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Vanzant E, Thompson A, Mendoza A, Yeh D. Current fistula management. Curr Opin Crit Care 2024; 30:172-177. [PMID: 38441138 DOI: 10.1097/mcc.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Enterocutaneous fistulas (ECFs) pose a significant impact in the healthcare system, both financially and in resource utilization. Delivery of optimal care is complex and involves intensive wound care, complex nutritional delivery and multidisciplinary care teams for optimization. Recently, there have been pushes to modernize the traditional approach to ECF care to a new paradigm of protocol-based individualized delivery of care. RECENT FINDINGS There is an increased trend towards pushing enteral nutrition for the management of ECF patients. Adjuncts, including improved fistuloclysis devices, supplements and absorptive aides have challenged the conventional dogma of ECF treatment. There has also been increased focus on surgical prehabilitation and the ability to improve patient outcomes. SUMMARY ECF care is complex and requires a multidisciplinary approach focused on source control, nutritional optimization with focus on enteral nutrition, wound care and prehabilitation.
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Affiliation(s)
- Erin Vanzant
- University of Florida, Gainesville, Florida, USA
| | | | - April Mendoza
- University of California San Francisco-East Bay, Oakland, California
| | - Dante Yeh
- Denver Health Medical Center, Denver, Colorado
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2
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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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3
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Alemanno G, Tirloni L, Morabito A, Coletta R, Prosperi P. Use of a novel chyme reinfusion device during damage control surgery to improve nutritional status in a patient with a proximal ileostomy: A video vignette. Colorectal Dis 2022; 24:1255-1256. [PMID: 35502796 DOI: 10.1111/codi.16166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/06/2022] [Accepted: 04/26/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Giovanni Alemanno
- Emergency Surgery Department, Careggi University Hospital, Florence, Italy
| | - Luca Tirloni
- Emergency Surgery Department, Careggi University Hospital, Florence, Italy
| | - Antonino Morabito
- Department of Pediatric Surgery, Meyer Children's Hospital, Florence, Italy
| | - Riccardo Coletta
- Department of Pediatric Surgery, Meyer Children's Hospital, Florence, Italy
| | - Paolo Prosperi
- Emergency Surgery Department, Careggi University Hospital, Florence, Italy
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4
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Liu C, Bhat S, Bissett I, O’Grady G. A review of chyme reinfusion: new tech solutions for age old problems. J R Soc N Z 2022. [DOI: 10.1080/03036758.2022.2117832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Chen Liu
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Ian Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- The Insides Company Ltd, Auckland, New Zealand
- Auckland City Hospital, Te Whatu Ora (Te Toka Tumai Auckland), Auckland, New Zealand
| | - Gregory O’Grady
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- The Insides Company Ltd, Auckland, New Zealand
- Auckland City Hospital, Te Whatu Ora (Te Toka Tumai Auckland), Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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5
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Nikoupour H, Theodorou A, Arasteh P, Lurje G, Kalff JC, von Websky MW. Update on surgical management of enteroatmospheric fistulae in intestinal failure patients. Curr Opin Organ Transplant 2022; 27:137-143. [PMID: 35232927 DOI: 10.1097/mot.0000000000000960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The surgical management of enteroatmospheric fistula (EAF) in patients with intestinal failure represents a major challenge for a surgical team and requires proficiency in sepsis management, nutritional support and prehabilitation, beside expertise in visceral and abdominal wall surgery. This review provides an update on the current recommendations and evidence. RECENT FINDINGS Reconstructive surgery should be performed at a minimum of 6-12 months after last laparotomy. Isolation techniques and new occlusion devices may accelerate spontaneous EAF closure in selected cases. Chyme reinfusion supports enteral and parenteral nutrition. Stapler anastomosis and failure to close the fascia increase the risk of EAF recurrence. Posterior component separation, intraoperative fascial tension and biological meshes may be used to accommodate fascial closure. SUMMARY Timing of reconstructive surgery and previous optimal conservative treatment is vital for favorable outcomes. Wound conditions, nutritional support and general patient status should be optimal before attempting a definitive fistula takedown. Single stage procedures with autologous gut reconstruction and abdominal wall reconstruction can be complex but well tolerated.
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Affiliation(s)
- Hamed Nikoupour
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Peyman Arasteh
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Georg Lurje
- Department of Surgery, Charité Berlin, Berlin, Germany
| | - Joerg C Kalff
- Department of Surgery, University Hospital of Bonn, Bonn
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Liu C, Ludlow E, Davidson RB, Davidson JB, Chu KS, O’Grady G, Bissett IP. Stoma-Output Reinfusion Device for Ileostomy Patients: A Feasibility Study. Dis Colon Rectum 2021; 64:e662-e668. [PMID: 34623353 PMCID: PMC9561225 DOI: 10.1097/dcr.0000000000002233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is available in the text.
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Affiliation(s)
- Chen Liu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Emma Ludlow
- Department of Surgery, University of Auckland, Auckland, New Zealand
- The Insides Company, Auckland, New Zealand
| | | | | | | | - Gregory O’Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
- The Insides Company, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Ian P. Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
- The Insides Company, Auckland, New Zealand
- Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
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7
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Chymus-Reinfusion als Therapieoption für enterokutane Fisteln. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00566-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Ribeiro-Junior MAF, Yeh DD, Augusto SDS, Elias YGB, Néder PR, Costa CTK, Maurício AD, Saverio SD. THE ROLE OF FISTULOCLYSIS IN THE TREATMENT OF PATIENTS WITH ENTEROATMOSPHERIC FISTULAS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2021; 34:e1605. [PMID: 34669893 PMCID: PMC8521894 DOI: 10.1590/0102-672020210002e1605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/08/2021] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
| | - Daniel Dante Yeh
- Division of Trauma and Surgical Critical Care, Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | | | - Paola Rezende Néder
- Medical College, University Santo Amaro Medical School, São Paulo, SP, Brazil
| | | | | | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, Regione Lombardia, Varese, Italy
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9
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Solis E, Wright DB, O'Grady G, Ctercteko G. Chyme reinfusion nutritional management for enterocutaneous fistula: first international application of a novel pump technique. Colorectal Dis 2021; 23:1924-1929. [PMID: 33742548 DOI: 10.1111/codi.15643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/16/2021] [Accepted: 02/27/2021] [Indexed: 12/13/2022]
Abstract
AIM High-output enterocutaneous fistulas (ECFs) are an established cause of intestinal failure. Parenteral nutrition (PN) remains the gold standard for nutritional management but is complex, expensive and associated with significant complications. Chyme reinfusion (CR) has been reported by multiple centres as a viable option for nutritional management that improves nutritional status, provides the capacity to cease PN and is cost-effective. The aim of this paper is to describe the first use of a novel pump device (The Insides System™) by an independent centre in Australia for the nutritional management of a patient with high-output ECF. METHOD CR was performed on a 66-year-old woman with a high-output ECF. The device consists of two main components: a centrifugal pump that sits inside the stoma appliance and a battery-powered driver that is magnetically coupled externally onto the pump. The device allows for bolus CR at a rate of infusion that is manually controlled by the patient based on comfort, volume and effluent viscosity. RESULTS CR provided adequate nutritional support, with successful cessation of PN. Effective use of the device was learnt easily by the patient with minimal demands on nursing assistance. Side effects of CR (diarrhoea, abdominal cramping) were overcome by the patient's ability to manually adjust the reinfusion rate. CONCLUSION Our experience with the novel Insides System™ device showed promising results in maintaining nutritional status as well as providing a minimally invasive, easy to use and low-cost system for CR. CR should be considered as a viable alternative for the nutritional management of patients with a high-output ECF.
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Affiliation(s)
- Edgardo Solis
- Department of Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,Discipline of Surgery, Westmead Clinical School, the Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Danette B Wright
- Department of Surgery, Blacktown and Mount Druitt Hospital, Blacktown, New South Wales, Australia
| | - Greg O'Grady
- Department of Surgery, Auckland University, Auckland, New Zealand.,The Insides Company, Auckland, New Zealand.,Auckland Bioengineering Institute, Auckland, New Zealand
| | - Grahame Ctercteko
- Department of Colorectal Surgery, Westmead Hospital, Westmead, New South Wales, Australia
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10
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Huang J, Ren H, Jiang Y, Wu X, Ren J. Technique Advances in Enteroatmospheric Fistula Isolation After Open Abdomen: A Review and Outlook. Front Surg 2021; 7:559443. [PMID: 33553237 PMCID: PMC7855170 DOI: 10.3389/fsurg.2020.559443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 12/03/2020] [Indexed: 12/15/2022] Open
Abstract
Enteroatmospheric fistula (EAF) after open abdomen adds difficulties to the management and increases the morbidity and mortality of patients. As an effective measurement, reconstructing gastrointestinal tract integrity not only reduces digestive juice wasting and wound contamination, but also allows expedient restoration of enteral nutrition and intestinal homeostasis. In this review, we introduce several technologies for the temporary isolation of EAF, including negative pressure wound therapy, fistuloclysis, fistula patch, surgical covered stent, three-dimensional (3D) printing stent, and injection molding stent. The manufacture and implantation procedures of each technique with their pros and cons are described in detail. Moreover, the approach in combination with finger measurement, x-ray imaging, and computerized tomography is used to measure anatomic parameters of fistula and design appropriate 3D printer-recognizable stereolithography files for production of isolation devices. Given the active roles that engineers playing in the technology development, we call on the cooperation between clinicians and engineers and the organization of clinical trials on these techniques.
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Affiliation(s)
| | | | | | - Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
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11
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Somashekar U, Sharma D. Comment on: Novel chyme reinfusion device for gastrointestinal fistulas and stomas: feasibility study. Br J Surg 2020; 107:e556. [PMID: 32820813 DOI: 10.1002/bjs.11815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Uday Somashekar
- Department of Surgery, Government NSCB Medical College, Jabalpur, MP, India
| | - Dhananjaya Sharma
- Department of Surgery, Government NSCB Medical College, Jabalpur, MP, India
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12
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Picot D, Layec S, Seynhaeve E, Dussaulx L, Trivin F, Carsin-Mahe M. Chyme Reinfusion in Intestinal Failure Related to Temporary Double Enterostomies and Enteroatmospheric Fistulas. Nutrients 2020; 12:nu12051376. [PMID: 32403450 PMCID: PMC7285017 DOI: 10.3390/nu12051376] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022] Open
Abstract
Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous supplementations (IVS) for parenteral nutrition and hydration compensate for intestinal losses. Chyme reinfusion (CR) artificially restores continuity pending surgical closure. CR treats intestinal failure and is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) when possible. The objective of this study was to show changes in nutritional status, intestinal function, liver tests, IVS needs during CR, and the feasibility of continuing it at home. A retrospective study of 306 admitted patients treated with CR from 2000 to 2018 was conducted. CR was permanent such that a peristaltic pump sucked the upstream chyme and reinfused it immediately in a tube inserted into the downstream intestine. Weight, plasma albumin, daily volumes of intestinal and fecal losses, intestinal nitrogen, and lipid absorption coefficients, plasma citrulline, liver tests, and calculated indices were compared before and during CR in patients who had both measurements. The patients included 185 males and 121 females and were 63 ± 15 years old. There were 37 (12%), 269 (88%) patients with EAF and DES, respectively. The proximal small bowel length from the duodeno-jejunal angle was 108 ± 67 cm (n = 232), and the length of distal small intestine was 117 ± 72 cm (n = 253). The median CR start was 5 d (quartile 25-75%, 2-10) after admission and continued for 64 d (45-95), including 81 patients at home for 47 d (28-74). Oral feeding was exclusive 171(56%), with enteral supplement 122 (42%), or with IVS 23 (7%). Before CR, 211 (69%) patients had IVS for nutrition (77%) or for hydration (23%). IVS were stopped in 188 (89%) 2 d (0-7) after the beginning of CR and continued in 23 (11%) with lower volumes. Nutritional status improved with respect to weight gain (+3.5 ± 8.4%) and albumin (+5.4 ± 5.8 g/L). Intestinal failure was cured in the majority of cases as evidenced by the decrease in intestinal losses by 2096 ± 959 mL/d, the increase in absorption of nitrogen 32 ± 20%, of lipids 43 ± 30%, and the improvement of citrulline 13.1 ± 8.1 µmol/L. The citrulline increase was correlated with the length of the distal intestine. The number of patients with at least one liver test >2N decreased from 84-40%. In cases of Type 2 intestinal failure related to DES or FAE with an accessible and functional distal small bowel segment, CR restored intestinal functions, reduced the need of IVS by 89% and helped improve nutritional status and liver tests. There were no vital complications or infectious diarrhea described to date. CR can become the first-line treatment for intestinal failure related to double enterostomy and high output fistulas.
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