Simplified Method for Refeeding Succus Entericus: Pediatric Surgery Difficult...

Fistulolysis is enteral nutrition via refeeding of either succus entericus or formula into a distal fistula and can successfully replace parenteral nutrition

Fistulolysis is significantly less expensive than total parenteral nutrition, especially in low resource environments

In a 29-week gestational age infant with multiple small bowel atresias, the distal small bowel was only 3 millimeters in diameter with microcolon

A balloon catheter cannot be used when bowel is so small (3mm) because even minor inflation of the balloon risks rupture of the small caliber bowel

The technique requires divided ostomies and uses a 5 French nasogastric feeding tube passed through a baby nipple, inserted 3 centimeters into the mucous fistula

Trophic feeds are administered at 1 to 2 mL per hour, though higher volume feeds are possible for true fistulolysis in other patient types

The technique allows radiographic surveillance of the distal bowel to assess growth and readiness for reconnection, and permits mucous fistulograms to look for stenosis before stoma closure

When fistulolysis is done with adults, almost always either a gastrostomy tube or a Foley catheter with a balloon is used to occlude the bowel and prevent the tube from falling out

The ideal indication is when bowel is so small (3-5 millimeters diameter) that there will be a functional obstruction if proximal dilated bowel is anastomosed to tiny distal bowel

The patient with multiple atresias and very small distal bowel is probably ideal for this technique

In older children with fully developed, normal-size bowel, it is not necessary to use the feeding tube and nipple; a Foley catheter or balloon gastrostomy tube can be used instead

If you refeed the proximal stoma output into the distal stoma, there is a decrement in the amount that comes out of the proximal stoma, which helps with fluid and electrolyte management

Clear silicone baby nipples are available and allow visualization of catheter position underneath the nipple

Placing two pieces of Duoderm on either side of the disc prevents tape from touching the baby's skin during long-term use

Three babies in the past year and a half perforated with this technique despite great care, using soft silicon catheters not inserted too far, all developing acute peritonitis, and one baby died

Magic marker pen marks can sometimes be obscured and catheters can be inserted farther than intended; in the three perforation cases, catheters were inserted just 1-2 centimeters too far

Perforations have occurred primarily when people try to put a balloon catheter in (even a very small Foley catheter is quite dangerous) or when people try to dilate the stoma by passing red rubber catheters (10 French or so)

The success of this technique is totally dependent on NICU nurses; if they are committed it can have great results, but if they fight you it will absolutely not work