Fistuloclysis : an option for the nutritional management of adult intestinal failure patients in South Africa

Du Toit, Anna-Lena (2016-03)

Thesis (MNutr)--Stellenbosch University, 2016.

Thesis

ENGLISH SUMMARY : Introduction: The development of intestinal failure is the consequence of diverse aetiologies and pathophysiological causes. Fistuloclysis is an effective means of nutritional support in selected intestinal failure patients. This study aimed to investigate the management of adult intestinal failure patients in hospitals in South Africa, determining how practical and acceptable fistuloclysis is. Methods: The study included three phases. Phase 1 consisted of a retrospective record review of adult patients admitted to Groote Schuur Hospital Intestinal Failure Unit between January 2009 and May 2014. Data collected included demographics, surgical interventions, gastrointestinal anatomy, nutritional management, biochemical markers and intake and output. Phase 2 consisted of a purposefully selected case study report published in a peer-reviewed journal. Phase 3 investigated the current management of type 2 and type 3 intestinal failure patients in South African hospitals, evaluating perceptions and opinions among South African doctors, stoma therapists and dietitians by means of occupation-specific questionnaires. Results: Phase 1: Seventeen intestinal failure patients receiving fistuloclysis were included in the study. During the fistuloclysis period, the median daily output was 1 478ml with a median of 71% of effluent received back via fistuloclysis. Four patients went home for a median period of 32,5 days on fistuloclysis. There was a statistically significant increase in the median albumin level between day 0 and day 28 of fistuloclysis, however body weight did not improve during this period. Postoperative complications occurred in only three patients. Patients were discharged after a median of 12 days post definitive surgery, with three complicating postoperatively and all patients regaining nutritional autonomy. Phase 3: Twenty-seven dietitians participated in the survey, the majority (67%) having been involved with patient management in this field for one – five years. All indicated high fistula outputs would be defined as intestinal failure. Only 47% gave the correct definition, with 28% currently utilising fistuloclysis. All respondents agreed that unsuccessful implementation of fistuloclysis was due to training shortfalls and resistance from clinicians and nursing staff. Ten stoma therapists entered the survey but only two fitted the inclusion criteria. Both worked in the private sector, with >10 years of experiece in the management of intestinal failure patients. Only one of the two proceeded with further questions. Four doctors managing intestinal failure responded. All respondents indicated high fistula outputs as associated with intestinal failure. The aetiology of intestinal failure indicated was postoperative complications by 75% of the respondents. The majority of respondents (75%) indicated that keeping patients nil by mouth was common practice, 50% of respondents indicated routine usage of pharmacological agents to decrease output or transit time. All respondents gave the correct explanation of fistuloclysis with 50% currently using fistuloclysis. Conclusion: Fistuloclysis is not superior, but equivalent to conventional methods of intestinal failure management. From this study and other available literature it is evident that fistuloclysis can replace PN support in selected patients. From the different occupation group surveys it is evident that there is a positive perception and awareness of fistuloclysis; however numerous stumbling blocks hamper the wider use of this novel treatment.

AFRIKAANSE OPSOMMING : Inleiding: Die ontwikkeling van intestinale versaking is die gevolg van diverse etiologiee en patofisiologiese oorsake. Fistuloklisie is ‘n doeltreffende manier van voedingsondersteuning vir geselekteerde pasiente. Hierdie studie was daarop gemik om die behandeling van volwasse pasiente met intestinale versaking in hospitale in Suid-Afrika te ondersoek en te bepaal hoe prakties en aanvaarbaar fistuloklisie is. Metodes: Die studie het bestaan uit drie fases. Fase 1 was ‘n retrospektiewe rekordhersiening van volwasse pasiente wat tussen Januarie 2009 en Mei 2014 in Groote Schuur Hospitaal se eenheid vir intestinale versaking opgeneem is. Data wat ingesamel is, sluit in demografiese gegewens, chirurgiese intervensies, gastrointestinale anatomie, voedingsbehandeling, biochemiese merkers en vloeistofbalans. Fase 2 was ‘n doelgerigte gevallestudie wat gepubliseer is in ‘n vaktydskrif. Fase 3 het gebruik gemaak van beroepspesifieke vraelyste om huidige behandeling van pasiente met tipe 2 en 3 tipe intestinale versaking in Suid-Afrikaanse hospitale te ondersoek, sowel as persepsies en menings oor fistuloklisie onder Suid-Afrikaanse dokters, stomaterapeute en dieetkundiges te bepaal. Resultate: Fase 1: Sewentien pasiente met intestinale versaking wat behandel is met fistuloklisie is ingesluit in die studie. Gedurende die fistuloklisietydperk was die mediaan uitskeiding 1 478ml per dag met ‘n mediaan van 71% wat teruggeplaas is deur fistuloklisie. Vier pasiente kon ontslaan word vir ‘n mediaantydperk van 32,5 dae op fistuloklisie. Daar was ‘n statisties beduidende toename in die mediaanalbumien vlak tussen dag 0 en dag 28 van fistuloklisie, maar liggaamsgewig het nie verbeter nie. Chirurgiese komplikasies het by slegs drie pasiente voorgekom. Pasiente is ‘n mediaan van 12 dae na chirurgie ontslaan en alle pasiente het voedingsoutonomie herwin. Fase 3: Sewe en twintig dieetkundiges het aan die opname deelgeneem. Die meerderheid (67%) het een tot vyf jaar ondervinding gehad in die behandeling van pasiente. Almal het aangedui dat hoe fisteldreinering gedefinieer sou word as intestinale versaking. Slegs 47% het die korrekte definisie vir fistuloklisie gegee, terwyl 28% tans daarvan gebruik maak. Al die respondente het saamgestem dat onsuksesvolle implementering van fistuloklisie te wyte is aan ‘n tekort aan opleiding en weerstand van dokters en verpleegpersoneel. Tien stomaterapeute het deelgeneem, maar slegs twee het voldoen aan die insluitingskriteria. Albei was werksaam in die privaatsektor, met >10jaar ondervinding in die behandeling van hierdie pasiente. Slegs een het die vraelys verder voltooi. Vier dokters het die vraelys voltooi. Almal het hoe fisteldreinering geassosieer met intestinale versaking. Die etiologie van die intestinale versaking is aangedui as chirurgiese komplikasies deur 75% van respondente. Die meerderheid van respondente (75%) het aangedui dat dit algemene praktyk is om pasiente nil per mond te hou, terwyl 50% roetineweg farmakologiese middels voorskryf om dreinering of deurgangstyd te verminder. Al die respondente het die korrekte definisie van die term gegee terwyl slegs 50% tans fistuloklisie gebruik. Gevolgtrekking: Fistuloklisie is gelykstaande aan konvensionele behandeling van intestinale versaking. Uit die resultate van hierdie studie en beskikbare literatuur is dit duidelik dat fistuloklisie parenterale voeding by gepaste pasiente kan vervang. Uit beroepsopnames is daar ‘n positiewe persepsie en bewustheid van fistuloklisie, maar ook talle struikelblokke wat die wyer gebruik belemmer.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/98318
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