Chyme reinfusion nutritional management for enterocutaneous fistula: first international application of a novel pump technique

Current fistula management

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.

A review of chyme reinfusion: new tech solutions for age old problems

High-output double enterostomies (DES) and enteroatmospheric fistulae (EAF) are associated with significant morbidity, including infection, malnutrition, and prolonged hospital admissions. Management is complex and has remained a challenging surgical problem for many decades in both adult and paediatric patient populations. Chyme reinfusion (CR) from the proximal to distal DES or EAF limb is a potential therapeutic solution which has been shown to be safe and beneficial; however, early methods have involved the manual handling of chyme, which is labour intensive and poorly tolerated by both patients and staff. Over the past four decades, there has been growing interest in the application and development of medical device technology to improve the effectiveness and user-friendliness of CR. New Zealand (NZ) has been at the forefront of innovation in this field, with exciting translational research projects in both adults and neonates (funded and enabled by the NZ MedTech CORE). This narrative review provides a summary of the evolution of CR technology globally, synthesises the extant clinical evidence and highlights future directions.

Update on surgical management of enteroatmospheric fistulae in intestinal failure patients

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.