Triple tube therapy: a novel enteral feeding technique for short bowel syndrome in low-income countries

Systematic review on management of high-output enterostomy in children: An urgent call for evidence

OBJECTIVES/BACKGROUND

High-output stoma is one of the most common major morbidities in young children with an enterostomy that could lead to intestinal failure. Management of high-output enterostomy in children is mostly based on personal experience. This systematic review aims to clarify the evidence-based therapeutic approach of high-output enterostomy in children.

METHODS

A systematic review was performed using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published until March 20, 2023, following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. The study population comprised children (i.e., age <18 years) with high-output enterostomy (i.e., jejuno-, ileo-, and/or colostomy), regardless of underlying aetiology. Interventions comprised any (non)pharmacological and/or surgical treatment. Interventions were compared with each other, placebos, and/or no interventions. Primary outcome was reduction of enterostomy output. Secondary outcomes were morbidity, mortality, quality of life, associated healthcare costs, and adverse events.

RESULTS

The literature search identified 4278 original articles of which 366 were screened on full text, revealing that none of the articles met the inclusion criteria.

CONCLUSION

This first systematic review on management of high-output enterostomy in children revealed that any evidence on the primary and secondary outcomes is lacking. There is an urgent need for evidence on conservative treatment strategies including fluid restrictions, dietary advices, oral rehydration solution, chyme re-infusion, and pharmacological and surgical treatments of high-output enterostomy in children, aiming to reduce the risk for short- and long-term complications. Till more evidence is available, a systematic and multidisciplinary step-up approach is needed. Therefore, a therapeutic work-up is proposed that could guide the care.

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.

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.

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.

The feasibility of routine use of distal stoma refeeding method in newborns with enterostomy

Objective: Temporary enterostomies are life-saving in neonatal surgery, however, causing loss of fluid electrolyte, delays in distal bowel adaptation and thus delayed growth of newborns. In this study, we aimed to present the method and clinical results of distal stoma refeeding in premature and mature neonates.Methods: Between January 2012 and December 2017, records of newborn patients who underwent enterostomy and distal stoma refeeding were retrospectively analyzed. Premature and full term neonates who had distal stoma refeeding were evaluated by stoma indications, resection status, duration of total parenteral nutrition use, time of stoma closure operation and surgery findings.Results: Distal stoma refeeding was performed to 23 newborns in study period. Surgical diagnosis of newborns were meconium ileus, focal intestinal perforation, volvulus, necrotizing enterocolitis, ileal atresia, jejunal atresia, and gastroschisis. The bowel resection was performed in 14 patients. Stoma closure was done on the average day 77th. Total parenteral nutrition was given average 28 d and no total parenteral nutrition complication was seen. The stoma closure operations were performed easily.Conclusions: Distal stoma refeeding is safe and successful method. The success of distal stoma refeeding depends on expert team, time, and equipment.

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.

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.

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.