Continuous extracorporeal chyme reinfusion using the veraflo system in open abdomen with duodenostomy: a case report

Abstract

This case report describes a novel approach to optimizing nutrition in a 47-year-old male who underwent multiple laparotomies following sulfuric acid ingestion. The resulting necrosis necessitated a total gastrectomy and subtotal jejunal resection, leaving the abdomen open and the bowel in discontinuity. The team utilized the 3 M Veraflo wound vac system to continuously draw digestive contents from the duodenum and infuse them with enteral feed via a Y-connector into the proximal ileum. While specialized chyme reinfusion devices exist, this paper highlights a unique application of the 3 M Veraflo system to circumvent disrupted anatomy and optimize recovery in a critically ill patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-026-03810-6.

Background

Digestion is a complex process requiring coordinated mechanical and chemical actions. The stomach serves as the primary reservoir, initiating protein digestion via hydrochloric acid and pepsin and secreting intrinsic factors essential for vitamin B12 absorption. Its pyloric sphincter regulates the delivery of chyme into the duodenum to optimize nutrient exposure [1]. The jejunum, comprising the proximal two-fifths of the small intestine, is the principal site for the absorption of carbohydrates, proteins, and water-soluble vitamins. Its extensive surface area, characterized by long villi and deep crypts, is critical for the majority of nutrient uptake [2, 3]. The loss of these segments, as seen in the present case, results in profound malabsorption and rapid nutritional decline. Disruption of the GI tract leads to deficiencies in fat-soluble vitamins (A, D, E, K), muscle wasting, and a weakened immune response [3]. The two primary modalities are Total Parenteral Nutrition (TPN) and Enteral Nutrition (EN). TPN is used when the GI tract is non-functional but carries risks of infection and metabolic derangement [3]. EN remains the gold standard for trauma patients, as it maintains gut integrity and reduces sepsis [4, 5]. In patients with an open abdomen and extensive damage control surgery or compartment syndrome, restoring bowel continuity is the ultimate goal [6]. However, when the bowel is left in discontinuity, digestive fluids are often lost, leading to severe fluid and electrolyte imbalances [7, 8]. On rare occasions when continuity is lost, digestive fluids can be collected and reintroduced. While specialized devices like the Enteromat^® or Actilink^® are designed for chyme reinfusion, they may not be readily available in all trauma settings. Historically, extracorporeal EN has often involved intermittent, manual administration of chyme [4, 7, 9–11].

This case explores the feasibility of repurposing a common negative pressure wound therapy system to achieve continuous, automated reinfusion. Our paper provides a unique method of continuous extracorporeal recycling of the duodenal content from the duodenostomy tube to the ileostomy tube along with an EN formula using a 3 M Veraflo wound vac system.

Case report

A 47-year-old male with no significant past medical history presented to the emergency department after out-of-hospital cardiac arrest with return of spontaneous circulation (ROSC). On arrival, laboratory evaluation revealed severe metabolic acidosis with a pH of 6.5, and an orogastric (OG) tube returned 200 mL of frank blood. Given concern for catastrophic intra-abdominal pathology, a computed tomography (CT) scan of the abdomen and pelvis was performed, demonstrating diffuse gastric swelling and evidence of small bowel obstruction (Fig. 1). Emergency exploratory laparotomy was undertaken and revealed diffuse gastric gangrene secondary to sulfuric acid ingestion. Intraoperative findings included a globally necrotic, hemorrhagic stomach (Fig. 2) and a gangrenous segment of small intestine (Fig. 3).

Fig. 1.

CT imaging revealed diffuse gastric swelling and small bowel obstruction

Fig. 2.

Stomach specimen: Internal view of the diffuse hemorrhagic gastric necrosis

Fig. 3.

Surgical exposure of a gangrenous portion of the small intestine

Initial investigations

This patient underwent five major laparotomies, resulting in a total gastrectomy, splenectomy, cholecystectomy, and subtotal resection of the jejunum (Fig. 3). The abdomen remained open in discontinuity to allow for further revisions, leaving approximately 110–130 cm of viable distal ileum. There were multiple failed attempts to re-anastomose the bowel. These challenges arose because the duodenal edge at the site of the duodenostomy remained edematous, indurated, and friable, while the proximal part of the remaining ileum became immobile due to adhesions. Faced with these challenges, our team developed an innovative approach enabling the continuous delivery of enteral nutrition (EN) through a 3 M Veraflo wound vacuum system.

To accomplish this, we redirected the patient’s duodenostomy output including duodenal, biliary, and pancreatic secretions through the wound vac and into his ileostomy tube using one limb of a Y-connector. Simultaneously, EN was administered through the remaining limb of the Y-connector, allowing the proximal gastrointestinal (GI) contents to mix with the nutritional supplement. Forward movement of the chyme and enteral formula was achieved despite bowel discontinuity by creating a controlled pressure gradient within the extracorporeal circuit. The Veraflo system generated gentle, indirect negative pressure within the wound bed (-70 to -90 mmHg), which facilitated the passive withdrawal of duodenal effluent into the tubing without exposing the mucosa to direct suction. The device’s intermittent instillation cycles produced a pulsatile flow pattern that further promoted distal propulsion.

The system was configured so that the duodenostomy outlet was positioned higher than the ileostomy limb, providing a gravity-assisted component to the flow. Additionally, the use of a low-resistance, closed-tubing circuit minimized energy loss and ensured consistent lumen filling. Together, these elements enabled the reliable and continuous delivery of mixed endogenous secretions and enteral formula into the remaining ileum, despite the absence of anatomical continuity (Fig. 4). We created a schematic drawing of our design for simplicity, which is shown below in (Fig. 5).

Fig. 4.

Wound vac and associated settings cropped into one image, arrows demonstrating the direction of flow (inflow A → outflow B)

Fig. 5.

Schematic representation of the 3 M Veraflo wound vac recycling apparatus. (Made with the Ai graphic tool notebookLM from the rough sketch attached.)

Post operative wound vac placement

The patient underwent continuous reinfusion for 10–14 days and demonstrated clinical improvement during this period. No duodenal mucosal injury attributable to indirect negative pressure was observed, and serial inspections demonstrated intact mucosa. There was a progressive correction of electrolyte derangements, ileostomy output became more physiologic, and serum nutritional parameters, including albumin and pre-albumin, showed early recovery.

Surgical timeline and series of laparotomies

Due to the progressive nature of the caustic injury, the patient underwent five laparotomies over the course of 11 days (Table 1). The details of these interventions are summarized below:

Table 1.

Laparotomy Timeline:

Laparotomy	Timing (Post-Presentation)	Indication	Resections/Interventions
1st (Emergency)	Day 0	Suspected perforation/hemorrhage	Total gastrectomy; damage control; abdomen left open.
2nd (Planned)	Day 1	Re-assessment of bowel viability	Splenectomy and cholecystectomy due to adjacent caustic necrosis.
3rd	Day 3	Evolving jejunal gangrene	Subtotal resection of the jejunum; the bowel was left in discontinuity.
4th	Day 6	Fever and leukocytosis	Abdominal washout; minor debridement of edematous duodenal edges.
5th	Day 11	Attempted closure/anastomosis	Adhesiolysis; failed re-anastomosis due to tissue friability; placement of duodenostomy/ileostomy.

Nutritional management: 1. supply specific nutritional goal data

The patient’s nutritional goals were calculated at 25–30 kcal/kg/day and 1.5–2.0 g/kg/day of protein to meet the high metabolic demands of caustic trauma and open-abdomen wound healing [12–14] (Table 2).

Table 2.

Nutritional Summary

Parameter	Target Goal	Achieved (Day 10–14)	Clinical Justification
Total Caloric Intake	25–30 kcal/kg/day	~ 40–50% via EN reinfusion	To meet metabolic demands while reducing TPN-associated liver cholestasis.
Protein Intake	1.5–2.0 g/kg/day	Supplemented via EN. ~1.5 g/kg/day was constantly achieved.	Essential for wound healing in an “open abdomen” and to offset protein loss in effluent.
Serum Pre-albumin	Rising trend	Early recovery noted	Serves as a sensitive marker (2-day half-life) for acute nutritional improvement.
Electrolytes	Normalization	Progressive correction	Reintroduction of biliary and pancreatic secretions stabilizes potassium and acid-base balance.

Impact on metabolic stability

The reduction in TPN dependency was evidenced by the progressive correction of electrolyte derangements and the early recovery of serum nutritional parameters like pre-albumin. Pre-albumin, with its short half-life of 2 days, is a sensitive marker of acute nutritional changes, and its rise during the 10–14 days of reinfusion confirmed that the patient was successfully utilizing the enteral supplements despite the disrupted anatomy [12].

Updated outcome and decision-making

Nutritional goals in our case were set and pursued according to established critical care nutrition principles, with targets of 25–30 kcal/kg/day (≈ 1,800–2,000 kcal/day) and 1.5–2.0 g/kg/day of protein to support severe caustic trauma, open-abdomen wound healing, and ongoing catabolism.

During continuous extracorporeal chyme reinfusion with the 3 M Veraflo system, EN delivered approximately 40–50% of the targeted caloric requirements, while parenteral nutrition supplied the remaining 50–60%. Though a protein supplement of around 1.5 g/kg/day was consistently achieved. This regimen resulted in clear biochemical evidence of nutritional response, with rising serum albumin and pre-albumin over the 10–14-day reinfusion period, indicating that the enteral component was being effectively utilized despite the disrupted anatomy. Although optimum caloric and protein targets were maintained and the patient demonstrated sustained improvement from a nutritional standpoint, the overall clinical course remained driven by impending multiorgan failure and severe physiological stress.

During this time, Intestinal transplantation was considered but deemed inappropriate due to active multisystem failure and the severity of the initial caustic insult. After a comprehensive discussion with the family regarding the prognosis and details of long-term reconstruction, the patient was transitioned to hospice care respecting the family wishes. He was subsequently transferred to an external long-term hospice facility, where he passed away several weeks later due to complications of pneumonia and acute renal failure.

Discussion

Severe caustic ingestion with resulting gastric necrosis, bowel discontinuity, and an open abdomen presents an extreme form of intestinal failure in which conventional routes of EN are often difficult [13]. In such situations, clinicians frequently rely on prolonged PN, accepting the risks of liver dysfunction, catheter-related infections, and loss of distal bowel function [14]. Chyme reinfusion has been introduced as a physiologic option to preserve the absorptive capacity of the remaining intestine by restoring exposure to endogenous secretions and nutrients, even when anatomical continuity cannot be re-established immediately [15, 16].

Within this context, we explored whether existing wound management technology could be repurposed to deliver continuous chyme reinfusion in a critically ill trauma patient. Some studies in literature supports this approach in s high-output stomas, fistulas, and temporary double enterostomies [17]; For e.g., Picot et al. (2020) in 306 patients stated that chyme reinfusion substantially improved intestinal function, reducing losses by 86%, increasing nitrogen absorption by 73%, and lipids by 91% also eliminating PN needs in 89% of some cases [17]; similarly Koelfat KVK et al. (2021) showed that reinfusion restores the bile salt-FGF19 axis, improving nutritional condition and distal bowel adaptation in intestinal failure patients dependent on PN [18]; and Solis et al. [19] established chyme reinfusion as a practical option for high-output enterocutaneous fistulas and stomas, confirming its feasibility and clinical benefits. These reports validate the physiologic rationale behind our adaptation of the 3 M Veraflo system to achieve continuous reinfusion despite anatomical discontinuity in this critically ill trauma patient.

Nutrition in Abdominal Trauma: Patients with extensive caustic injuries and multiple laparotomies experience a profound systemic inflammatory response, significantly increasing energy expenditure [20]. Protein Requirements: Higher protein intake (1.5–2.0 g/kg/day) is essential in “open abdomen” cases to compensate for the significant nitrogen and protein loss through abdominal effluent and to support wound healing and immune function [21]. We try to follow the standard guidelines and our numbers align with the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM) guidelines, which recommend 25–30 kcal/kg/day for most critically ill patients to avoid underfeeding while preventing the metabolic complications of overfeeding [22, 23] .

Achieving a 40–50% caloric contribution from EN is a clinically significant milestone in a patient with total gastric and subtotal jejunal resection. Even submaximal enteral feeding (often as little as 10–20% of goals) is sufficient to maintain gut-associated lymphoid tissue (GALT) and prevent the mucosal atrophy associated with prolonged TPN [24–26]. Reaching 40–50% provides substantial ‘trophic’ support to the remaining 110–130 cm of ileum, as even low-dose enteral feeding helps maintain mucosal structure and function while reducing the complications of exclusive parenteral nutrition [25]. Transitioning nearly half of the caloric needs to the EN route allowed for a significant reduction in the volume and osmolarity of TPN. This directly lowers the risk of TPN- Associated Liver Disease (PNALD) by stimulating bile flow through the reintroduction of endogenous biliopancreatic secretions into the ileum [27–29]. Lower glucose concentrations in TPN can reduce the risk of hyperglycemia-induced immune dysfunction and catheter related bloodstream infections [30]. Unlike TPN, the reinfused chyme has physiological superiority as it contains essential digestive enzymes, bile salts, and specialized nutrients (like glutamine) that facilitate the adaptation of the remaining ileum, increasing its future absorptive capacity [31]. Negative pressure wound therapy (NPWT) facilitates wound healing by removing exudate and decreasing surface pressure [32, 33]. The 3 M Veraflo system further enhances this approach by enabling the instillation of topical solutions [34]. In this case, we adapted the negative pressure function to aspirate chyme and used the instillation feature to reinfuse it. The benefits of early EN are well-documented for maintaining gut integrity and reducing inflammation [35].

While bowel discontinuity is often viewed as a contraindication for EN, chyme reinfusion (also known as succus entericus reinfusion) allows the distal bowel to continue its absorptive function [36]. Our approach differs from previous literature in the hardware utilized. Specialized devices such as the Enteromat^® and Actilink^® have been established for continuous chyme reinfusion in patients with high-output fistulas or short bowel syndrome. However, these are specialized tools [11]. By using the 3 M Veraflo system, a staple in modern trauma centers, we demonstrated a method for continuous reinfusion using existing tools within the infrastructure.

In a few previous cases, such as those by Wang et al. and McCain et al., manual or intermittent reinfusion methods were utilized [4, 7]. Wang et al. used a healthcare provider to manually inject chyme into a temporary double enterostomy [4]. McCain et al. highlighted the importance of recycling jejunal fluids to maintain electrolyte balance [7]. Our method advances these concepts by automating the process, reducing the burden on nursing staff, and ensuring a constant, physiologic nutrient flow.

Limitations include the requirement for close monitoring to prevent mechanical failure or contamination, as well as the need to carefully regulate applied pressure to avoid mucosal injury. In our case, the 3 M Veraflo system was repurposed from its original indication as a negative-pressure wound therapy device to enable extracorporeal chyme reinfusion, and its use in this context remains off-label and technically demanding. To date, there are no published data on the long-term use of this specific system for providing enteral nutrition pending reanastomosis, so its safety and efficacy beyond short-term, carefully supervised application are unknown. Consequently, future studies are needed to compare repurposed NPWT platforms with dedicated chyme-reinfusion devices in randomized trials and to develop standardized protocols for critically ill patients, and we plan to reserve this approach for selected future cases when clearly clinically indicated.

Conclusion

This case demonstrates a novel application of the 3 M Veraflo system for continuous chyme reinfusion in a patient with severe caustic injury. While specialized reinfusion systems exist, the use of a wound vacuum offers a viable alternative when specialized equipment is unavailable. This strategy provides a short-term solution for sustaining enteral nutrition in complex “open abdomen” cases, though it requires a highly regulated environment and constant observation to ensure safety and sterility. This case demonstrates a workable alternative for nutritional support in critically ill patients, more clinical evaluation and development are necessary before it can be recommended for wider use in modern surgical therapy. More clinical testing and development are required before this case can be suggested for broader use in contemporary surgical practice, even though it shows a viable substitute for nutritional support in a small number of critically ill patients.

Abbreviations

TPN

Total Parenteral Nutrition

EN

Enteral Nutrition

NPWT

Negative pressure wound therapy

TDE

Temporary double enterostomy

MSOF

Multiple system organ failure

Authors’ contributions

Conceptualization: KS, RA, MRData curation: MR, JYInvestigation: AZ, NHMethodology: KS, AZ, NHResources: MR, RASupervision: KS, RAWriting original draft: JY, AZ, HBWriting review & editing: KS, HBAll authors reviewed and approved the final manuscript.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This case report was conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments. According to the Institutional policy, ethical approval is not required for single-patient case reports.

Consent for publication

Consent for publication was obtained from the patient.

Competing interests

The authors declare no competing interests.