Fistuloclysis and distal enteral feeding in acute intestinal failure

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.

Distal feeding-bowel stimulation to treat short-term or long-term pathology: a systematic review

BACKGROUND

Distal feeding (DF) describes the insertion of a feeding tube into a fistula or stoma to administer a liquid feed into the distal bowel. It is currently used clinically in patients who are unable to absorb enough nutrition orally. This systematic review investigates DF as a therapeutic measure across a spectrum of patients with stomas and fistulae.

METHODS

A total of 2825 abstracts and 44 full-text articles were screened via OVID. Fifteen papers were included for analysis. Randomised controlled trials, cohort and observational studies investigating DF as a therapeutic measure were included.

RESULTS

Three feeds were used across the studies-reinfusion of effluent, infusion of prebiotic or a mixture. The studies varied the length of feeding between 24 hours and 61 days, and the mode of feeding, bolus or continuous varied.DF was demonstrated to effectively wean patients from parenteral nutrition in two papers. Two papers demonstrated a significant reduction in stoma output. Three papers demonstrated improved postoperative complication rates with distal feeding regimens, including ileus (2.85% vs 20% in unfed population, p=0.024). One paper demonstrated a reduction in postoperative stool frequency.

CONCLUSIONS

This review was limited by study heterogeneity and the lack of trial data, and in the patient groups involved, the variability in diet and length of regimen. These studies suggest that DF can significantly reduce stoma output and improve renal and liver function; however, the mechanism is not clear. Further mechanistic work on the immunological and microbiological action of DF would be important.

[Management of patients with enterocutaneous fistulae]

Enterocutaneous fistula (ECF) is the most serious postoperative life-threating complication of various abdominal surgical interventions. Treatment of patients with ECF is associated with life-threatening complications including sepsis and septic shock, intestinal failure and severe water-electrolyte disorders that causes high mortality rates (35-75% according to national authors and 6-33% according to foreign colleagues). This issue is especially relevant in the cases of enteroatmospheric fistulae and high ECF with loss of intestinal contents of more than 500 ml per day. In the absence of correct conservative therapy, this quickly results progression of sepsis and development of multiple organ failure. Surgery without complex preoperative preparation in this period may be fatal and lead to clinical aggravation and death of patient in early postoperative period. Each patient requires an individual approach. However, there are general principles of treatment too. This literature review describes the main aspects of conservative treatment of patients with enteric fistulae.