Chyme reinfusion in patients with intestinal failure due to temporary double enterostomy: a 15-year prospective cohort in a referral centre

International audienceBackground and aims Patients with double temporary enterostomy may suffer from intestinal failure (IF). Parenteral nutrition (PN) is the gold standard treatment until surgical reestablishment of intestinal continuity. Chyme reinfusion (CR) is a technique consisting in an extracorporeal circulation of the chyme. The aims were to determine: i) whether CR could restore intestinal absorption, decrease PN needs, improve nutritional status and plasma liver tests; ii) the feasibility of home CR. Methods From the 232 patients IF consecutively referred for CR from 2000 to 2014, the 212 patients with IF, technical feasibility of CR, and effectively treated by CR, were included. Were collected prospectively before and during CR: daily stomal and fecal outputs, coefficients of nitrogen (CNDA) and fat (CFDA) digestive absorption, weight loss, body mass index (BMI), Nutritional Risk Index (NRI), plasma albumin, citrulline, and liver tests. Results 183 patients had temporary double enterostomy and 29 exposed enterocutaneous fistulas. CR reduced the intestinal output (2444 ± 933 vs 370 ± 457 ml/day, P<0.001), improved CNDA (46 ± 16 vs 80 ± 14%, P<0.001) and CFDA (48 ± 25 vs 86 ± 11%, P<0.001), and normalized plasma citrulline concentration (17.6 ± 8.4 vs 30.3 ± 11.8 μmol/l, P<0.001). PN was stopped in 126/139 (91%) patients within 2 ± 8 d. Nutritional status improved (P<0.001): weight (+4.6 ± 8.6%), BMI (+3.8 ± 7.7%), plasma albumin (+6.2 ± 6.1 g/l), and NRI (+10.9 ± 9.5). The proportion of patients with plasma liver tests abnormalities decreased (88 vs 51%, P<0.01). Home CR was feasible without any serious complications in selected patients. Conclusions CR corrected the intestinal failure by restoring intestinal absorption, allowing PN weaning in 91% of patients. CR contributes to improve nutritional status and to reduce plasma liver tests abnormalities, and is feasible at hom

Chyme Reinfusion in Intestinal Failure Related to Temporary Double Enterostomies and Enteroatmospheric Fistulas

Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous supplementations (IVS) for parenteral nutrition and hydration compensate for intestinal losses. Chyme reinfusion (CR) artificially restores continuity pending surgical closure. CR treats intestinal failure and is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) when possible. The objective of this study was to show changes in nutritional status, intestinal function, liver tests, IVS needs during CR, and the feasibility of continuing it at home. A retrospective study of 306 admitted patients treated with CR from 2000 to 2018 was conducted. CR was permanent such that a peristaltic pump sucked the upstream chyme and reinfused it immediately in a tube inserted into the downstream intestine. Weight, plasma albumin, daily volumes of intestinal and fecal losses, intestinal nitrogen, and lipid absorption coefficients, plasma citrulline, liver tests, and calculated indices were compared before and during CR in patients who had both measurements. The patients included 185 males and 121 females and were 63 ± 15 years old. There were 37 (12%), 269 (88%) patients with EAF and DES, respectively. The proximal small bowel length from the duodeno-jejunal angle was 108 ± 67 cm (n = 232), and the length of distal small intestine was 117 ± 72 cm (n = 253). The median CR start was 5 d (quartile 25–75%, 2–10) after admission and continued for 64 d (45–95), including 81 patients at home for 47 d (28–74). Oral feeding was exclusive 171(56%), with enteral supplement 122 (42%), or with IVS 23 (7%). Before CR, 211 (69%) patients had IVS for nutrition (77%) or for hydration (23%). IVS were stopped in 188 (89%) 2 d (0–7) after the beginning of CR and continued in 23 (11%) with lower volumes. Nutritional status improved with respect to weight gain (+3.5 ± 8.4%) and albumin (+5.4 ± 5.8 g/L). Intestinal failure was cured in the majority of cases as evidenced by the decrease in intestinal losses by 2096 ± 959 mL/d, the increase in absorption of nitrogen 32 ± 20%, of lipids 43 ± 30%, and the improvement of citrulline 13.1 ± 8.1 µmol/L. The citrulline increase was correlated with the length of the distal intestine. The number of patients with at least one liver test >2N decreased from 84–40%. In cases of Type 2 intestinal failure related to DES or FAE with an accessible and functional distal small bowel segment, CR restored intestinal functions, reduced the need of IVS by 89% and helped improve nutritional status and liver tests. There were no vital complications or infectious diarrhea described to date. CR can become the first-line treatment for intestinal failure related to double enterostomy and high output fistulas

Efficacy of a Ready-to-Drink Gelled Water and of a Thickening Powder in Patients with Oropharyngeal Dysphagia: a Crossover Randomized Study

International audienceAbstract Management of oropharyngeal dysphagia (OD) is mainly based on modifying liquid viscosity and solid consistency in order to preserve oral feeding while avoiding unsafe swallowing. Adding thickening powders (TP) to water is the most common practice in patients suffering from OD to liquids, but ready-to-use gelled waters (RGW) can also be proposed. The main objective of this study was to assess the efficacy of a RGW and a TP on swallowing in hospitalized patients with different OD etiologies. This open, crossover, multicenter trial recruited thirty hospitalized patients with OD to liquids, confirmed by positive 3-ounce water test or positive Practical Aspiration Screening Scheme test. The patient’s ability to swallow 120 g of a RGW (IDDSI level 4) and a drink prepared with TP (nectar viscosity; NTP, 291 cP, IDDSI level 2; or if necessary, honey; HTP, 769 cP, IDDSI level 3) was evaluated in a random order at 1- to 3-day intervals. The main criterion was the efficacy of each product, defined as the proportion of patients who successfully swallowed without immediate reflexive cough. The RGW and TP were successfully swallowed in respectively 93.3% (95% CI: 77.9–99.2) and 82.8% (95% CI: 64.2–94.2) of patients with different dysphagia etiologies (stroke, neurodegenerative diseases, or aging) and unable to swallow thin water. Taste and texture of both study products were well appreciated by patients, with a preference for the RGW over TP. Therefore, the use of these thickened products could be part of the therapeutic strategy for patients with OD to liquids

Chyme reinfusion restores the regulatory bile salt-FGF19 axis in intestinal failure patients

International audienceBackground and aims - Automated chyme reinfusion (CR) in patients with intestinal failure (IF) and a temporary double enterostomy (TDE) restores intestinal function and protects against liver injury, but the mechanisms are incompletely understood. The aim was to investigate whether the beneficial effects of CR relate to functional recovery of enterohepatic signaling through the bile salt-FGF19 axis. Approach and results - Blood samples were collected from 12 patients, 3 days before, at start, and 1, 3, 5, and 7 weeks after CR initiation. Plasma FGF19, total bile salts (TBS), 7-α-hydroxy-4-cholesten-3-one (C4; a marker of bile salt synthesis), citrulline (CIT), bile salt composition, liver tests, and nutritional risk indices were determined. Paired small bowel biopsies prior to CR and after 21 days were taken, and genes related to bile salt homeostasis and enterocyte function were assessed. CR induced an increase in plasma FGF19 and decreased C4 levels, indicating restored regulation of bile salt synthesis through endocrine FGF19 action. TBS remained unaltered during CR. Intestinal farnesoid X receptor was up-regulated after 21 days of CR. Secondary and deconjugated bile salt fractions were increased after CR, reflecting restored microbial metabolism of host bile salts. Furthermore, CIT and albumin levels gradually rose after CR, while abnormal serum liver tests normalized after CR, indicating restored intestinal function, improved nutritional status, and amelioration of liver injury. CR increased gene transcripts related to enterocyte number, carbohydrate handling, and bile salt homeostasis. Finally, the reciprocal FGF19/C4 response after 7 days predicted the plasma CIT time course. Conclusions - CR in patients with IF-TDE restored bile salt-FGF19 signaling and improved gut-liver function. Beneficial effects of CR are partly mediated by recovery of the bile salt-FGF19 axis and subsequent homeostatic regulation of bile salt synthesis