The most important thing is to recognize that patients who are undergoing emergency surgery particularly for ischemic gut or perforated small bowel may be suitable for chyme reinfusion. Whenever a patient is having a proximal stoma being fashioned the distal limb should also be brought to the surface alongside the end enterostomy. It is my practice to insert a 20 or 22 F foley catheter into the distal limb at the end of the procedure with 3-4 ml of fluid in the balloon. The catheter is then curled up in the stoma bag for future use. The advantages of forming a double stoma are threefold. First, it provides the ability to use the distal part of the small bowel and colon for hydration and nutrition. Second, it prevents the mucosal and muscular atrophy associated with the diversion of the distal bowel. Third, it allows for possible reconstruction and without a very major laparotomy.
In my role as clinical director of the New Zealand National Intestinal Failure and Rehabilitation Service I have the opportunity to speak with clinicians as they plan treatment for patients with intestinal catastrophes. This gives me the chance to encourage the formation of double stomas and the consideration of the use of the distal opening for re-infusion of chyme in the setting of an entero-atmospheric fistula.
If patients have a double stoma formed and a catheter inserted into the distal limb at initial surgery, I am happy to begin chyme reinfusion when the patient is stable and the proximal stoma is functioning. We perform a contrast study of the distal intestine to ensure there is no distal pathology (obstruction or perforation) prior to beginning the chyme reinfusion. In the setting of an entero-atmospheric fistula we would wait until there has been some healing of the wound and the fistula has protruded like a stoma. The abdominal wound needs to be able to be managed with a wound bag and the distal bowel cannulated and assessed with a contrast study. Usually this maturation of an entero-atmospheric fistula takes about 6 weeks.
I do not use Chyme reinfusion if there is no access to the distal limb, there is damage or obstruction of the distal limb, or if it is not possible to contain the fistula output in a stoma bag. Chyme reinfusion is not usually used where the stoma output is thick and there is adequate nutrition and hydration without reinfusion.
In New Zealand we have been able to get the system funded in many of the hospital which are state run. This was enabled by the device achieving CE-Marking for Europe and Medsafe registration in New Zealand. As the business case demonstrates that it is considerably cheaper than standard care with PN and the clinical benefits are also considerable making a cost-effectiveness case is straight forward.
In our setting we discuss all these patients in our Nutrition support Team which consists of Surgeons, a gastroenterologist, nurses and dieticians with further input from pharmacy and psychology as needed.
In patients who have a double stoma formed and no distal intestinal pathology we would consider going straight to chyme reinfusion when they start oral intake and not using PN at all. In patients with a long period of diversion of the distal small bowel (usually longer than about 6 weeks) we would start reinfusion slowly with about 100ml twice daily and increase the volume depending on patient’s symptoms (pain and distension). Once patients are tolerating oral feeding of adequate calories and reinfusion of most of the stoma output, we would wean the PN usually within 48 hours.
We ensure that patients can phone for advice or support as needed and we would bring them in to hospital if they need to be seen by their clinician. In the first month it is important to ensure that they are managing, and weekly contact or visit is advised. Once the feeding is established, we would need to see them to replace the feeding tube at least monthly. This can be achieved with a home visit if resources are available.
Repair of an entero-atmospheric fistula is a high-risk procedure and should be performed when the inflammatory and fibrotic peritoneal reaction is completely resolved, and the patient is nutritionally replete. In terms of the resolution of the peritoneal reaction this usually requires about 12 months from the time of the initial surgery and the clinical signs of a soft abdomen, the appearance of a wound hernia, the ability to lift the skin off the underlying small bowel by pinching the skin and prolapse of the exposed fistula/stoma. In terms of general fitness for surgery there should be a return of body weight, return of mobility, reasonable exercise tolerance and a normal serum albumin.
In these patients if they have not had extensive peritoneal contamination the procedure can be performed as a local stoma especially if the stoma is separate from the midline wound. Again, I like to see some prolapse of the stoma to indicate that the peristomal area is not too adherent.
This has been a surprising finding for me. I have had patients with fibrotic and stenosed distal limbs prior to reinfusion and in the space of 6-8 weeks of reinfusion the distal limb has become pliable, and the diameter has increased to something similar to the original lumen size.
The main difference is in the flexibility and caliber of the distal limb. This makes the formation of an anastomosis more straight forward.
We have been pleased with the speed of recovery of bowel function after stoma closure in patients with chyme reinfusion. I presume this is because the distal bowel has already adapted to the reintroduction of food and fluid prior to the surgery. It is not uncommon after fistula closure for the patient to be tolerating a normal diet in 48 hours in this setting.
Encourage your colleagues to bring out both ends when forming a stoma in an emergency.