Mucous Fistula Refeeding Protocol

Guideline · May 2020 · 2 min read

In brief

Clinical protocol for refeeding proximal ostomy output through a distal mucous fistula to promote intestinal adaptation and maintain distal bowel function in patients with diverted intestinal segments.

Written by the GCMD Library team from the guideline.

Patient Candidacy for Mucous Fistula Refeeding

Candidates include infants post-intestinal resection who are not suitable for primary anastomosis but are stable enough for additional operative time to create a mucous fistula. Prerequisites include confirmed distal bowel patency (verified intraoperatively or via contrast study), tolerance of enteral nutrition for at least 2 days, and stoma output exceeding 5 mL/day.

Intraoperative Technical Steps for MF Creation

Surgical technique involves aligning proximal and distal bowel mesenteries, tunneling the MF tube through the abdominal wall away from the stoma, and placing a 5-8 French feeding tube into the distal bowel secured with purse-string suture. The tube is then stamped to the abdominal wall with adequate separation between stoma and MF to allow independent ostomy bag placement.

Refeeding Initiation Protocol

Refeeding begins after resolution of postoperative ileus with a graduated advancement schedule starting at 5 mL every 12 hours on Day 1. The protocol progresses over 5 days to full stoma output refeeding every 3-4 hours, with bolus volumes exceeding 10 mL administered via pump at maximum 30 mL/hr rate over up to 3 hours. Thick effluent should be strained and may be diluted with warm water to prevent tube clogging.

Troubleshooting Common Refeeding Complications

Management strategies address four main complications: dislodged MF tubes require prompt replacement by pediatric surgery fellows, leakage necessitates tube placement verification and contrast study to exclude distal obstruction, and clogged tubes are cleared with warm water or carbonated water. Metabolic acidosis (bicarbonate <20) requires cessation of refeeding until normalization, with gradual resumption after excluding other acidosis etiologies.

Statements in this guideline

Mucous fistula refeeding is considered for infants after intestinal resection who are not good candidates for primary anastomosis and are stable enough to allow extra operative time to create a mucous fistula.
EstablishedIs patient a candidate for MF refeeding?
Distal bowel patency must be assessed either in the operating room or with a contrast study before mucous fistula refeeding.
RecommendationIs patient a candidate for MF refeeding?
The infant must be tolerating enteral nutrition for at least 2 days before starting mucous fistula refeeding.
RecommendationReady to begin refeeding?
The patient must have more than 5 mL of stoma output per day to be a candidate for mucous fistula refeeding.
RecommendationReady to begin refeeding?
The maximum refeed bolus push is 10 mL.
RecommendationHow to initiate refeeding
If stoma output exceeds 10 mL, refeeds should be run over a pump with a maximum rate of 30 mL per hour.
RecommendationHow to initiate refeeding
Infusion time can be extended as needed to a maximum of 3 hours.
RecommendationHow to initiate refeeding
If stoma effluent is thick, it should be strained to prevent mucous fistula tube clogging and may be diluted with a small amount of warm water as needed.
RecommendationHow to initiate refeeding
On Day 1, refeed 5 mL every 12 hours.
RecommendationHow to initiate refeeding
On Day 2, refeed 5 mL every 6 hours if on enteral bolus feeds or every 8 hours if on continuous enteral feeds.
RecommendationHow to initiate refeeding
On Day 3, refeed 10 mL every 6 hours or every 8 hours if on continuous feeds.
RecommendationHow to initiate refeeding
On Day 4, refeed 10 mL every 3 hours or every 4 hours if on continuous feeds.
RecommendationHow to initiate refeeding
Beginning Day 5, refeed all stoma output every 3 or 4 hours depending on the type of feeds.
RecommendationHow to initiate refeeding
The patient must continue to tolerate enteral nutrition during mucous fistula refeeding.
RecommendationHow to initiate refeeding
Line up the mesenteries of proximal and distal bowel during intraoperative mucous fistula tube placement.
RecommendationTechnical Key Steps
Tunnel the mucous fistula tube through the abdominal wall and away from the stoma.
RecommendationTechnical Key Steps
Place a 5-8 French feeding tube into the distal bowel with a purse string suture.
RecommendationTechnical Key Steps
Stamm the mucous fistula tube to the abdominal wall.
RecommendationTechnical Key Steps
The stoma and mucous fistula should be far enough apart for placement of separate ostomy bags.
RecommendationTechnical Key Steps
Mucous fistula refeeding should begin after the postoperative ileus has resolved.
RecommendationAfter post-op ileus has resolved
If the mucous fistula tube falls out, alert pediatric surgery fellows to replace it on morning or evening rounds.
RecommendationTroubleshooting Refeeding Challenges
If there is leakage around the mucous fistula, check tube placement and order a contrast study to rule out distal obstruction.
RecommendationTroubleshooting Refeeding Challenges
If the mucous fistula tube is clogged, instill warm water, and if that does not work, try carbonated water.
RecommendationTroubleshooting Refeeding Challenges
If the patient is acidotic with bicarbonate less than 20, rule out other causes of metabolic acidosis.
RecommendationTroubleshooting Refeeding Challenges
If the patient is acidotic with bicarbonate less than 20, stop mucous fistula refeeding and resume refeeds slowly after bicarbonate has normalized.
RecommendationTroubleshooting Refeeding Challenges

Full text

Pathway for Mucous Fistula (MF) Refeeding •Intestinal resection but not a good candidate for primary anastomosis?•Is infant stable to allow for extra operative time to create MF? •Distal bowel assessed for patency?◦Either in OR or with contrast study•Tolerating enteral nutrition for at least 2 days?•Has >5 mL of stoma output/day? Refeed proximal stoma effluent into mucous fistula to create an artificial ‘continuity’◦Max refeed bolus push = 10 mL.If >10 mL, run refeeds over a pump with max rate of 30 mL/hr. Can extend infusion time as needed to 3 hours maximum.◦If thick stoma effluent, strain to prevent MF tube clogging. May also dilute w/small amount of warm water PRN. 1)Place MF refeeding order in EPIC◦Day 1: Refeed 5 mL q12h ◦Day 2: Refeed 5 mL q6hr (if on enteral bolus feeds) or q8H (if enteral continuous feeds)◦Day 3: Refeed 10 mL q6hr (or q8H if on continuous feeds)◦Day 4: Refeed 10 mL q3hr (or q4H if on continuous feeds) ◦Beginning Day 5, refeed all stoma output q3 or q4 hours (depending on type of feeds) 2) Ensure that patient continues to tolerate enteral nutrition Intra-Operative: Ready to begin refeeding? How to initiate refeeding : v2 Updated 5/20 •Line up mesenteries of proximal and distal bowel (Fig. 1)•Tunnel MF tube through abdominal wall & away from stoma•Place 5-8 French feeding tube into distal bowel (MF) with purse string suture (Fig. 2)•Stamm MF tube to abdominal wall (Fig. 3)•Stoma and MF should be far enough apart for placement of separate ostomy bags (Fig. 4) Place MF tube intra-operatively Is patient a candidate for MF refeeding? If yes, create MF After post-op ileus has resolved Figure 1. Figure 2. Figure 3. Figure 4.Technical Key Steps: If yes to all 3, then can start refeeding MF tube fell out•Alert PedSurg Fellows to replace MF tube on morning or evening rounds Leakage around MF•Check tube placement •Order contrast study to r/o distal obstruction Troubleshooting Refeeding Challenges: MF tube is clogged •Instill warm water; if that doesn’t work then try carbonated waterPatient is acidotic (bicarb < 20)•Rule out other causes of metabolic acidosis •Stop MF refeeding, then resume refeeds slowly after bicarb has normalized Refeeding: 1 2 3 4

Figure 1.Figure 2. Figure 3.Figure 4.

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