The use of an ileostomy connector to diminish the frequency of defecation prior to ileostomy closure in patients with a pelvic pouch

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.

Preoperative bowel stimulation prior to ileostomy closure to restore bowel function more quickly and improve postoperative outcomes: a systematic review

AIM

Closure of a diverting ileostomy following restorative surgery is often associated with significant short-term morbidity and variable long-term bowel function. The aim of this systematic review was to investigate if preoperative stimulation of the defunctioned bowel restores bowel function more quickly after ileostomy closure and improves postoperative outcomes when compared with standard preoperative care.

METHOD

MEDLINE, Embase, CENTRAL, Google Scholar and ClinicalTrials.gov were searched for studies evaluating preoperative bowel stimulation in patients with a temporary ileostomy after low anterior resection or ileal pouch-anal anastomosis, regardless of their design, publication type or language. Study selection, data extraction and study assessment were performed by one reviewer and verified by another. Study results were synthesized narratively. The GRADE approach was used to assess the quality of evidence.

RESULTS

Eight studies involving a total of 267 participants were included. The studies had a moderate to high risk of bias and were of varying methodological quality. Preoperative stimulation of the defunctioned bowel reduced the time to postoperative restoration of bowel function and the length of hospital stay when compared with standard preoperative care. Other functional outcomes and postoperative complication rates were similar to those of standard preoperative care. The overall quality of evidence was very low.

CONCLUSION

Despite these promising early results, there is insufficient high-quality evidence to recommend routine implementation of preoperative bowel stimulation in clinical practice. Nevertheless, there is no evidence suggesting that the intervention worsens outcomes or is unsafe, paving the way for rigorous assessment of effectiveness, acceptability and cost-effectiveness within the context of well-designed clinical trials.

Stimulation of the efferent limb before ileostomy closure: a randomized clinical trial

BACKGROUND

Postoperative ileus is the most common complication after ileostomy closure with an increase in morbidity, hospital stay, and health care costs.

OBJECTIVE

The aim of this study is to assess the utility of a new technique for reducing postoperative ileus after protective ileostomy closure.

DESIGN

This is a prospective randomized study registered at ClinicalTrials.gov (NCT01881594). Patients were randomly assigned to undergo either stimulation through the efferent limb of the ileostomy before surgery or nonstimulation before surgery.

SETTING

This study was conducted at the Department of Surgery of the Virgen de la Arrixaca Clinical University Hospital (Murcia).

PATIENTS

Seventy patients underwent surgery for ileostomy closure. In 35 patients, during the 2 weeks before surgery, daily stimulation of the defunctionalized stomal segment was performed by using a thick solution (500 mL of physiological saline associated with 30 g of thickening agent, Nestle Resource, Vevey, Switzerland). In the other 35 patients, stimulation was not performed before surgery.

MAIN OUTCOME MEASURES

The primary outcome was postoperative ileus. The secondary outcomes included time to tolerating a diet and postoperative stay.

RESULTS

Both groups of patients were homogenous for demographic data, characteristics of the first rectal cancer operation, and intersurgery periods. After ileostomy closure, the stimulated group of patients had an earlier return to oral tolerance (1.06 vs 2.57 days; p = 0.007) and passage of flatus or stool (1.14 vs 2.85 days; p <0.001) than the nonstimulated group of patients. The incidence of postoperative ileus (2.85% vs 20%; p = 0.024) and hospital stay (2.49 vs 4.61 days; p = 0.002) was also lower in the stimulated patients.

LIMITATIONS

Small numbers of patients means that no definitive statements can be made regarding the effectiveness of this technique.

CONCLUSIONS

Stimulation of the efferent limb of the ileostomy before closure is a safe technique that reduces postoperative ileus and fosters early intestinal transit and oral tolerance with a shorter postoperative hospital stay.