Prasanth, D (2020) Refeeding Enteroclysis: An Alternative to Total Parenteral Nutrition in Small Bowel Ostomies. Masters thesis, Stanley Medical College, Chennai.
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Abstract
INTRODUCTION In the course of an intestinal surgery procedure, several clinical situations lead the surgeon to undertake a double temporary enterostomy (small bowel resection, peritonitis, fistulae, anastomosis protection...) or could be complicated of enterocutaneous fistula (ECF) (peritonitis, anastomosis leakage, digestive adherences…). These conditions could constitute a short bowel syndrome and are often complicated with intestinal failure (IF), especially when the stoma output is equal or higher than 1500 ml/24h. These lead to serious complications resulting in hospital readmissions, such as acute or chronic dehydration, renal failure, electrolyte disturbances, micronutrients and mineral deficiencies, and malnutrition, thus increasing healthcare-related costs and affecting patients’ quality of life [1]. IF was recently defined by the European Society for Clinical Nutrition and Metabolism (ESPEN) as “the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth” [2]. In case of temporary double enterostomy or ECF, the IF is type 2, and defines as a prolonged acute condition, often in metabolically unstable patients, requiring complex multi-disciplinary care and intravenous supplementation over periods of weeks or months [2]. At this time, the current gold standard therapy indicated until the surgical reestablishment of digestive continuity is home parenteral nutrition (HPN) [3]. However, HPN has its own morbidity and, in the absence of expertise, the risks of infectious, hepatic dysfunction, mechanical and metabolic complications are increased [1,3]. Therefore, the availabilities of low cost, safer, and easy-to-use nutrition support techniques could be of high added value in these type 2 IF patients. Refeeding enteroclysis [5,6,10] could be the technique. AIMS & OBJECTIVES: A clinical study to determine the technical principles of refeeding enteroclysis and its beneficial effects in their clinical practice and reducing the need for parenteral nutrition. MATERIALS AND METHODS PLACE OF STUDY: Department of General Surgery, Govt. Stanley Medical College & Hospital, Chennai. DURATION: 12 months. STUDY DESIGN: Non Randomized single blinded open labelled control trial. SAMPLE SIZE : 32. Sample size is calculated using Openepi software version 3.0 With the expected mean difference is mean number of days of TPN needed between the intervention and control group to be 28, the sample size is estimated at 16 in each arm with 95% confidence level, 80% power and ratio between intervention and control arm as 1:1 INCLUSION CRITERIA: Age >14 years Existence of a double/loop enterostomy or at least two orifices of ECF visible on the abdominal wall. Absence of obstruction of digestive fistula between the mouth and the afferent stoma, and in the efferent intestinal tract; Ability to catheterize the efferent stoma with a feeding tube on more than 15cm; Full agreement of the patient to carry out enteroclysis and accept the food constraints of ingesting smooth pure meals. EXCLUSION CRITERIA: Patient not willing for the procedu. Colostomy/sigmoidostomy done patients. Presence of obstruction of digestive tract between the mouth and the afferent stoma, and in the efferent intestinal tract. Patients with CKD/DCLD/Malignancy. METHODOLOGY: To obtain informed consent from all subjects before enrollment in the study. Patients are separated into 2 groups of 16 each control and study group. GROUP A : This is a test group with patients in this group are subjected to refeeding enteroclysis in a method described below and the need for total parenteral nutrition despite refeeding enteroclysis is noted. GROUP B : This is a control group with patients in this group are not subjected to refeeding enteroclysis but managed with Total parenteral nutrition if needed. Patients who are included in the study are started with enteral feeding on 1st postoperative day and the ostomy output will be monitored and refeeding will be started once the ostomy starts functioning. Before refeeding is initiated , one liter of oral rehydration solution, together with laxatives in case of fecal residues or fecaloma in the colon are given. At the same time, anti-motility drugs are stopped to prevent ileus. Antispasmodic agents could be useful in case of abdominal pain, and cholestyramine is given by enteroclysis in the event of diarrhea during the first days. Ostomy output collected from the afferent limb preserved after sieving to remove large food particle, every 6th hourly. A nasogastric tube after applying topical anaesthetic agent is inserted into the efferent limb of a length 10cm and fixed out through the ostomy bag. The preserved collection from the afferent limb is reinfused over the efferent limb via the nasogastric tube every 6th hourly. Ostomy output from the afferent limb, reinfused content volume over the efferent limb are recorded. Patient are maintained on strict input/output chart,weight chart,renal and hepatic parameters are monitored serially and the signs of dehydration are noted. Total parenteral nutrition of volume 1litre via central venous cannulation will be used in the study. Data were analyzed using the unpaired two-tailed t-tests and chisquare analysis and the results are tabulated. RESULT : Among 32 patients included in the study, in the test group A the usage of TPN was 18.75% when compared to control group B is 62.50% and the result was stastically significant with the p value 0f 0.029.The mean age group being 52 and th common cause of small bowel ostomy being SMA thrombosis. CONCLUSION : Refeeding enteroclysis serve as an alternative to total parenteral nutrition among small bowel stoma patients and their co-relation was established in the study. Refeeding enteroclysis being cost effective and also decreases the complication among high output stoma and alleviating the parenteral nutrition dependence.
| Item Type: | Thesis (Masters) |
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| Additional Information: | 221711061 |
| Uncontrolled Keywords: | Refeeding Enteroclysis, Alternative, Total Parenteral Nutrition, Small Bowel Ostomies. |
| Subjects: | MEDICAL > General Surgery |
| Depositing User: | Subramani R |
| Date Deposited: | 09 Feb 2021 01:39 |
| Last Modified: | 09 Feb 2021 01:39 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/13948 |
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