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

So today, I'm gonna talk about a simplified method for refeeding succus entericus. Um, for patients with, uh, uh, enterocutaneous fistulas. Um, another term for this technique is fistulolysis, and a simple definition of fistulolysis is enteral feeding, uh, sorry, sorry, it's enteral nutrition via refeeding of either succusentericus or formula into a distal fistula. This technique can be uh, successfully used to replace parenteral, uh, nutrition in the nutritional support of these types of patients. Uh, a side benefit, especially, uh, in low resource environments, is that it's significantly less expensive to do fistulaly for nutrition than to do total perennial nutrition. OK, let's get to the talk. Um, I'm going to begin first with a sample case of a type of patient that you would want to use this technique in. So, a surgeon is faced with a 29 week, uh, gestational age female with multiple small bowel atresias. The distal small bowel beyond the atresia is very small, only about 3 millimeters in diameter, and there is microcolon. This patient has a relatively short gut. The final surgical anatomy after laparotomy is an angiogenostomy with a mucous fistula and two intraabdominal enteroenterostomies distal to the mucous fistula. The surgeon is concerned about functional distal obstruction if the ostomy is closed due to the very small caliber of the distal atretic bowel. The surgeon decides that he's going to refeed the succus into the distal small bowel to nourish and stimulate this distal bowel for several weeks before attempting ostomy closure uh to perform trophic refeeding. The central problem for the surgeon is that it's difficult to maintain a catheter in the lumen of the distal small bowel, which is so small without the tube being dislodged. When the catheter falls out, there's suck is leaking onto the skin, which causes localized irritation. Uh, a balloon catheter really can't be used in this patient because the bowel is so small that even minor inflation of the balloon risks rupture of the small caliber bowel. Another problem is that the NICU nursing staff is very displeased with the surgeon and noncompliant with the surgeon's request to refeed succus due to the difficulty of maintaining the catheter in the bowel and the mess that it potentially causes. Here's an example of the, uh, what this patient's abdominal anatomy is. This patient has an endostomy and a mucous fistula. The endostomy is in the right lower quadrant and the mucous fistula is just above the, uh, transverse laparotomy, uh, scar. This patient has a very nice nipple above the skin level, which definitely facilitates this technique. Uh, here's this patient with pouching of the distal ostomy, and you can see that in addition to the pouch to collect the stool, uh, the, uh, distal, um, fistula or mucous fistula is surrounded by a stoma disc which fits very tightly around the ostomy in order to protect the skin. Here's what the, uh, setup looks like and I'll show you how to construct it. Basically, it's a baby nipple, uh, with a feeding catheter placed, uh, through it. You can see that the nurse here has applied a piece of, uh, tape to the, um, catheter to keep it from slipping out, but this is not always necessary. The equipment that you need to do this is uh very basic. You need a 5 French nasogastric feeding tube. You need a baby nipple, you need a stoma disc, and you need some tape. The method involves passing the tube through the nipple with a hemostat, and. I'll demonstrate that in a short video, and then inserting the feeding tube about 3 centimeters into the mucous fistula and then slowly feeding it 1 to 2 mL per hour. In the case of this patient, we're just trying to do trophic feeds, but it is possible to do higher volume feeds, uh, to do true enterolysis, or sorry, fistulolysis, uh, in other types of patients. The way that this setup is constructed, it, it requires divided ostomies, and one advantage of this technique is it's far easier to explain to people who change every shift where, where the tube goes, and it's more obvious and also allows you. Uh, distal control as the patient is growing and, um, improving, it's possible to do radiographic surveillance of the distal bowel to assess the growth of the bowel to see if it's ready to be, uh, uh, reconnected. It also allows you to do a a uh mucous fistulagram to look for stenosis before closure of a stoma like this. Uh, I have a short video that, uh, demonstrates, uh, how you construct this. It's incredibly simple. Um, you only need 3 pieces of equipment, the baby nipple, which you remove from the, uh, plastic screw cap, uh, mosquito hemostat, which you pass through the little hole in the distal end of the nipple, uh, you grasp the feeding tube, uh, and then pull it through the nipple, uh, to the depth that you want. Um, this fits actually quite tightly, and that piece of tape that was demonstrated in the previous slide is actually not necessary most of the time. Um, you can also place, uh, a mark with an indelible marker on the catheter so that everybody knows how deep it should be. Uh, I think one key trick here is to make sure that you have all of the holes from, uh, any type of tube that you're doing, uh, well inside of the stoma. And again, this is a non-balloon catheter because this baby's, uh, uh, bowel is so small that you couldn't use it, uh, you couldn't use a balloon catheter. Incidentally, um, when fistulolysis is done with adults, almost always either a gastrostomy tube or a, uh, Foley catheter with a balloon is used to, uh, to basically occlude the bowel to prevent leaking and also to prevent the tube from falling out. I think the innovation that the baby nipple, uh, provides is that it keeps the tube from falling out and it also keeps it upright and stable. Uh, that's, uh, that, that's essentially the technique. All right, thank you, Oliver, and uh, we, uh, we're gonna open this up for discussion and first of all, I want to invite all of our faculty, um, we have Doctor Blair joining us here. Can you hear us? My, my, my, my mug, my mug, you said. Doctor, hi, hi, good morning. Welcome. Thank you. All right, uh, we also have Cathy Burnwhite. Can you hear us as well? Yes, I can. Great. Hi, everybody. Hi, thank you for joining us. Um, and, uh, we also had, uh, Sharif Emil. His camera just went off, but he was there a second ago. Sharif, can you hear us? I can hear you, Todd. Good morning. Good morning. You can go ahead and turn your camera back on, um, and for the, um, I know it gets a little confusing because we have a lot of presenters and we have faculty, but right now we just want the faculty's cameras on. So, uh, Jose Prince, uh, if you can, are you with us, Jose? Yeah, I'm here, but I don't have video yet. OK, we're working on your video, uh, and, uh, in a minute you should see the webcam button above my head in the backstage presenter area, and then you could just put, uh, start my webcam. Um, so let me ask, let me open it up to the, uh, the virtual audience first. Anyone have any experience with using a technique similar to this? No one. I've I've tried, I've tried as a fellow, um, tube holders, kind of the kind that you use to hold the G tubes at times that are these, uh, have a self-adhesive with a plastic stem that comes up and will grip the catheter on both ends, but, uh, often without great success. So I'm, I was really intrigued by the presentation and I. I don't know if I could say I look forward to using it because it's not a simple patient to have to deal with, but certainly with the next one like this, I would very much consider it. Yeah, um, yeah, I, it's very cool. I, um, and you've, you've, you've solved two of the big challenges, you know, the nursing challenge, of course, because it is so messy and so, you know, uh, difficult to do at times. I love the piece on the skin that protects the skin, and you got a way to hold the catheter. Um, I think it's, it's fantastic that it works. I guess my push would be how often do we need to use it? When do we say something's too small and when should we be trying to connect things? I think we're getting more and more aggressive about trying to hook things back up so we don't get any scenarios. And when do you, when are you cornered and have to do this? I think it's when the bowel is really so small that you think there's going to be a functional obstruction. I've been. Faced with this case where you have some tiny, tiny distal bowel, a microcolon, and dilated proximal bowel, and you just know from experience that if you anastomose these two things, there's a functional obstruction at that anastomosis because the distal bowel has a diameter of 3 or 4 or 5 millimeters where it's very, very small. The patient with multiple atresias and very small distal bowel is probably ideal for this technique. Um, uh, and, and the concept is simple. Just basically provide trophic feeds distally to get them to grow. Now, in the case of older children, where you have children whose bowel is fully developed and of normal size or adult, uh, size bowel, I don't think it's necessary to use the feeding tube and the nipple. You can simply put a Foley catheter or a balloon gastrostomy tube in it, but again, you have the same hazard with balloon catheters. I've observed it where perforations have occurred because of overinflation of the Foley catheter and. Uh, you know, keeping this simple is the key to making it work because at least in the United States, we have to deal with 3 shifts of nurses every day. And if you make it too complicated, when the tube falls out at the, uh, in the middle of the next shift, now they don't get feedings all night again because no one knows how to do it. So, you have to have a technique that can be taught to 5 or 10 different nurses who will take care of the baby over weeks, um, and make, and keep it very, very simple. Uh, again, uh, the way I've used just a very low amount of feeding in this patient, one or two, Cs an hour because I'm just trying to achieve growth rather than nutrition. Another side benefit of, uh, this technique, fistulolysis is actually for reasons that are not clear to me, if you refeed the proximal stoma output into the distal stoma, there is actually a decrement in the amount that comes out of the proximal stoma, so it can also help you with fluid and electrolyte management. In these challenging patients, all right, did you have any comments, Jack? Yeah, I, I, I think this is great. I mean, we've been doing this for many years. I think there was a paper from, uh, I think it was from Hamilton, Ontario, where they, they termed it the poop and scoop technique. And, uh, I mean, it makes sense, but the big problem, as you said, has always been the, the nursing issues and keeping the catheter in. I guess the, the thing I worry about a little bit is, is you can't see what's going on underneath that nipple. So, you know, if the thing comes dislodged, you're just pouring the stuff onto the skin, right? The, the solutions to that, I think, are one, to, You know, you need to mark the catheter so you know how deep it is, so you can use a Sharpie type marker to mark it. And the other thing is they make clear silicone baby nipples. So if it's a problem in your unit, you can have a clear nipple and just see this happens to be what we have on our unit, but if it's really a chronic problem, you can just use a, a, a clear one. the other thing, other challenges in the um. Uh, slides, uh, you can see that there's tape actually on the baby's skin, and one way I get around that if you're doing it for a long time, is to put two pieces of Duoderm on either side of the, uh, car, uh, disc, so the tape never touches the baby's skin. Um, uh, this is, Oliver, I'll tell you, this whole tricks of the trade thing is for stuff just like this, you know, we, every, we talk about these symposiums with these complex operations and all this, but it's these tricks that we need to deal with every single day that make our practice much easier. Um, and so, uh, the ways, the reason I was alerted to it is the nurses told me how much they liked it. And uh when I heard that, I said, I really have to look into using this. So I, I, I wanna, before we go on any further, let me just do a couple of formal introductions with those who are up here. Um, Cathy Bernwhite is the chief of pediatric surgery at Miami Children's Hospital. She's also the fellowship, uh, program director. Uh, and, uh, so we thank her for coming. Jeffrey Blair is pediatric surgeon and University of British Columbia clinical professor, director of the Department of Surgery. So, uh, we also appreciate him joining us. Uh, we've already introduced Jack Langer, Jose Prince, uh, is the director of pediatric inflammatory Center, uh, Pediatric and inflammation Center for Immunology and inflammation. Jose, I'm curious. I want you to tell me what that's all about in a second. Uh, and, um, he is at Long Island Jewish. What is that about, Jose? Uh, that's my basic science lab effort. Uh, it's studying, uh, the innate immune response in infants and children. I always knew you were smart. You always looked smart, so that's not surprising to me. So they're good. Are you, uh, as you've had a productive lab? I'm working on it. That's the hard part. Good man. Well, hopefully we'll have you back to present something from your lab next year. Um, and then I, I also see on camera here my good friend, uh, Souad Abboul, who, uh, I, uh, had the pleasure of meeting in Kuwait, uh, uh, an incredible, incredible surgeon, uh, and good friend who is, uh, at the, uh, IBA SINA Hospital. Am I pronouncing that right, Suad? I don't know if she can hear us. Uh, looks like she can't hear us now, but, uh, she, she is at, at Kuwait and hopefully we'll get her audio connected so she can hear us. Um, so, uh, why don't we, I think that's all we have. Ayama, I see Yama, are you on the phone? Hello, yes, I'm here. Hey, Yama, turn on your camera so we can hear me? Yeah, we can hear you, but we want to see your beautiful face, so go ahead and turn your camera on. OK, I'll do that now. I never knew you to be shy. Uh, all right, so, uh, can you hear me? We can hear you, we just can't see you. So, um, I want to ask the faculty before we move on to the next presentation, which is actually Yama. Does anyone have any comments before we move out of this, uh, presentation? I think there's 40-something fellows in the country who are going to be grateful for this technique if they try it. I hope so. Oliver, uh, Jeff Blair here, um, can you hear me? Yes, I can. Uh, that was a good presentation. I, I like the trick. We've used something similar to that. Now, unfortunately with every trick there can be trouble. Um, we've had 3 babies in the past year and a half who have actually perforated with this technique despite great care, uh, using it. We actually use silicon catheters which are incredibly soft, softer than perhaps the tubes you're using. The tubes were not in too far at all, but all three babies developed acute peritonitis, and all 3 babies had a perforation, and 1 baby died. Wow. Um, so, um, it has to be done with care. There's always the tendency to, to, um, just take these things for granted, and I echo, uh, Jack's comments that even despite a clear nipple, you can. And the, uh, the magic marker, the, the marker pen marks can sometimes be obscured and can be inserted farther than it should be. So it's a great trick. We're gonna continue to use it, but we want to take great care of not inserting it too far, and each of the babies, it was inserted just 1 centimeter or two too far. Wow, uh, you know, I, I share that concern, and, and, uh, I think those are, uh, it's a very important message. The, uh, uh, you know, my, my experience with those kinds of events has been, uh, primarily if people are trying to put a balloon catheter in, even a very small Foley catheter, I think is quite dangerous, and then some people try to dilate the stoma. Uh, when they pass these catheters in, and, and that's the other scenario where I've seen people passing usually red rubber catheters, 10 French or so to try to dilate it, where, where I have seen perforations, but I think that is the key. It's never to force it and to put it in just as deep as it comfortably goes. Uh, because, uh, and then you, it requires really, you know, this is really not a surgeon's trick. This is a nursing trick. The success of this is totally dependent on your, uh, NICU nurses. Uh, if they are committed to doing this, you, I think you can have great results, and, uh, if they fight you all the time, this will absolutely not work. So I think that the, the benefit of this technique is it's simple and hopefully you can get them on your side to do this potentially messy. Uh, uh, project. Oliver, thank you for that presentation, and I was hoping, I don't know if you have stuff to do, if you could stick around a little longer and give your insight, um, we're gonna now move on to, uh, Professor.