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Early Enteral Nutrition Improves Outcomes of Open Abdomen in Gastrointestinal Fistula Patients
Complicated With Severe Sepsis
Yujie Yuan, Jianan Ren, Guosheng Gu, Jun Chen and Jieshou Li
Nutr Clin Pract 2011 26: 688
DOI: 10.1177/0884533611426148
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Clinical Research
included. Fifty-six (68.3%) patients survived to discharge. Fortyone (50%) patients received SER. EN was initiated within 14
days in 36 patients, with a mean initiation time at 8.3 3.4 days;
46 patients did not start any EN within 14 days (29.9 20.9 days).
The mean age, BMI, APACHE II score, and fistula characteristics
were similar between groups. The abdominal closure was accomplished more rapidly in patients fed within 14 days (142.8 vs 184.5
days, P = .017), with decreased mortality (11.1% vs 47.8%, P <
.001). Conclusions: Nutrition therapy plays an important role in
the management of gastrointestinal fistula with severe sepsis.
Early EN could be successfully delivered for that population, with
improved mortality risk. (Nutr Clin Pract. 2011;26:688-694)
688
Nutrition Therapy for Intestinal Fistula After an Open Abdomen / Yuan et al 689
Methods
Patient Population
The medical records of patients referred to our institute
were reviewed. The gastrointestinal fistula database was
queried to obtain a list of patients who developed severe
sepsis and were admitted to the intensive care unit with
open abdomens. Patients with admitting diagnoses involving severe sepsis and aged 18 years were eligible for
inclusion. The study period included patients admitted to
our clinic center between January 1999 and June 2009.
The patients who died within the first 4 days of the hospital stay were excluded from this study. All enrolled
patients were subsequently divided into 2 groups based
on the initiation time of EN, categorized as having
received EN within 14 days of admission or later, after 14
days of admission. The study protocol was approved by
the Jinling Hospital Ethical Subcommittee, with written
informed consent obtained from all subjects.
Nutrition Management
During the whole process of treatment, nutrition therapy,
including EN and PN (all-in-one PN, Jinling Hospital,
Nanjing, China), was given. Trophic feeds of at least
30 kcal/kg/d and 1.5 g of protein/kg/d were granted as
initial nutrition support goals, and 2 g of nitrogen per L
of intestinal fluid output was considered for nutrient
administration.4 The detailed therapeutic strategies, such
as the general approach of nutrition, route of delivery, and
ingredients of nutrients, varied somewhat by critical illness, tolerance to enteral feeding, stage of surgical intervention, nutrition status, and surgeon preference. To be
specific, early enteral feeding was preferred as initial
nutrition therapy in all patients except those who deteriorated due to hypotensive shock or severe ileus after an
attempt to feed enterally. EN was substituted with PN
promptly when aforementioned contradictions emerged.
Once the output of intestinal fluid was limited and
patients were satisfactorily maintained on enteral feeding,
EN was gradually introduced to reach the full feeding.
The nutrition regimen before and after fistula excision
was kept almost unchanged.
Succus entericus reinfusion (SER), outlined by
Calicis et al,15 was performed for patients who had proximal small bowel fistula with high-output volume (>500
mL/d) or multiple disseminated orificium fistulae. The
output from the proximal stoma was collected with a triple catheterization cannula connected to aspiration
pumps at a negative pressure of 150 to 200 millibars. The
freshly collected succus entericus was drained into a sterile catheter bag, and reinfused back to the distal limb of
the mucus fistula through a Foley catheter at specific rate
in accordance with the stoma output.
In addition, usually somatostatin (6 mg/d, Serono,
Feltham, UK) was infused intravenously to control the
Statistical Analysis
Nutrition Support
Results
General Characteristics of Patients
Ninety-two patients met the entry criteria during the interval of this study. Of this cohort, 10 patients died of irreversible septic shock within 4 days of admission and were not
further considered. For all other patients, 82 (male-female
ratio, 68:14) patients received open abdomen management
and nutrition therapy with mean age of 44.4 15.2 (range,
1983) years. Enteral feedings were initiated within
14 days of hospital stay in 36 patients, with a mean initiation
time of EN at 8.3 3.4 days. The remaining 46 patients
did not start any enteral feedings within the 14-day period,
with a mean initiation of EN at 29.9 20.9 days (P < .05).
The overall mortality of all patients was 31.7% (26/82).
Specifically, 11 patients died of intra-abdominal hemorrhage
Nutrition Therapy for Intestinal Fistula After an Open Abdomen / Yuan et al 691
Group 1a (n = 36)
Group 2b (n = 46)
P Value
43.1 13.5
20.2 1.2
34 (94.4)
45.3 16.4
21.1 1.3
34 (73.9)
.525
.782
.014*
11.8 5.0
2.6 1.9
4 (11.1)
15 (41.7)
12.9 6.6
3.9 3.7
12 (26.1)
32 (69.6)
.418
.059
.102
.014*
20
2
1
13
(55.6)
(5.6)
(2.8)
(36.2)
22 (47.8)
5 (10.9)
0 (0)
19 (41.3)
.513
.458
.439
.656
35 (97.2)
1 (2.8)
44 (95.7)
2 (4.3)
1.0
1.0
13 (36.1)
5 (13.9)
4 (11.1)
0 (0)
1 (2.8)
13 (36.1)
18 (39.1)
6 (13.0)
7 (15.2)
2 (4.3)
0 (0)
13 (28.4)
.822
.581
.748
.501
.439
.481
30 (83.3)
6 (16.7)
0 (0)
42 (91.3)
4 (8.7)
0 (0)
.322
.322
NA
3 (8.3)
4 (11.1)
3 (8.3)
1 (2.8)
25 (69.4)
8.3 3.4 (36)
13.3 5.2 (16)
4 (8.7)
5 (10.9)
3 (6.5)
2 (4.3)
32 (69.6)
29.9 20.9 (46)
28.9 20.2 (25)
.954
.972
.755
.707
.991
.001*
.005*
EN, d
PN, d
Combined EN + PN, d
110.6 64.8
84.3 80.6
8.2 5.9*
18.1 14.5
8.3 12.1
8.9 9.2
Group 1 (n = 36)
Group 2 (n = 46)
P Value
4 (11.1)
16 (44.4)
11(30.6)
0 (0)
15 (41.7)
0 (0)
16 (45.7)
0 (0)
22 (47.8)
11 (23.9)
1 (2.2)
14 (30.4)
3 (6.5)
25 (54.3)
.034*
.825
.617
.373
.355
.252
.528
5 (13.9)
35 (97.2)
7 (20)
4 (11.4)
0 (0)
1 (2.8)
2 (5.7)
5 (10.9)
35 (76.1)
8 (17.4)
1 (2.2)
2 (4.3)
0 (0)
4 (8.7)
.742
.010*
.780
.163
.501
.450
.690
Route of delivery
Oral Feeding
Nasogastric tube
Nasointestinal tube
Gastrostomy tube
Jejunostomy tube
Orificium fistula
SER
Nutrition products
Ensure Powder
Peptison (SP)
Nutrison Multi fibre
Nutrison
Anso
Elental
Protein Powder
Ensure powder (Abbott, Shanghai, China); Peptison (SP; Nutricia, Shanghai, China); Nutrison Multi fibre (Nutricia, Shanghai,
China); Nutrison (Nutricia, Shanghai, China); Anso (Abbott, Shanghai, China); Elental (Ajinomoto, Shanghai, China); Protein
Powder (Nutricia, Shanghai, China).
SER, succus entericus reinfusion.
*P < .05 is significant by 2 test.
Group 1
(n = 36)
Group 2
(n = 46)
P Value
2
1
4
3
1
0
0
0
4
7
4
1
12
7
3
0
1
1
7
18
.690
1.0
.102
.501
.627
NA
1.0
1.0
.747
.045*
a
Indicates the total number of patients who suffered from any
kind of postoperative complications.
*P < .05 is significant by 2 test.
Discussion
In this retrospective study, 56 (68.3%) patients survived
and were discharged from the hospital with successful
abdominal closure after an open abdomen. For all
patients, nutrition therapy, especially EN, can be successfully applied by various approaches. Although there were
46 patients unable to start enteral feeding within the first
14 days of admission because of critical illness or intolerance to EN (fever, severe diarrhea, increased bowel fluid
output, abdominal discomfort, distension, or emesis),
those patients could receive PN first and shift to EN
therapy gradually.
In this study, 72 (87.8%) patients had high-output
fistula; there were no patients presenting with low-output
fistula. Therefore, continuous intravenous infusion of
somatostatin (Merck Serono, UK, 6 mg/d) was used to
control the fistula output prior to the initiation of EN.
Once patients were satisfactorily maintained on enteral
feeding and output was limited, somatostatin was terminated and human growth hormone was administered with
EN for a month. Although the evidence is not strong
without a comparative study, it seems that those assistant
Nutrition Therapy for Intestinal Fistula After an Open Abdomen / Yuan et al 693
Conclusion
Our findings confirm the pivotal role of early EN in the
management of gastrointestinal fistula after an open
abdomen. Long-term EN can be successfully delivered in
that population and might be associated with the reduced
risk of mortality. Use of EN therapy, possibly associated
with early abdominal closure, should be encouraged as
early as possible, with careful monitoring and adjusting of
the nutrition plan according to the requirements of the
open abdomen.
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