Original Article
Recycling of bowel content: The importance of the right timing

https://doi.org/10.1016/j.jpedsurg.2012.07.064Get rights and content

Abstract

Introduction

Extracorporeal stool transport (recycling of chyme discharged from the proximal stoma end to the distal end of a high jejunostomy or ileostomy) is thought to be beneficial in preventing malabsoprtion, sodium loss, cholestasis and atrophy of the distal intestine until restoration of the intestinal continuity becomes possible. However little is known about its adverse effects. Our aim was to investigate the microbiological safety of recycling.

Material and Method

Native samples were taken from the proximal stoma in 5 premature neonates who underwent an ileostomy or a jejunostomy due to necrotising enterocolitis, for qualitative culture. The first sample was drawn immediately after the change of the stoma bag, further samples were sent from the stoma bag at 30, 60, 90, 120, 150, and 180 min later. The samples were inoculated by calibrated (10 μl) loops onto blood agar (5% sheep blood), eosin–methylene blue agar and anaerobic blood agar, respectively (Oxoid). The aerobic plates were incubated for 18–20 h at 5% CO2, whereas the anaerobic plates were incubated for 24–48 h in an anaerobic chamber (Concept 400). The bacterial strains were identified to species level by specific biochemical reactions, RapID-ANA II system (Oxoid) and ID32E, Rapid ID 32 Strep ATB automatic system cards (bioMérieux).

Results

The number of colony forming unit (CFU) of Gram-negative bacteria (mainly E. coli) exponentially increased after 30 min and reached 105/ml after 120 min. Gram-positive strains (primarily E. faecalis) were detected after 60 min and CFU increased to 105/ml after 120 min. The number of anaerobic (principally Bacteroides fragilis) CFU started to increase after 120 min. In two cases coagulase negative Staphylococcus strains were isolated the earliest in the chyme. The average of total CFU approached 105/ml after 90 min and exceeded 105/ml after 120 min.

Conclusion

The chyme in the stoma bag is colonized by commensal facultative pathogenic enteral/colonic as well as skin flora species after 120 min. Recycling of stoma bag content may be dangerous after 90 min.

Section snippets

Material and method

Between May 2010 and December 2011 native samples were taken from the proximal stomas in 5 premature neonates who underwent an ileostomy (n = 4) or a jejunostomy (n = 1) due to necrotising enterocolitis, for qualitative culture. The mean gestational age was 29 ± 4.18 weeks and mean birth weight was 1534 ± 1086.45 g. The first sample was drawn immediately after change of the stoma bag, further samples were sent from the stoma bag at 30, 60, 90, 120, 150, and 180 min later. During sampling, we followed the

Results

The results of chyme cultures from patients 1–5 are demonstrated in Fig. 1. Exponential growth was seen in the number of colony forming unit (CFU) of E. coli. In the samples from patient 1, the number of E. coli CFU was 103 at 30 min into the study, 104 at 60 min, reached 105 at 90 min, and remained 105 at 120, 150 and 180 min. Enterococcus faecalis CFUs were first detected at 120 min, with the number of 104. Elevation was detected at 150 min to 105 which remained the same at 180 min.

In the effluent

Discussion

Recycling stoma output is useful for stimulating mucosal growth, adaptation and absorption [3], [7], [8]. This recycling is an essential part of the Intestinal Rehabilitation Programme instituted in Manchester [2], [9]. This allows mucosal growth and adaptation and by intermittent clamping of the proximal stoma, allows absorption and CTE (controlled tissue expansion) in order to create enough tissue to safely perform lengthening procedures. According to the Manchester data, patients were also

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