Ensure powder

The mixed meal test was done using a standardized mixed meal, 10 Kcal/kg of Ensure powder (Abbott Nutrition, Abbott Laboratories). The mixed meal used composed of 57% carbohydrate (sugar 14.7 gm/100 gm), 13.5% fat and 15.1% protein. After an overnight fast of 12 hours, fasting samples for glucose, insulin, C-peptide, GIP (total), GLP-1 (total) and glucagon were collected. The mixed meal (10 Kcal/kg) diluted in 300 ml of water was consumed by the patient in 10 minutes. Repeat samples were drawn at 30, 60, 90,120,150 and 180 minutes. Samples for blood glucose were collected in fluoride vials, while those for insulin and C-peptide were collected in EDTA vials. Blood samples for GIP, GLP-1 and glucagon were collected in pre-chilled EDTA-coated tubes containing aprotinin and an inhibitor of dipeptidyl peptidase IV. The samples collected for these hormones were immediately centrifuged at 4 °C and plasma was stored at −80 °C until analysis at a later date.

The feeding goal was at least 30 kcal/kg⁻¹/d⁻¹ and 1.5 to 2 g of protein/kg⁻¹/d⁻¹, while 2 g of nitrogen for per liter of fistula output was administered. High-output EF required 1.5–2 times the usual calories because of the ongoing loss [15 (link)]. All patients received total parenteral nutrition (TPN) (all in one fluid, Jinling Hospital, Nanjing, China) for varying intervals before fistuloclysis/TEN to induce stability. Subsequently, in the fistuloclysis group, TEN and the collected succus entericus were infused into the distal fistula through the Foley catheter or through the nasojejunal tube (for patients with biliary fistula) for at least 28 days. If patients did not tolerate nonelemental feed (Ensure powder (Abbot, Shanghai, China), Nutrison (Nutricia, Shanghai, China)), then they changed to receive semielemental feed (Perative, Abbot, Shanghai, China) or elemental feed (Peptisorb, Abbot, Shanghai, China). In the control group, only TEN was applied for at least 28 days through similar ways as the fistuloclysis group. The fistula output was drained out through double-lumen tubes [13 (link)] and discarded, while the volume deficit was corrected by fluid replacement.