcomes

OBJECTIVE

The study aims to assess whether reinfusion of succus entericus prior to ileostomy closure can decrease postoperative length of stay and ameliorate low anterior resection score.

METHODS

This study is a retrospective analysis based on prospectively collected data. Patients were screened from May 2016 to November 2019. A total of 30 patients who underwent reinfusion with succus entericus (SER) were enrolled in the SER group and 42 patients without SER were enrolled in the non-SER group.

RESULTS

There was no significant difference in the incidence of postoperative ileus between succus entericus reinfusion (SER) group and the control group. Time to first passage of flatus or stool after surgery in the SER group (27.9 ± 6.02 h) is significantly shorter than the control group (32.3 ± 6.26, hours p = 0.004). Compared with the control group (5.52 (4.0-7.0) days), postoperative length of stay in the SER group was 4.90 (3.0-7.0)days (p = 0.009). As for low anterior resection score(LARS), the SER group had a lower score 1 week after discharge than the control group (p = 0.034). However, 1 month after discharge, the LARS in the two groups had no significant difference.

CONCLUSIONS

Self-administered succus entericus reinfusion is a feasible prehabilitation management for outpatients and can improve better outcomes. Compared with non-reinfusion group, succus enterius reinfusion group displays significantly shorter time for gastrointestinal function recovery and postoperative hospital stay without increasing complication, and it can bring better quality of life in a short term.

THE ROLE OF FISTULOCLYSIS IN THE TREATMENT OF PATIENTS WITH ENTEROATMOSPHERIC FISTULAS

Background:

Enterocutaneous fistulas represent a connection between the gastrointestinal tract and adjacent tissues. Among them, there is a subdivision - the enteroatmospheric fistulas, in which the origin is the gastrointestinal tract in connection with the external environment through an open wound in the abdomen. Due to the high output in enterocutaneous fistulas, the loss of fluids, electrolytes, minerals and proteins leads to complications such as sepsis, malnutrition and electrolyte derangements. The parenteral nutrition has its secondary risks, and the fistuloclysis, that consist in the infusion of enteral feeding and also the chyme through the distal fistula, represents an alternative to the management of these patients until the definitive surgical approach.

Aim:

To evaluate the current evidence on the fistuloclysis technique, its applicability, advantages and disadvantages for patients with high output fistulas.

Method:

A systematic literature search was conducted in May 2020 with the headings “fistuloclysis”, “chyme reinfusion” and “succus entericus reinfusion”, in the PubMed, Medline and SciELO databases. Results: There were 29 articles selected for the development of this narrative synthesis, from 2003 to 2020, including reviews and case reports.

Conclusion:

Fistuloclysis is a safe method which optimizes the clinical, nutritional, and immunological conditions of patients with enteroatmospheric fistulas, increasing the chances of success of the reconstructive procedure. In cases where the definitive repair is not possible, chances of reducing or even stopping the use of nutrition through the parental route are increased, thus representing a promising modality for the management of most challenging cases.

Short Bowel Syndrome in an Extremely Low Birth Weight Premature Infant with Wernicke Encephalopathy: A Case Report

BACKGROUND Short bowel syndrome in infants is relatively rare. It consists of malabsorption caused by a congenital short bowel or extensive resection of a large part of the small intestine. The postoperative mortality rate is high and surviving patients develop many complications. Wernicke encephalopathy is caused by vitamin B1 (thiamin) deficiency. Delayed treatment may lead to irreversible neuron necrosis, gliosis, severe amnesia, Korsakoff psychosis, or even death. CASE REPORT We report the case of a premature infant with extremely low birth weight and short bowel syndrome. He was treated with early enteral nutrition combined with succus entericus reinfusion with no complications. Four months after discharge, he was diagnosed with Wernicke encephalopathy. He was treated with intravenous vitamin B1 (100 mg IV/d) and was administered oral vitamin B1 (20 mg 3 times daily) by his wet nurse. Vitamin B1 levels returned to normal after 4 days (69.8 nmol/L). Physical development was normal at the follow-up at a corrected age of 2 years. CONCLUSIONS Preventive measures for Wernicke encephalopathy should be implemented in patients with long-term malnutrition or absorption disorders. The risk of vitamin B1 deficiency increases in patients receiving parenteral nutrition and medical staff should be aware of the importance of the vitamin B1 status.

Chyme Reinfusion for Small Bowel Double Enterostomies and Enteroatmospheric Fistulas in Adult Patients: A Systematic Review

BACKGROUND

High-output double enterostomies (DESs) and enteroatmospheric fistulas (EAFs) of the small bowel account for substantial patient morbidity and mortality. Management may include parenteral nutrition (PN) and prolonged admissions, at high cost. Reinfusion of chyme into the distal bowel is a proposed therapeutic alternative when the distal DES limb is accessible; however, standardized information on this technique is required. This review aimed to critically assess the literature regarding chyme reinfusion (CR) to define its current status and future directions.

METHODS

A systematic search of medical databases was conducted for articles investigating CR in adults. Articles reporting indications, methods, benefits, technical issues, and complications resulting from CR were reviewed. A narrative synthesis of the retrieved data was undertaken.

RESULTS

In total, 24 articles reporting 481 cases of CR were identified, although articles were heterogeneous in their structure and reporting. CR was most frequently performed for remediation of high-output DES and intestinal failure and for proximally located DES. Effluent output collection was commonly manual, with distal reinfusion more commonly automated, and with few dedicated systems. Multiple benefits attributed to CR were reported, encompassing weight gain, cessation of PN, and improvements in liver function. Technical problems included distaste, labor-intensive methods, reflux of contents, and tube dislodgement. No serious AEs or mortality directly attributable to CR were reported.

CONCLUSIONS

CR appears to be a promising, safe and well-validated intervention for small bowel DES and EAF. However, more efficient and acceptable methods are required to promote greater adoption of the practice of CR.

Optimization of extra corporeal enteral prosthesis (ECEP) by selective aspiration of the digestive flow

Reinfusion is a medical process which collects digestive flow from a proximal stoma to a distal one, in patient who had a post-operative double enteral stoma. This process avoids the risk of under nutrition and frees the patient from a Total Parenteral Nutrition to offset the digestive loss. Most of the previous ways of reinfusion first collect the digestive flow into a bag before instillation. We developed an ambulatory reinfusion pump (ECEP) which had the advantage to collect the digestive flow directly from the proximal stoma and to pump it to the distal one. However, the main risk of such a continuous pumping process is to create mucosae lesions by direct suction. The aim of this study is to up-grade our device by introducing a selective aspiration based on the arrival of digestive flow.