Puncture and catheterization of the ascending colon for succus entericus reinfusion in a patient with a high-output single-lumen stoma: a case report

Abstract

Background

High-output enterostomy is a common complication following ostomy procedures. In patients with loop ileostomies, the incidence of dehydration can reach 30%, and it represents the most frequent cause of readmission after ileostomy surgery, with rates as high as 16.9%. In severe cases, this condition can progress to renal failure (Dis Colon Rectum 55: 175-80, 2021, J Gastrointest Surg 17: 298-303, 2013, Nurs Stand 37: 71-6, 2022). High-output ileostomy (HOI) often imposes dietary restrictions on patients, increasing the risk of malnutrition. Previous studies have demonstrated that ileostomy fluid reinfusion can effectively address dehydration, electrolyte imbalances, renal dysfunction, and malnutrition (Gastroenterol Rep (Oxf) 12: goae100, 2024). However, the primary physiological benefit of reinfusion, particularly into the colon, is rehydration and electrolyte reabsorption, with nutritional improvement likely attributable to concurrent enteral support and intestinal adaptation.

Case presentation

A 73-year-old female patient underwent ultrasound-guided puncture of the ascending colon for placement of a feeding tube, establishing a route for ileostomy fluid reinfusion. Combined with total enteral nutrition support and distal colon fluid reinfusion, this method was used to manage HOI in a patient with a small bowel single-lumen stoma.

Conclusions

This case demonstrates that ultrasound-guided catheterization of the ascending colon provides a feasible and effective approach for succus entericus reinfusion (SER) in patients with high-output single-lumen ileostomies. The intervention improved hydration, renal function, and nutritional status, facilitating safe stoma reversal. This technique offers a promising alternative for managing high-output stomas when conventional reinfusion pathways are not available.

Background

High-output stomas (HOS), clinically defined by a daily output exceeding 1500–2000 mL, often lead to severe complications such as dehydration, electrolyte disturbances, malnutrition, and renal impairment [1–5]. Managing these issues is particularly complex in patients with single-lumen ileostomies, where traditional SER cannot be performed due to the absence of a distal intestinal segment for reinfusion access [6]. Consequently, prolonged reliance on parenteral nutrition or intravenous fluid supplementation becomes unavoidable for many patients [7].

Evidence highlights SER’s role in mitigating fluid losses, enhancing nutrient uptake, and promoting intestinal adaptation [8]. The primary physiological benefit of colonic reinfusion is rehydration and electrolyte reabsorption, leveraging the colon’s inherent absorptive capacity. A groundbreaking advancement involves ultrasound-guided catheter placement into the ascending colon, which circumvents the anatomical limitations of single-lumen stomas. By partially restoring intestinal continuity, this method leverages the colon’s reabsorptive capacity, offering a promising strategy to stabilize patients and reduce dependency on invasive therapies.

Case presentation

A 73-year-old female patient with a single-lumen ileostomy was admitted to our center. Two months prior, the patient had undergone partial small bowel resection due to small bowel necrosis, leaving approximately 190 cm of the proximal small bowel and 5 cm of the distal small bowel. While 190 cm of residual small bowel is not typically classified as short bowel syndrome, the patient developed persistent high output with associated renal dysfunction, which justified the need for intervention. Postoperatively, the patient developed high-output ileostomy, with daily output ranging from 1500 mL to 2000 mL, accompanied by a progressive increase in serum creatinine levels. Over the two months following surgery, the patient experienced a weight loss of 5 kg. To manage the HOI, the patient was initiated on exclusive enteral nutrition therapy via a nasogastric tube, with a daily energy intake of 1500 kcal and a fluid intake of 1500 mL. Despite these measures, the patient’s ileostomy output remained high at approximately 2000 mL per day. Under ultrasound guidance, a catheter was inserted into the ascending colon (Fig. 1). The ileostomy fluid was filtered to remove solid debris and then continuously reinfused into the ascending colon at a rate of 100 mL/hour using an infusion pump.

Fig. 1.

Under ultrasound guidance, a catheter was inserted into the ascending colon. A Axial CT scan demonstrating the tip of the catheter positioned within the lumen of the ascending colon. B Coronal CT image. C Percutaneous puncture under color Doppler ultrasound guidance, with catheter placement in the lumen of the ascending colon. D Image of the patient in a standing position

Follow-up

After receiving training on exclusive enteral nutrition via nasogastric tube and ileostomy fluid reinfusion during hospitalization, the patient continued the treatment at home. Three months later, the patient was readmitted for evaluation. As shown in Table 1, the patient’s body weight increased by 5.4 kg, serum creatinine levels decreased from 203 µmol/L to 90.5 µmol/L, and albumin levels improved from 31.9 g/L to 34.3 g/L. Consequently, the patient successfully underwent ostomy reversal surgery.

Table 1.

Clinical data of the patient before and after infusion

Parameter	Pre-Infusion	Post-influsion
Weight (kg)	45.0	50.4
BMI (kg/m2)	17.6	19.7
Creatinine (umol/L)	203.0	90.5
Albumin (g/L)	31.9	34.3

BMI Body mass index

Discussion and conclusions

High-output jejunostomies are often necessitated by various pathological conditions, including ischemic bowel disease, Crohn’s disease, radiation enteritis, enterocutaneous fistulae secondary to iatrogenic injury, enteroatmospheric fistulae associated with open abdominal malignancies, and severe gastrointestinal dysmotility [9, 10]. In such cases, the distal small intestine is frequently inaccessible for exteriorization due to technical limitations, leading surgeons to oversew the distal limb. Early stoma reversal was not considered feasible in this patient due to the extremely short distal limb (5 cm) and the high surgical risk posed by concurrent malnutrition and renal impairment. Patients with high-output end jejunostomies are at increased surgical risk during stoma closure due to complications such as malnutrition, electrolyte imbalances, and hepatic dysfunction, often requiring prolonged hospitalization for parenteral nutritional support [10].

This case report presents a novel approach involving ultrasound-guided percutaneous placement of a feeding tube into the ascending colon with concurrent reinfusion of enteric fluid. This technique effectively alleviated dehydration and nutritional deficits, optimizing the patient’s condition for subsequent stoma closure. The observed clinical improvement likely resulted from a combination of factors: colonic reabsorption of fluid and electrolytes, dedicated enteral nutritional support, and natural intestinal adaptation over time. Notably, intraoperative findings during closure revealed adhesion formation between the intestinal wall at the catheter insertion site and the abdominal wall, which serendipitously prevented intraperitoneal leakage and infectious complications.

However, several unresolved issues warrant further investigation. We acknowledge that less invasive alternatives, such as subcutaneous fluid administration, may be considered for some patients; however, in this case, the severity and volume of the output necessitated a sustained and efficient fluid management strategy that colonic reinfusion provided. For instance, the surgical repair of the catheter-induced colotomy during stoma closure raises concerns about potential increases in the risk of postoperative enterocutaneous fistula. Additional studies are required to evaluate the long-term safety and broader applicability of this innovative intervention.

Abbreviations

HOI

High-output ileostomy

SER

Succus entericus reinfusion

HOS

High-output stomas

Authors’ contributions

Conception and design (Jia Ke); acquisition of data (Sicong Lai); analysis and interpretation of data (Sicong Lai, Huanxin Hu); writing and revision of the manuscript (Sicong Lai, Huanxin Hu, Xijian Zhang); review of the manuscript (Keming Jiang, Xinzhe Zhao, Jia Ke).

Funding

Supported by National Key Clinical Discipline and Guangzhou Science and Technology - Young Doctor Program (SL2023A04J2247).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Written informed consent was obtained from the patient to participate to this case report.

Consent for publication

Informed written consent was obtained from the patient for the publication of the clinical details and clinical images.

Competing interests

The authors declare no competing interests.