A Randomized Multicenter Open-label Controlled Trial to Show That Mucous Fistula Refeeding Reduces the Time From Enterostomy Closure to Full Enteral Feeds (MUCous FIstula REfeeding ("MUC-FIRE") Trial)
Phase: NA
Conditions: Enterostomy
Sponsor: University of Leipzig

 
 
 
 
 
 
 
 
STUDY PROTOCOL 
 
A randomized multicenter open-label controlled trial to show that mucous fistula refeeding 
reduces the time from enterostomy closure to full enteral feeds 
(MUCous FIstula REfeeding (“MUC-FIRE”) trial) 
 
Version No 4.0, Version date 05/12/2022 
 
 
 
 
 
 
 
 
 
CONFIDENTIALITY AGREEMENT 
This document contains confidential information which is the property of the sponsor. Except as may be 
otherwise agreed to in writing, by accepting or reviewing these materials, you agree to hold such 
information in confidence and not to disclose it to others (except where required by applicable law), nor 
to use it for unauthorized purposes. In the event of actual or suspected breach of this obligation, the 
sponsor should be promptly notified. 
 
 

 
 
 
 
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TABLE OF CONTENTS 
LIST OF ABBREVIATIONS .......................................................................................................................... 4 
STUDY SYNOPSIS ..................................................................................................................................... 5 
RESPONSIBILITIES .................................................................................................................................. 10 
1 
SCIENTIFIC BACKGROUND AND STUDY RATIONALE ...................................................................... 11 
1.1 
The Medical Problem ............................................................................................................ 11 
1.2 
Evidence ................................................................................................................................ 11 
1.3 
The need for a study .............................................................................................................. 12 
1.4 
Risk-Benefit-Assessment ....................................................................................................... 12 
2 
STUDY DESIGN, OBJECTIVES AND ENDPOINTS .............................................................................. 13 
2.1 
Study Design .......................................................................................................................... 13 
2.2 
Study Objectives .................................................................................................................... 13 
2.3 
Study Endpoints ..................................................................................................................... 13 
2.4 
Study Duration....................................................................................................................... 15 
3 
STUDY POPULATION ...................................................................................................................... 16 
3.1 
Study Population ................................................................................................................... 16 
3.2 
Inclusion Criteria .................................................................................................................... 16 
3.3 
Exclusion Criteria ................................................................................................................... 16 
3.4 
Feasibility of recruitment ...................................................................................................... 17 
3.5 
Achievability of recruitment rate .......................................................................................... 17 
3.6 
Discontinuation Criteria ........................................................................................................ 17 
4 
STUDY PROCEDURES ..................................................................................................................... 18 
4.1 
Study Calendar ...................................................................................................................... 18 
4.2 
Standardized protocol for creation of a small bowel enterostomy (all patients): ................ 19 
4.3 
Standardized protocol on perioperative mucous fistula refeeding (MFR): .......................... 19 
4.4 
Standardized protocol for enterostomy closure (all patients): ............................................. 20 
4.5 
Standardized protocol on parenteral nutrition during treatment phase (all patients): ....... 20 
4.6 
Standardized protocol for management of nutrition after enterostomy closure (all 
patients): ........................................................................................................................................... 21 
4.7 
Further documentations after enterostomy closure (all patients): ...................................... 23 
4.8 
Additional treatments ........................................................................................................... 23 
4.9 
Control(s)/Comparator(s) ...................................................................................................... 23 
4.10 
Frequency and scope of study visits ...................................................................................... 23 
4.11 
Assessment of safety ............................................................................................................. 23 
4.12 
Timeframe complete study ................................................................................................... 24 

 
 
 
 
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5 
ADVERSE EVENTS ........................................................................................................................... 24 
6 
STATISTICAL ANALYSIS ................................................................................................................... 25 
6.1 
Methods against bias ............................................................................................................ 26 
6.2 
Proposed sample size/Power calculations ............................................................................ 27 
6.3 
Compliance/Rate of loss to follow up ................................................................................... 27 
7 
DATA MANAGEMENT .................................................................................................................... 29 
8 
QUALITY ASSURANCE AND MONITORING ..................................................................................... 29 
8.1 
Data Monitoring Committee ................................................................................................. 30 
9 
ETHICAL AND LEGAL CONSIDERATIONS, ADMINISTRATION ......................................................... 30 
9.1 
Patient Information and Informed consent .......................................................................... 30 
9.2 
Patient Insurance................................................................................................................... 30 
9.3 
Data Protection ..................................................................................................................... 31 
9.4 
Registration ........................................................................................................................... 31 
9.5 
Record Retention ................................................................................................................... 31 
9.6 
Financing ............................................................................................................................... 31 
9.7 
Patient Involvement .............................................................................................................. 31 
10 
HANDLING OF BIOMATERIAL .................................................................................................... 31 
11 
PUBLICATION ............................................................................................................................. 32 
13 
REFERENCES .............................................................................................................................. 33 
14 
SIGNATURES .............................................................................................................................. 35 
 
 
 

 
 
 
 
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LIST OF ABBREVIATIONS 
AE 
adverse event 
ALT 
alanine transaminase 
AST 
aspartate transaminase 
CVL 
central venous line  
DMC 
Data Monitoring Committee  
eCRF 
electronic case report form 
FIP 
focal intestinal perforation 
FTT 
failure to thrive 
FU 
follow-up 
GGT 
gamma-Glutamyltransferase 
ZKS 
Zentrum für klinische Studien der MHH (Center for clinical trials at MHH) 
ICD 
International Statistical Classification of Diseases and related Health Problems 
ICH-GCP 
International Conference on Harmonisation – Good Clinical Practice  
IMC 
intermediate care ward 
IVH 
intraventricular hemorrhage 
ITT 
intention to treat 
IVH 
intraventricular hemorrhage 
MFR 
mucous fistula refeeding 
MHH 
Medizinische Hochschule Hannover (Hannover Medical School) 
NEC 
necrotizing enterocolitis 
NEK 
Nekrotisierende Enterokolitis 
NG 
nasogastric 
NICU 
neonatal intensive-care units 
OR 
operation room 
PC 
phosphatidylcholine 
PNALD 
parenteral nutrition-associated liver disease 
POD 
postoperative day 
SAE 
serious adverse event 
SBBO 
small bowel bacterial overgrowth 
SOP 
standard operating procedure 
TPN 
total parenteral nutrition 
WHO 
World Health Organisation 
 
 
 
 
 
 
 
 

 
 
 
 
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STUDY SYNOPSIS 
Title of Study 
A randomized multicenter open-label controlled trial to show that mucous 
fistula refeeding reduces the time from enterostomy closure to full enteral 
feeds (MUCous FIstula REfeeding (“MUC-FIRE”) trial) 
Short Term 
MUC-FIRE 
Responsible Investigators 
(equal contributions) 
Prof. Dr. med. Martin Lacher 
University of Leipzig 
Head of Department of Pediatric Surgery  
Liebigstr. 20a 
04103 Leipzig, Germany 
Email: martin.lacher@medizin.uni-leipzig.de 
Tel.: +49-341-972-6400 
Fax: +49-341-972-6409 
 
Dr. med. Omid Madadi-Sanjani 
Hannover Medical School 
Department of Pediatric Surgery  
Carl-Neuberg-Str. 1 
30625 Hannover, Germany 
Email: madadi-sanjani.omid@mh-hannover.de 
Tel.: +49-176-1532-8071 
Fax: +49-511-532-8095 
Study Design 
Randomized, multicenter, open-label, controlled, parallel group research 
study 
Patient Population 
Infants who underwent creation of an enterostomy receiving postoperative 
care and awaiting enterostomy closure 
Participating Study Sites 
Total:                  n = 17 
Germany:           n = 13 
Austria:               n = 2 
Netherlands:       n = 2 
Sample Size 
To be assessed for eligibility: n = 230 
To be assigned to the study: n = 120 
To be analysed: n = 120 
Objectives 
The primary objective of this study is to demonstrate that mucous fistula 
refeeding between enterostomy creation and enterostomy closure 
reduces the time to full enteral feeds after enterostomy closure compared 
to standard of care.  

 
 
 
 
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Endpoints 
Primary efficacy endpoint: 
Time to full feeds (hours), defined as time to actual enteral intake of the 
age-dependent caloric requirements per day (defined as 90 or 
120 kcal/kg/24h) for at least 24 hours and a concomitant reduction of 
parenteral fluids to < 20 ml/kg/24h [32, 33]. 
The decision about the full feed kcal goal is made before randomization 
by the treating physician, depending on the birth weight of the infants and 
mother’s gestation week at birth: 
1) The nutrition aim is 120 kcal/kg/24h for premature infants with a 
birth weight < 1000 g or premature infants with a birth weight 
≥ 1000 g and mother’s gestation week at birth before 37+0. 
2) The nutrition aim is 90 kcal/kg/24h for born mature infants, e.g. 
mother’s gestation week at birth at least 37+0. 
Key secondary endpoints: 
1) Reoperation 
2) Time to first bowel movement after enterostomy closure (mucous 
stool is considered a bowel movement) 
Cleaning and changing of infants diapers will be performed 
according to a fixed schedule in order to uniformly document the 
time to first bowel movement following enterostomy closure. 
3) Postoperative 
weight 
gain 
(g/d) 
(daily 
documentations 
recommended, minimum 2x per week), regular Z-Score (standard 
deviation score) documentation [WHO - weight-for-age] (daily 
documentations recommended, minimum 2x per week). This will 
be carried out according to a fixed schedule during morning 
rounds prior to feeding in an unclothed status. 
4) Days of postoperative total parenteral nutrition (> 20 ml/kg/24h) 
before and after the 2nd operation (=ostomy takedown).  
Days of total parenteral nutrition (TPN) are counted, starting on 
the day of enterostomy closure and ending on the day of full 
enteral nutrition. The parenteral nutrition is manufactured by the 
hospital pharmacy on a daily basis, while considering the 
simultaneous enteral caloric intake. 
5) Laboratory 
parameters 
indicating 
cholestasis 
(conjugated 
bilirubin, GGT, ALT, AST, hemoglobin) and sodium resorption 
(sodium in urine). 
Time points for harvesting of blood samples: Baseline at the time 
of randomization, then every 2 weeks until enterostomy takedown 
and at the 3-months follow-up in cases of pathological clinical 
signs (jaundice, acholic stools) 
6) Weight gain during the subsequent 5 days after reaching the 
primary endpoint 

 
 
 
 
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7) Central venous line (CVL) duration (days) and number of CVL 
infections (definition of infection: Neo-Kiss Guidelines) 
8) Length of hospital stay (days) 
9) Estimated ratio of the diameter of the two bowel loops which are 
anastomosed. 
10) Time to full age-dependent volume intake per day (defined as 
150 ml/kg/24h for premature infants and 120 ml/kg/24h for mature 
born infants as well as corrected mature infants) (in hours) [32,33] 
a) The volume aim is 150 ml/kg/24h for premature infants with a 
birth weight < 1000g or premature infants with a birth weight 
≥ 1000g and mother’s gestation week at birth before 37+0. 
b) The volume aim is 120 ml/kg/24h for born mature infants, e.g. 
mother’s gestation week at birth at least 37+0. 
11) Assessment of safety: 
Assessment of possible (serious) adverse events (AEs/SAEs) 
after randomization (e.g. death, sepsis, bowel perforation, stoma 
prolapse, abscess)  
Inclusion and Exclusion 
Criteria 
Key inclusion criteria: 
 
Infants < 366 days 
 
Ileostomy / Jejunostomy,  
 
double loop enterostomies and split enterostomies (with 
mucous fistula) 
 
Signed 
written 
informed 
consent 
obtained 
by 
parents/legal guardians and willingness of parents/legal 
guardians to comply with treatment and follow-up 
procedures of their child 
Notice: All patients with meconium ileus are included. If later 
diagnostics verify cystic fibrosis, diagnostics and diagnoses need 
to be documented in the eCRF and in further analysis subgroups 
will be established. 
 
Key exclusion criteria: 
 
resection of ileocecal valve,  
 
colostomy,  
 
small bowel atresia,  
 
multiple ostomies (more than just an enterostomy and a 
mucous fistula),  
 
chromosomal abnormalities (if known at the time of 
randomization),  

 
 
 
 
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 
Hirschsprung's disease,  
 
participation in another drug-intervention study  
 
Intestinal perforation due to congenital heart defects with 
impairment of hemodynamics 
Reoperation (e.g. relaparotomy) prior to randomization is not an 
exclusion criterion, these patients may still be included in the 
study.  
Short bowel syndrome is not a criterion for exclusion. 
Intervention 
All patients will receive standard care with standardized enterostomy 
creation and closure and will be treated according to a standardized 
feeding protocol.  
Experimental intervention: 
Perioperative mucous fistula refeeding between enterostomy creation and 
enterostomy closure 
Control intervention: 
No perioperative mucous fistula refeeding between enterostomy creation 
and enterostomy closure 
Duration of intervention per patient of the intervention group: minimum 21 
days/3 weeks until patient’s weight > 2000 g (averaged 6 weeks between 
enterostomy creation and enterostomy closure).  
Follow-up per patient: 
3 months and 6 months postoperatively, following enterostomy closure 
(12-month follow-up only applicable for patients that are recruited early 
enough to complete this follow-up within the 48 month of overall study 
duration).  
 
 
Study Duration 
Recruitment: approx. 60 months (258 weeks) 
Study duration per patient: Maximum 58 weeks to minimum 32 weeks 
Duration of the entire study (first patient in to last patient out): 72 months 
(310 weeks) 
Statistical Analysis 
Efficacy: The type-one error rate is set to 5% (two-sided). 
Description of the primary efficacy: The primary analysis is performed on 
the intention to treat population (ITT). The aim of this study is to 
demonstrate superiority of perioperative mucous fistula refeeding 
compared to no mucous fistula refeeding in reducing the time to full enteral 
feeds after enterostomy closure. The treatment effect will be estimated 
with a Cox-regression adjusted for treatment, weight and mother’s 

 
 
 
 
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gestation week at birth (< 1000 g and before 37+0 / ≥ 1000 g and before 
37+0 / ≥ 1000 g and at least 37+0), study center as well as height of the 
stoma (jejunostomy/proximal Ileostomy or terminal ileostomy) and will be 
assessed by the estimated hazard ratio (refeeding vs no refeeding) for 
reaching full enteral feeds. Superiority of the refeeding procedure will be 
concluded if the lower bound of the corresponding two-sided 95%-
confidence interval for the treatment effect hazard ratio is greater than 1.  
Safety: (Serious) adverse events (AEs/SAEs) will be compared between 
treatment groups with a chi-square test and other appropriate tests. P-
values will be assessed descriptively. 
Secondary endpoints: All secondary analyses will be explorative.  
 
 
 

 
 
 
 
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RESPONSIBILITIES 
Responsible Investigators 
(equal contributions) 
 
 
 
 
 
 
 
 
 
 
 
Project Management 
Regulatory Affairs 
Prof. Dr. med. Martin Lacher 
University of Leipzig 
Head of Department of Pediatric Surgery  
Liebigstr. 20a 
04103 Leipzig, Germany 
Email: martin.lacher@medizin.uni-leipzig.de  
Tel.: +49-341-972-6400 
Fax: +49-341-972-6409 
PD Dr. med. Omid Madadi-Sanjani 
Hannover Medical School 
Department of Pediatric Surgery  
Carl-Neuberg-Str. 1 
30625 Hannover, Germany 
Email: madadi-sanjani.omid@mh-hannover.de 
Tel.: +49 (0) 176-15329053 
Fax: +49-511-532-8095 
 
Study office: 
University of Leipzig 
Department of Pediatric Surgery  
Liebigstr. 20a 
04103 Leipzig, Germany 
Email: muc-fire-leipzig@medizin.uni-leipzig.de 
Tel.: +49-341-972-6055 
Project Management, Data 
Management, Monitoring 
Hannover Medical School 
 
Zentrum für Klinische Studien (ZKS) 
Prof. Christoph Schindler 
Carl-Neuberg-Str. 1 
30625 Hannover, Germany 
Data Analysis 
Prof. Dr. Armin Koch,  
Dr. Anika Grosshennig, Sören Wiesner, Benjamin Otte 
Hannover Medical School 
Institute for Biostatistics 
Carl-Neuberg-Street 1 
30625 Hannover, Germany 
Supervision of Dutch sites 
Research Drive BV 
Clinical Research Management 
P.O. Box 85,  
9330 AB Norg, The Netherlands 
Phone: +31 (0)592 614812 
Fax: +31 (0)592 615422 
www.researchdrive.com 
 
 
 

 
 
 
 
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1 
SCIENTIFIC BACKGROUND AND STUDY RATIONALE 
Enterostomies in infants may be created for different reasons. During the presence of an 
enterostomy, the regular stool transfer is interrupted since the distal part of the bowel (the part 
following the enterostomy) does not participate in the processing of stool. Therefore, it does 
not contribute to the resorption of enteral nutrients. As a consequence, these infants need 
additional parenteral nutrition. Due to the negative side-effects of parenteral nutrition all 
patients should return to enteral nutrition as soon as possible. Consequently, many pediatric 
surgical centers worldwide routinely perform mucous fistula refeeding (MFR) into the former 
unused bowel after enterostomy creation because case reports and retrospective analyses 
show low complication rates and faster postoperative weight gain. Several providers, however, 
shy away from this approach because to date there is still no high-quality evidence for the 
benefit of this treatment. The aim of this study is to assess the effects of mucous fistula 
refeeding in a prospective randomized trial. We hypothesize that MFR between enterostomy 
creation and enterostomy closure reduces the time to full enteral feeds after enterostomy 
closure compared to standard care. Moreover, the side effects of parenteral nutrition may be 
reduced and the postoperative hospital care of infants undergoing ostomy closure shortened. 
1.1 
The Medical Problem 
After creation of any enterostomy the bowel distal to the enterostomy is not in use. Therefore, 
the physiologic passage of stool, nutrient uptake and growth of the bowel distal of the 
enterostomy are interrupted. At the time of enterostomy takedown, the surgeon often sees an 
enormous discrepancy in diameters of the proximal and the distal loops of the bowel. In these 
cases, the postoperative increase of enteral feeds and the dependence of infants on parenteral 
nutrition may be prolonged. Furthermore, it is well known that continuous parenteral nutrition 
is associated with several side effects including cholestasis and central line infections [1]. The 
physiological passage of stool through the bowel is important for enterohepatic circulation, 
resorption of fluids, electrolytes, vitamins, and enteral growth. Moreover, the passage of stool 
per rectum is important for developing a regular defecation reflex. 
1.2 
Evidence 
Gause et al. presented their results on MFR in neonatal patients [2, 3]. In their retrospective 
analysis of 28 patients (13 in the MFR group and 15 in the control group) a shorter duration of 
parenteral nutrition and a faster time to full enteral feeds in the MFR group were reported. 
Recently, Yabe et al. reported on the beneficial effect on MFR in low-birth-weight infants, 
showing better weight gain and again a shorter duration of parenteral nutrition compared to a 
historical control group. [31] In 2006, Richardson et al. performed a systematic review on case 
reports and small case series of MFR after enterostomy creation [4]. The authors concluded 
that MFR was safe, as no complications were identified in any of the cited publications. In 
conclusion, studies published so far showed a faster weight gain in the group of MFR 
compared to controls [2, 4, 5, 6, 7]. These promising results need to be confirmed by a 
randomized, controlled study, which is the intention of this proposal. 
 

 
 
 
 
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1.3 
The need for a study 
As suggested by Gause et al. [3] a multicenter study of MFR is warranted in order to address 
the limitations of retrospective studies carried out so far. The results of this randomized 
controlled study may strongly influence the perioperative care of neonates within the pediatric 
surgical community. If our hypothesis is confirmed, the postoperative hospital stays of infants 
undergoing ostomy closure will be shortened. The benefits of MFR include a shorter duration 
and therefore less side effects of parenteral nutrition. Moreover, an economic benefit through 
lower costs for TPN and a shorter hospital stay may be reached. 
1.4 
Risk-Benefit-Assessment 
Many pediatric surgical centers worldwide routinely perform MFR after enterostomy creation. 
However, due to a lack of prospective studies the level of evidence showing a benefit of this 
treatment strategy is low. Although the systematic review by Richardson et al. [4] showed no 
complications using this technique, MFR into the distal bowel loop may potentially cause 
complications such as bowel perforation. The risk for possible complications can be minimized 
by careful and standardized manipulation of the enterostomies. The local condition of the 
ostomy will be investigated twice daily. 
If our hypothesis is confirmed, the postoperative hospital care of infants undergoing ostomy 
closure will be shortened. The benefits of MFR may include a shorter duration and therefore 
less side effects of parenteral nutrition, especially PN-associated liver disease (PNALD). 
Moreover, an economic benefit through lower costs for TPN and a shorter hospital stay may 
be reached.  
The results of the current study may influence the standard of neonatal intensive care. 
Therefore the potential benefits of MFR outweigh the possible risks of this study.  
 
Results of data analyses including all data how to perform MFR will be published. If the results 
of this study will show significant differences between the intervention group and controls, MFR 
will become the new standard of care for neonates with enterostomies. 
In Germany, the current national guideline for neonatal and surgical treatment of necrotizing 
enterocolitis (NEC) is currently in revision [Leitlinie 024-009: Nekrotisierende Enterokolitis 
(NEK)]. One of the principal investigators of the study (Prof. Dr. Martin Lacher) is coauthor of 
this guideline. If the current study proves the hypothesis that MFR is beneficial for these infants 
it may not only change the national guideline for the best treatment after enterostomy creation 
in Germany but in other countries too. 
 
 

 
 
 
 
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2 
STUDY DESIGN, OBJECTIVES AND ENDPOINTS 
2.1 
Study Design 
This is a randomized, multicenter, open-label, parallel group, controlled research study to 
demonstrate that mucous fistula refeeding between enterostomy creation and enterostomy 
closure reduces the time to full enteral feeds after enterostomy closure compared to standard 
of care. 
Intervention scheme/Study Flow 
 
2.2 
Study Objectives 
The primary objective of this study is to demonstrate that mucous fistula refeeding between 
enterostomy creation and enterostomy closure reduces the time to full enteral feeds after 
enterostomy closure compared to standard of care. 
2.3 
Study Endpoints 
2.3.1 Outcome measures 
Time to full enteral feeds (age-dependent caloric requirements per day) after enterostomy closure 
(hours) was chosen as the primary outcome parameter because of its clinical relevance 
representing the influence of MFR on the intestinal autonomy in the course of the disease. The 
endpoint is highly objective due to the strict and well-defined feeding protocol (see 3.1). In most 
of the referenced publications, postoperative weight gain early after surgery was chosen as 
the primary outcome parameter.  
However, body weight is always affected by the shift of body fluids into the third space. 
Therefore, postoperative weight does not always correlate with enteral/parenteral caloric 
supplementation as a sign of enteral resorption. For this reason, it was not selected as the 
primary outcome parameter but will be assessed as secondary outcome measure.  
Secondary outcome measures further include the time to full age-dependent volume intake, 
number of days of postoperative total parenteral nutrition (TPN) and the cholestasis 
parameters (conjugated bilirubin, GGT, ALT, AST) as indicators for hepatotoxicity of parenteral 
nutrition. The “time to first bowel movement” (hours) which correlates to the postoperative 
transanastomotic passage of stool, will be another secondary outcome parameter. A bowel 
movement consisting of only mucous rather than stool is also considered a bowel movement. 
Finally, all outcome parameters including possible complications will be assessed during the 
follow-up 3, 6 and 12 months (12-month follow-up only applicable for patients that are recruited 
early enough to complete this follow-up within the 48 month of overall study duration) after 
enterostomy closure. 
 
 

 
 
 
 
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2.3.2 Determination of primary and secondary measures 
Primary efficacy endpoint: 
Time to full feeds (hours), defined as time from enterostomy closure to actual enteral intake of 
the age-dependent caloric requirements per day for at least 24h and a concomitant reduction 
of parenteral fluids to < 20 ml/kg/24h. 
For determining the time to full enteral feeds, the feeding advancement will be carried out 
according to the predefined nutritional protocol after 6-8 tolerated feedings in 3-4 hour intervals 
(24 hours). “Full feeds” is therefore defined age-dependent as 90 or 120 kcal/kg/24h (full feed 
kcal goal) actual enteral intake [8, 9, 32, 33]. The nurses will document any increase and 
decrease of nutrition precisely and daily controls will be carried out by the responsible 
neonatologist and pediatric surgeon. 
 
The decision about the full feed kcal goal is made before randomization by the treating 
physician, depending on the birth weight of the infants and mother’s gestation week at birth: 
- 
The nutrition aim is 120 kcal/kg/24h for premature infants with a birth weight < 1000 g 
or premature infants with a birth weight ≥ 1000 g and mother’s gestation week at birth 
before 37+0. 
- 
The nutrition aim is 90 kcal/kg/24h for born mature infants, e.g. mother’s gestation week 
at birth at least 37+0. 
In the case unforeseen circumstances lead to an unexpected maturation of the infant, at the 
time of enterostomy closure an infant formerly classified as “premature” can be re-classified 
as “mature”, following justified reasoning concerning laboratory parameters and consultation 
with the principal investigators. To rule out a biased decision by the investigators, an 
independent reviewer will review these decisions at the end of the study.   
As the full feed kcal goal is implemented firstly in the study protocol version 3.0 the independent 
reviewer will also be provided with the data of patients that were randomized before study 
protocol version 3.0 and that did not achieve time to full feeds with the initial kcal goal of 
120 kcal/kg/24h. On the basis of the individual patient information the independent reviewer 
will assess the primary endpoint with respect to the specific kcal goal defined above. 
 
 

 
 
 
 
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Secondary endpoints: 
1) 
Reoperation 
2) 
Time to first bowel movement after enterostomy closure (mucous stool is considered a 
bowel movement) 
Cleaning and changing of infants diapers will be performed according to a fixed schedule 
in order to uniformly document the time to first bowel movement following enterostomy 
closure. 
3) 
Postoperative weight gain (g/d) (daily documentations recommended, minimum 2x per 
week), regular Z-Score (standard deviation score) documentation [WHO - weight-for-age] 
(daily documentations recommended, minimum 2x per week), This will be carried out 
according to a fixed schedule during morning rounds prior to feeding in an unclothed 
status.  
4) 
Days of postoperative total parenteral nutrition (> 20 ml/kg/24h) before and after the 2nd 
operation (= ostomy takedown) (TPN)  
Days of postoperative total parenteral nutrition (TPN) are counted, starting on the day of 
enterostomy closure and ending on the day of full enteral nutrition. The parenteral nutrition 
is manufactured by the hospital pharmacy on a daily basis, while considering the 
simultaneous enteral caloric intake. 
5) 
Laboratory parameters indicating cholestasis (conjugated bilirubin, GGT, ALT, AST, 
hemoglobin) and sodium resorption (sodium in urine).  
Time points for harvesting of blood samples during clinical routine blood withdrawal: 
Baseline at the time of randomization, then every 2 weeks until enterostomy takedown, at 
the 3-months follow up and in cases of pathologic clinical signs (jaundice, acholic stools) 
6) 
Weight gain during the subsequent 5 days after reaching the primary endpoint 
7) 
Central venous line (CVL) duration (days) and number of CVL infections (definition of 
infection: Neo-Kiss Guidelines) 
8) 
Length of hospital stay (days) 
9) 
Estimated ratio of the diameter of the two bowel loops which are anastomosed 
10) Time to full oral volume intake (based on age-dependent daily fluid requirements), for at 
least 24h. The feeding advancement will be carried out according to the predefined 
nutritional protocol. “Full oral volume intake” is therefore defined as 150 ml/kg/24h 
(premature infants) and 120 ml/kg/24h (born mature as well as corrected mature infants) 
actual enteral volume intake (as in synopsis) [32,33] 
11) Assessment of safety: Assessment of possible (serious) adverse events (AEs/SAEs) after 
randomization (e.g. death, sepsis, bowel perforation, stoma prolapse, abscess) 
2.4 
Study Duration 
Recruitment: 
Approximately 60 months (258 weeks) 
Study duration per patient: 
Maximum 58 weeks to minimum 32 weeks 
Duration of the entire study (first patient in to last patient out): 
72 months (310 weeks) 

 
 
 
 
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3 
STUDY POPULATION 
3.1 
Study Population 
Infants who underwent creation of an enterostomy receiving postoperative care and awaiting 
enterostomy closure: 
to be assessed for eligibility: n = 230 
to be assigned to the study: n = 120 
to be analysed: n = 120 
Duration of intervention per patient of the intervention group: minimum 21 days/3 weeks until 
patient’s weight >2000 g, averaged 6 weeks between enterostomy creation and enterostomy 
closure 
Follow-up per patient: 3 months, 6 months and 12 months following enterostomy closure (12-
month follow-up only applicable for patients that are recruited early enough to complete this 
follow-up within the 48 months of overall study duration). 
3.2 
Inclusion Criteria 
1. Only infants younger than 366 days of age with status post ileostomy or jejunostomy 
creation (double loop enterostomies and split enterostomies (with mucous fistula)) will 
be included in the study to create a homogenous cohort of patients with similar 
diseases (e.g. necrotizing enterocolitis [NEC], focal intestinal perforation [FIP]). Also, 
infants of this age group are unique in several respects such as the response to 
parenteral nutrition and its hepatic toxicity resulting into neonatal cholestasis.  
The ostomy localization is restricted to the jejunum and ileum. Therefore, the cohort of 
patients shows a similar bowel length for fluid-, vitamin- and electrolyte resorption. 
2. All patients with meconium ileus are included into the study. If later (required) 
diagnostics verify cystic fibrosis, the diagnostics as well as the diagnosis need to be 
documented in the eCRF and in further analysis subgroups will be established. 
3. Signed written informed consent obtained by parents/legal guardians and willingness 
of parents/legal guardians to comply with treatment and follow-up procedures of their 
child. 
3.3 
Exclusion Criteria 
1. The resection of the ileocecal valve is an exclusion criterion because of its association 
with extensive bowel resection and therefore prolonged parenteral nutrition [10] 
2. Colostomy 
3. Patients with small bowel atresia are excluded because of prenatally underdeveloped 
bowel distal to the atresia 
4. Multiple ostomies (more than just an enterostomy and a mucous fistula) 
5. Patients with chromosomal abnormalities (if known at the time of randomization) are 
excluded because of potential malabsorption and malnutrition due to an underlying 
syndrome. 
6. Hirschsprung disease secondary exclusion 
7. Participation in another drug-intervention study  
8. Intestinal perforation due to congenital heart defects with impaired hemodynamics  
 

 
 
 
 
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Specifications: 
The application of prokinetic drugs is not allowed throughout the study especially after 
enterostomy closure. 
 
Reoperation (e.g. relaparotomy) prior to randomization is not an exclusion criterion, these 
patients may still be included in the study. 
3.4 
Feasibility of recruitment 
The participating sites represent institutions treating a large patient volume and are located in 
different regions of Germany, Austria and the Netherlands. All of them are academic 
(university) hospitals with large neonatal intensive-care units (NICU).  
3.5 
Achievability of recruitment rate 
In order to achieve a total sample size of 120 patients during 72 months, 17 sites participate 
to the study.  
The number of participating sites was increased by new partners during the course of the 
study. All sites have experience in adhering to scientific protocols and have participated in 
prospective studies. The adapted required patient number (n = 120) calculated by the power 
analysis will be achieved in a five-year period according to the patient numbers of the individual 
sites.  
The Hannover Medical School and the University of Leipzig have already participated in 
several (multicenter) prospective studies without any problems in patient recruitment after 
being properly counseled and informed about study objectives, protocols and the potential 
complications in relation to the estimated benefits [11-25].  
Patients in this study are recruited after enterostomy creation. As patients should be clinically 
stable at this time, parents/legal guardians (will) have sufficient time to decide whether they 
want their infant to participate in the trial. 
 
3.6 
Discontinuation Criteria 
The following reasons may lead to discontinuation of the study in a patient 3:  
1. Death 
2. Iatrogenic bowel perforation of the distal bowel loop during catheterization for refeeding 
3. Withdrawal of written consent 
Patients who discontinue treatment for any reason will remain in the study to be evaluated for 
efficacy and safety endpoints, and will be expected to continue study visits. 
 
 

 
 
 
 
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4 
STUDY PROCEDURES 
No study procedures are allowed to be conducted until the parents’/legal guardians’ written 
informed consent has been obtained (please also refer to chapter 9.1). The investigator is 
responsible for obtaining the parents’/legal guardians’ written informed consent after adequate 
explanation of the aim, study assessments, potential risks and benefits and consequences of 
the study as well as alternative treatment options. 
4.1 
Study Calendar 
 
 
Enterostomy 
Creation 
Screening 
Pre-Treatment 
Phase 
Treatment 
Phase 
(Refeeding or 
Control) 
End of 
Treatment**** 
 
(Enterostomy 
Closure) 
Post-
Treatment 
Phase 
FU 1 
3 months 
 
3 months 
after 
Entero-
stomy 
Closure) 
FU 2 
6 months 
 
6 months 
after 
Entero-
stomy 
Closure) 
(FU 3 
12 
months)* 
 
12 months 
after 
Entero-
stomy 
Closure) 
at least 1 
week 
up to 6 weeks 
at least 3 
weeks 
up to 8 weeks  
approx. 6 
weeks after 
Enterostomy 
Creation 
at least 2 
weeks  
up to 8 weeks 
Data 
Assessment 
 
 
daily 
daily 
 
daily 
Outpatient 
clinic 
Outpatient 
clinic 
Outpatient 
clinic 
Randomization 
 
 
x 
 
 
 
 
 
 
Demographic 
data 
 
x 
 
 
 
 
 
 
 
Informed 
consent 
 
x 
 
 
 
 
 
 
 
In-/ Exclusion 
criteria 
 
x 
 
 
 
 
 
 
 
Operation 
protocol 
x 
 
 
 
x 
 
 
 
 
Body weight 
 
x 
x 
x 
 
x ** 
x 
x 
x 
Laboratory 
 
 
x *** 
x *** 
 
x *** 
 
 
 
Refeeding 
protocol 
 
 
 
x 
 
 
 
 
 
Nutrition 
protocol 
 
 
 
x 
 
x 
 
 
 
Medical history 
 
x 
 
 
 
 
 
 
 
Adverse events 
 
 
x 
x 
x 
x 
x 
x 
x 
Time to first 
bowel 
movement after 
enterostomy 
closure [hours] 
 
 
 
 
 
x 
 
 
 
*only applicable for patients that are recruited early enough to complete the 12-month follow-up within 
the 48 months of overall study duration 
**weight is measured during the subsequent 5 days after reaching the primary endpoint 
***every 2 weeks starting at randomization and in cases of pathologic clinical signs (jaundice, acholic 
stools); Laboratory analysis: During routine blood withdrawal, laboratory analysis for the blood 
parameters of GGT, ALT, AST, hemoglobin and conjugated bilirubin will be performed every 2 weeks 
starting from randomization until enterostomy closure. Additionally, in urine, sodium concentration is 
determined in the same time interval. No additional sample volume is necessary for this study.  
****the day of enterostomy closure (day of operation) is the last day within the treatment phase, the day 
after operation is set as the 1st day of the post-treatment phase 
 
 

 
 
 
 
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4.2 
Standardized protocol for creation of a small bowel enterostomy (all 
patients):  
- Exploratory laparotomy (transverse preferred) 
- Possible resection of necrotic bowel 
- Identification of bowel for the enterostomy 
- Proximal and distal limbs of the bowel loop are pulled through the abdominal wall muscles 
and skin (Loop enterostomy) via the abdominal incision or separate incision (preferred). 
- Measurement of the length of small bowel between  
a) the ligament of Treitz (or if malrotation the first mobile part of the duodenum) and the 
enterostomy and  
b) the enterostomy and the ileocecal valve [cm].  
The measurement should be undertaken at the antimesenteric wall of the bowel. 
- Closure of laparotomy: 
- Fascia with continuous suture Polyglactin 2-3/0 
- Subcutaneous interrupted sutures Polyglactin 4/0 
- Intracutaneous interrupted sutures Poliglecaprone 5/0 
- Documentation of operative time (OR-Time in minutes). 
- Daily documentation of the patient´s weight recommended (minimum 2x per week). 
4.3 
Standardized protocol on perioperative mucous fistula refeeding (MFR):  
Definition: Infants are considered capable for MFR after 2 weeks following enterostomy 
creation if no contraindications for MFR, like sepsis, are present. 
 
- Start 14-42 days after enterostomy creation (modified according to Wong et al. [6])  
- Content to be transferred: the infant’s own stool. 
- Intervals of stool transfer: 6-8 hours as a bolus or continuously via a catheter introduced into 
the distal bowel loop (blocked with 0.5 ml of water).  
- Amount of stool transfer: Initiation with 0.5 ml/kg/h per day. Increase of 5 ml/kg/24h or as 
tolerated. 
- If the stool is too thick to be transferred, it may be diluted with normal saline 0,9%. (or glucose 
5% in case of hypernatremia), no dilution with formula. 
- Maximum amount of stool transfer (goal): whole amount of own stool.  
- Documentation of time point and amount  
a) when the maximum amount of feeds are tolerated  
b) if and when the entire amount of stool is transferred  
c) if the entire amount of stool cannot be transferred, the maximum amount     
    transferred is quantified and documented in this “partial-MFR subgroup”. 
- Duration of refeeding: at least 3 weeks and until the infant’s weight exceeds 2000 g. 
- Probiotics may be given as per protocol of the local institution. 
- Prokinetic agents are not allowed during the entire trial.  
- MFR should at least be performed for 21 days. 
- Documentation whether the full amount of stool has been transferred (yes/no). 
 

 
 
 
 
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4.4 
Standardized protocol for enterostomy closure (all patients):  
- Timing of surgery: at least three weeks of MFR or standard treatment and an infant’s body 
weight of > 2000 g 
- Preoperative contrast study of the distal loop of the enterostomy to rule out stenosis is only 
necessary if the infants have not reached MFR of the total stool amounts of the preceding 
24h. For all other infants preoperative contrast studies can be performed voluntarily. This 
study may be performed on the NICU by plain abdominal X-ray with enteral contrast (water-
soluble isoosmolar). 
- Central line placement if an adequate amount of calories cannot be provided via a peripheral 
line.  
- No preoperative bowel preparation 
- Placement of nasogastric (NG) tube in the operation room (OR) 
- Size NG tube: 
- Premature infants up to 3 months of age: 6F catheter  
- 3 to 12 months of age: 8F catheter  
- Small bowel anastomosis: Interrupted sutures with 
- 5/0 Polyglactin in infants below 6 months of age  
- 4/0 Polyglactin in infants above 6 months of age  
- Perioperative antibiotic therapy: type and length based on bacteria profile have to be 
documented. Suggestion: Perioperative single shot antibiotic treatment. Different antibiotic 
regimes, adjusted to microbe profiling is possible, but should be documented precisely.   
 
4.5 
Standardized protocol on parenteral nutrition during treatment phase (all 
patients): 
 
It is referred to the recommendations in “Neugeborenenintensivmedizin” by Rolf Maier and 
Michael Obladen (9th edition, 2017) on nutrition: 
- fluid (ml/kg body weight/24h) 
 
110 – 180 
- energy (kcal/kg body weight/24h)  
  80 – 160 
- amino acid (g/kg body weight/24h)  
    2 – 4 
- lipid (g/kg body weight/24h) 
 
    2 – 3 
 
 

 
 
 
 
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4.6 
Standardized protocol for management of nutrition after enterostomy 
closure (all patients):  
Parenteral nutrition: 
- Calories of the parenteral nutrition [8, 9] if there is no hyperglycemia (> 200 mg/dl), sepsis, 
hemodynamic instability that require a different caloric intake. 
- Day of surgery, starting 6h post operation: 50 – 90 kcal/kg/24h 
- POD (postoperative day) #1: 80-120 kcal/kg/24h  
- POD #2: 80-120 kcal/kg/24h 
- POD #3: 80-120 kcal/kg/24h 
- POD #4: 80-120 kcal/kg/24h  
- Composition of lipid, amino acid and energy may vary according to the need of the patient 
and depending on the options (CVL or peripheral catheter)  
- Trophic oral feeding of <3 ml x 8 (max 24 ml/24h) is allowed on day of surgery 
 
Enteral nutrition: 
- Initiation: POD #1  
 
- Standardized feeding source 
 
- In all infant´s age-specific feeding sources will be used  
- Breast milk (if available) as there is a general consensus that breast milk (70 
kcal/100ml) is the most effective protection against the development of necrotizing 
enterocolitis (Good et al.[26]) (document amount used each day) 
- Alternative 1: donor breast milk (document amount used each day) 
- Alternative 2: Formula for preterm infants (name, manufacturer, the kcal/ml and the 
amount should be documented in the eCRF) 
- Condition of the milk needs to be documented (raw or pasteurized) 
- Caloric enhancement of the milk: pure human milk or preterm formula is given until 
a feeding amount of 100ml/kg/d is tolerated, then the energy content of human milk 
can be enhanced – type and extent of caloric enhancement should be documented 
precisely 
Notice: As a large variety of institutional protocols on the fortification of the milk 
exist, the type of fortification is left to the discretion of the institution but should be 
documented. 
- Documentation of the selected fortifiers, their amount and the caloric content of the 
milk 
- parallel to the increase of oral food concomitant reduction of parenteral fluids to 
< 20 ml/kg/24h 
 
- Prerequisite: continuous measurement of the gastric residual via the nasogastric tube prior 
to the next feeding 
 
 
 
 

 
 
 
 
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Protocol 1: Gastric residual is below 3 ml/kg/nursing-shift or 10 ml/kg/24h 
Feeding protocol (modified protocol of Bohnhorst et. al [27])  
 
 
- Initial amount of enteral nutrition: 20 ml/kg/24h (in intervals of 3 or 4 hours) 
- Increase by 30 ml/kg/24h, when 8 (or 6, depending on feeding intervals) 
consecutive feedings were accepted 
 
Example (infant’s weight 2000 g): 
POD # 1: 8 x 5 ml 
 
= 40 ml  
 
(20 ml/kg/24h) 
POD # 2: 8 x 12,5 ml  
= 100 ml  
 
(50 ml/kg/24h) 
POD # 3: 8 x 20 ml   
= 160 ml  
 
(80 ml/kg/24h)  
POD # 4: 8 x 27,5 ml  
= 220 ml 
 
(110 ml/kg/24h) 
POD # 5: 8 x 35 ml 
 
= 280 ml 
 
(140 ml/kg/24h) 
 
Protocol 2: Gastric residuals prior to the feeding is 20-50% of the previous feeding 
For the consecutive feeding, 20% of the preceding feeding volume (= accepted gastric 
residual) is added to the current volume while the previous gastric residual (> 20%) is 
subtracted of the total volume: 
Adapted amount of feeding volume =  
current feeding-volume + 20% of the preceding volume – whole amount of previous gastric residuals 
 
1. Example: 
Enteral intake 6 x 60 ml; gastric residual 21 ml (= gastric residual 35%) 
  
Calculation: 
60 mL (feeding) + 12 ml (20% of the previous feeding)  
– 21 ml (gastric residual prior to the feeding)    
 51 ml 
 
2. Example: 
Enteral intake 6 x 72 ml; gastric residual 30 ml (= gastric residual 42%) 
 
Calculation: 
72 ml (feeding) + 14 ml (20% of the previous feeding)  
– 30 ml (gastric residual prior to the feeding)   
 56 ml 
 
The next feeding is continued regularly and the feeding volume is then again increased after 
six consecutive accepted feeds.  
 
Protocol 3: Gastric residuals prior to the feeding exceeds 50% of the previous feeding 
If gastric residuals exceed 50% of the previous feeding volume or infant´s vomiting, one 
feeding is skipped  
Protocol 4: Gastric residuals prior to the feeding reaches 100% of the previous feeding 
If gastric residue reaches 100% of the previous feeding volume or infant´s vomiting, two 
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4.7 
Further documentations after enterostomy closure (all patients):  
1. Duration (minutes) of surgery (enterostomy closure) 
2. Postoperative 
duration 
of 
assisted 
respiration 
(hours) 
prior versus post extubation 
3. Daily documentation of the administration of opioids (influencing bowel movement and 
therefore our primary outcome) 
4. Documentation of analgesia type (especially peridural anesthesia catheters, 
influencing postoperative bowel motility)  
4.8 
Additional treatments 
The additional treatment of the patient (intervention) group involves the MFR (see 4.3 
„standardized protocol on perioperative MFR“) with daily introduction of a catheter into the 
distal bowel loop followed by stool transfer.  
Despite the standardized MFR no additional surgical or drug therapy is planned. 
4.9 
Control(s)/Comparator(s) 
Infants of the control group will receive the current perioperative care. 
4.10 Frequency and scope of study visits 
All patients will be continuously monitored on the intensive care unit (NICU) or intermediate 
care ward (IMC) by neonatologists, pediatric surgeons, and nursery staff. Medical records will 
be analyzed including vital signs, weight, oral intake, and medications. 
All participating sites will be visited by the coordinating investigators before the start of the 
study. During the the complete study period, investigators from all sites will meet once a year, 
either digitally (during pandemic periods) or in person, to share information about the feasibility 
of the protocols and to discuss complications and serious adverse events related to the study. 
Study coordinators are in close contact with the study investigators via phone and email. 
Medical information will be exchanged electronically via encrypted email, phone, and fax on a 
regular basis during the course of the study.  
4.11 Assessment of safety 
Assessment of possible (serious) adverse events (AEs/SAEs) after surgery (e.g. intestinal 
bleeding, bowel perforation, sepsis, abscess) from randomization at least until reaching the 
primary endpoint and 12 months following enterostomy closure  
AEs and SAEs will be classified at the end of the trial to achieve standardized grouping and 
minimize intergroup differences. The Clavien-Dindo system will be used to classify 
postoperative complications (see chapter 5). 
 

 
 
 
 
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4.12 Timeframe complete study 
 
 
5 
ADVERSE EVENTS 
The documentation of all adverse events and complications (AEs/SAEs) occurring in patients 
within the study period is obligatory. 
Current data suggest a low complication rate of the mucous fistula refeeding. Lau et al. [28], 
with the largest study population to date (n=77), documented no major complications. 
However, in a retrospective analysis by Haddock et al. [25] with an inhomogeneous population, 
the risk of bowel perforation, bleeding, and death associated with mucous fistula refeeding was 
reported.  
Despite the obligation to document all events and complications in our study population, we 
selected adverse events of special interest (AESIs) based on the current literature.  
Those AESIs include: 
 
events related to the underlying disease and the management in the NICU, e.g.  
ursodeoxycholic acid-therapy due to cholestasis and cholestasis (without ursodeoxycholic 
acid therapy), sepsis, and central line complications (except sepsis) 
 
events related to the surgery, e.g. small bowel obstruction (ileus), stoma stenosis, 
parastomal hernia and stoma prolapse  
 
events related to the mucous fistula refeeding, e.g. bowel perforation 
All AEs/SAEs have to be documented and reported in the eCRF and on paper forms (source 
data) collected in the TIF. 
All documented AEs/SAEs are classified according to the Clavien-Dindo classification and 
complications are assessed daily.  
If an AE or SAE causally related to the intervention occurs, it will be immediately reported by 
the study site to the study coordination in Leipzig and from there to the ethics committees. All 
other AEs/SAEs not related to the intervention will be summarized and sent once a year by the 
study coordination in Leipzig to the ethics committees via the Safety Report. 

 
 
 
 
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6 
STATISTICAL ANALYSIS 
The primary analysis will be performed on the ITT population, i. e. all randomized patients will 
be analyzed in the treatment group to which they have been initially allocated. The treatment 
effect will be assessed by the Hazard Ratio for reaching full enteral feeds estimated with a Cox 
regression adjusted for center, weight and mother’s gestation week at birth (< 1000 g and 
before 37+0 /< 1000 g and before 37+0 / ≥ 1000 g /and at least 37+0), height of stomata and 
treatment (jejunostomy/proximal Ileostomy or terminal ileostomy), and the respective 95% 
confidence interval. Superiority of the refeeding procedure will be concluded if the lower bound 
of the two-sided 95%-confidence interval for the Hazard Ratio (refeeding vs no refeeding) is 
greater than 1. In case of missing information on the time to full feeds, patients will be censored 
at the last known status before full feeds.  
Extensive sensitivity analyses will be performed to assess the impact of the specification of the 
primary endpoint definition with study protocol version 3.0, specifically consistency of patient 
population before and after the specification will be analyzed and subgroup analyses for the 
defined strata will be performed. 
Furthermore, time to full feeds after randomization (in days) will be analyzed in line with the 
cox regression model for the primary endpoint. 
All secondary analyses will be tested exploratory using a two-sided significance level of 5%. 
For all analyses estimates, their associated two-sided 95% confidence intervals and p-values 
from regression models will be provided and conducted on the ITT population. The analysis 
strategy for the key secondary endpoints will be as followed: 
 
The secondary endpoints “Time to first bowel movement after enterostomy closure” 
and “Time to full oral volume intake” will be analyzed using a cox-regression model in 
line with the primary analysis strategy. 
 
The secondary endpoint “Reoperation” will be analyzed using a logistic regression 
model to compare both treatment arms stratified by center, weight and mothers 
gestation week at birth.  
 
The secondary endpoints “Postoperative weight gain (g/d)”, “Days of postoperative 
total parenteral nutrition (TPN)”, “Laboratory parameters indicating cholestasis 
(conjugated bilirubin, GGT, ALT, AST, hemoglobin) and sodium resorption (sodium in 
urine)”, “Weight gain during the subsequent 5 days after reaching the primary 
endpoint”, “Central venous line (CVL) duration (days) and number of CVL infections”, 
“Length of hospital stay (days)” and “Estimated ratio of the diameter of the two bowel 
loops which are anastomosed” will be analyzed using a linear regression model to 
compare both treatment arms stratified by center, weight and mothers gestation week 
at birth.  
 
To evaluate the feasibility of the intervention and the refeeding protocol 2 additional subgroup 
analyses will be performed, each comparing 3 groups in the MFR treatment arm. A period of 

 
 
 
 
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7 days prior to the last day before the surgery for enterostomy closure is considered resulting 
in classifications for these groups: 
First additional subgroup analysis: 
1. No refeeding:  
0 days of refeeding protocol adherence (0%) 
2. Partially refeeding: 
1-3 days of refeeding protocol adherence (1% - 50%) 
3. Full refeeding:  
4-7 days of refeeding protocol adherence (51% - 100%) 
 
Second additional subgroup analysis: 
1. No refeeding:  
0 days of total volume refed (0%) 
2. Partially refeeding: 
1-3 days of total volume refed (1% - 50%) 
3. Full refeeding:  
4-7 days of total volume refed (51% - 100%) 
These subgroup analyses will each be performed descriptively using a two-sided Kruskal-
Wallis-Test comparing the respective three groups. 
Safety analyses 
Occurrence of AEs and SAEs will be analyzed descriptively using absolute and relative 
frequencies for the whole population and separately for the intervention and control groups 
and will be compared with chi-squared tests. The grading of each event according to the 
Clavien-Dindo classification, the outcome of the event and ICD-10 terms will be compared 
descriptively. Furthermore, events classified as AESIs will be analysed descriptively 
additionally in sub-group investigations. 
 
6.1 
Methods against bias 
This is an open-label study. Blinding is not possible because active refeeding of stool in the 
intervention group is obvious to any person participating in the medical care of the patient. 
Randomization will be performed centrally via fax (with variable block length) and stratified by 
study center, height of stomata (jejunostomy/proximal Ileostomy or terminal ileostomy) [29, 
30], weight (< 1000g / ≥ 1000g) and mother’s gestation week at birth (before 37+0  / at least 
37+0), as this are important prognostic factors for the primary endpoint. Randomization will 
take place after enterostomy creation in order to reduce the amount of missing values due to 
patient exclusion after surgery (e.g. due to unforeseen need for resection of ileocecal valve) 
and after the treating physician has determined the full feed kcal goal on the basis of the 
stratification. The primary analysis will be performed on the ITT population as this is an open 
study and parents/legal guardians may have preferences not outspoken before randomization. 
A per protocol analysis will be conducted as a sensitivity analysis in all patients that have no 
substantial protocol deviations. Consistency between the findings in the ITT population and 
the per-protocol population will be examined, as it is an important pre-requisite for a successful 
interpretation of the study.  

 
 
 
 
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In general, dropouts are not expected because all patients will constantly undergo neonatal 
intensive care and will therefore not be lost to follow-up. If parents/legal guardians withdraw 
their infant from study participation, they will be asked to allow data collection at a final analysis 
to avoid wasting that information. Nevertheless, up to now, we recognized that for some 
individual patients it is not feasible to abide by the protocol, especially the nutrition protocol 
after enterostomy closure. Therefore, if missing values occur (e.g. due to death, or 
parents’/legal guardians’ refusal of data collection), observations will be censored at the last 
time point with known enteral feeding status. Since this censoring may be informative, missing 
values for time to full feeds will be replaced by the worst observation in each group in a 
sensitivity analysis in order to check how censoring may have influenced the results. If any 
death occurs before the respective patient reaches full enteral feeds, a sensitivity analysis will 
be performed for all surviving patients. 
To avoid direct influence on the change of kcal goal of the treating physician during the study, 
an independent reviewer will assess at least all changes of kcal goals at the end of the study. 
6.2 
Proposed sample size/Power calculations 
The literature of MFR is scarce and information on the primary endpoint “time to full enteral 
feeds” is limited [4]. A recently published retrospective analysis of 24 patients [3] of whom 13 
received refeeding of stool to the mucus fistula and 11 of whom did not receive refeeding of 
stool showed a median time from enterostomy takedown to enteral feeds of 7 days in the 
control group and 4 days in the refeeding group. The data presented for the control group is in 
line with retrospective data of 42 patients collected at Hannover Medical School. These 42 
patients are all patients fulfilling the inclusion criteria who were treated at Hannover Medical 
School between 2005 and 2015. They did not receive refeeding of stool and had a median 
time to full enteral feeds of 7 days. According to Gause et al. [3], a survival analysis is 
appropriate. In their respective publication, median times are reported corresponding to a 
hazard ratio of 1.751 for time to enteral feeds (4 days vs 7 days), 2.331 for parenteral nutrition 
discontinuation (6 days vs 14 days) and 2.667 for goal feeds (7.5 days vs 20 days). Because 
time to enteral feeds in this publication is in line with our retrospective data of time to full feeds, 
a hazard ratio of 1.751 is assumed for the treatment effect. In order to show a treatment effect 
with a power of 80% and a two-sided type I error probability of 5% with a logrank test, a total 
of 100 events (full enteral feeds) is required, if the hazard ratio for the treatment effect is 1.751. 
Since patients will be in neonatal intensive care, every patient is expected to reach full enteral 
feeds. Nonetheless, to account for possible deaths and patients that are not able to reach full 
enteral feeds or abide the study protocol, the sample size was increased by 20 patients, 
resulting in a total of 120 patients. Sample size was estimated in nQuery Advisor 7. 
6.3 
Compliance/Rate of loss to follow up 
Several retrospective data analyses show low complication rates related to MFR. During 14 
years of MFR, a group from the University of Hong Kong observed no major complications 
associated with refeeding in 77 patients with necrotizing enterocolitis [28].  
All centers participating in the current study have experience with MFR and did not record 
major complications in any of the centers. This observation is well in line with data from 13 
patients undergoing MFR at the Department of Pediatric Surgery at Johns Hopkins University 

 
 
 
 
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School of Medicine in Baltimore. The authors did not document major complications associated 
with refeeding but observed benefits of the intervention [3]. 
We are very confident that the loss of follow-up in this study at the end will be quite small. Due 
to the severe course of the diseases, parents/legal guardians of patients with neonatal surgical 
conditions have an intense emotional relationship with the treating surgeons and 
neonatologists. Almost all parents/legal guardians prefer follow-up appointments at the treating 
hospital after their infants have been discharged from the hospital. We therefore do not expect 
any loss of follow-up. However, as a precaution, the patient recruitment was increased to 13 
centers with 230 expected patients. 
 
 

 
 
 
 
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7 
DATA MANAGEMENT 
 
All study data will be collected by the investigator and/or other study personnel. A validated 
clinical trial data base (electronic case report form) is provided in which the data are entered.  
AEs and SAEs and further relevant diagnoses will be coded using ICD 10 coding system 
(International Statistical Classification of Diseases and Related Health Problems). 
Authorized and trained staff of the study sites will enter the data in the eCRF in a timely manner.  
Verification of the data in the eCRF occurs by risk-based monitoring as well as via range, 
validity and consistency checks programmed in the system. Additionally, manual queries can 
be raised in the system if discrepancies are detected. Based on the queries, the investigator 
can review the data and resolve the discrepancy or justify the entered data directly in the 
system. All changes of data entered in the eCRF are documented in an audit trail. A quality 
control will be performed before the database is closed. This procedure is documented. Finally, 
data transfer takes place for statistical evaluation. 
The data management plan contains further details about data management processes. 
8 
QUALITY ASSURANCE AND MONITORING 
 
All initiation visits, onsite monitoring visits, close-out visits and in-house monitoring will be 
conducted by monitors of ZKS (ZKS, MHH) or an external qualified CRO. ZKS SOPs will be 
utilized. Prior to the start of the study, pre-study visits by the primary investigators will be 
conducted to be able to instruct the local investigators in how to follow the study protocol and 
documentation of data. Initiation visits will be done in each study site prior to patient recruitment 
to ensure adherence with all study procedures by the monitor of ZKS or an external CRO and 
the study coordinators. To assure high data quality and patients safety, regular on-site 
monitoring visits will be performed by monitors. Checking of signed informed consents and 
source data verification will be carried out according to a risk adapted approach. At the end of 
the study, close out visits will be performed at all study sites. Project managers, monitors, study 
coordinators and PIs will be in close and regular contact throughout the study and with all study 
sites. 
Monitoring details will be summarized in a monitoring plan which will be prepared by the lead 
monitor (ZKS). The monitoring plan will be reconciled with the coordinating investigator and 
members of the clinical project management. It will serve as guiding document for all monitors 
and will contain details on monitoring activities, responsibilities and interfaces between study 
team, data management, source data and adverse events. In-house monitoring will assure 
high data quality. Data capture will be achieved by electronic data capture (electronic CRF). 
On-site source data verification will be done according to a risk adapted monitoring afterwards. 
In total, 2 monitoring and 1 close-out visits are planned per study site. 
 

 
 
 
 
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8.1 
Data Monitoring Committee 
An independent Data Monitoring Committee (DMC) is implemented to detect possible harms 
and to assure continuous risk/benefit assessment. A DMC is a group of independent experts 
external to the study assessing the progress, safety data and, if needed, critical efficacy 
endpoints. Details of the definition of DMC, its composition and its roles and responsibilities 
can be found in the separate DMC charter. 
9 
ETHICAL AND LEGAL CONSIDERATIONS, ADMINISTRATION 
The study will be conducted in accordance with the principles of ICH-GCP (as far as possible 
for this kind of study) and the Declaration of Helsinki. 
Study protocol and patient consent form will be submitted to the Ethics Committees for review 
prior to the start of the study. No amendment to the protocol may be made without 
consideration by the Ethics Committee. 
9.1 
Patient Information and Informed consent  
The investigator is responsible for obtaining the parents’/legal guardians written informed 
consent after adequate explanation of the aim, study assessments, potential risks and benefits 
and consequences of the study as well as alternative treatment options. Parents/legal 
guardians will have sufficient time to ask questions before deciding on whether or not to 
participate in the study. The patient information/informed consent form has to be signed in 
duplicate by the patient’s parents/legal guardians and the investigator. One document will be 
given to the parents/legal guardians, the other one will be kept at the participating study sites. 
No study procedures are allowed to be conducted until parents’/legal guardians’ written 
informed consent has been obtained. 
The patient information/informed consent form has to be revised whenever important new 
information becomes available that may be relevant to the parents’/legal guardians’ consent. 
In case of the infants transfer into another clinic, the investigator obtained the informed consent 
from the parents/legal guardians to release the physicians in the external clinic from their 
medical confidentiality to retrieve the data for the study. 
Participation in this clinical trial is voluntary. Withdrawal from the study at any time and for any 
reason is without any disadvantages to the patient’s further treatment. 
9.2 
Patient Insurance 
The trial will be covered by a participant insurance in case the trial site (clinic) does not cover 
the study by its liability insurance (Haftpflichtversicherung). All subjects (parents/legal 
guardians) will be informed about their rights and obligations in regard to insurance policies 
before participating in the study. A copy of the insurance policies will be handed out to each 
patient (parents/legal guardians). 
 
 
 

 
 
 
 
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9.3 
Data Protection 
Data collection, handling, storage and analysis will be in accordance with national regulations.  
All study staff are obliged to duly observe data protection and medical confidentiality. 
If the participant withdraws the previously given informed consent, the participant has the right 
to demand the deletion of all data collected so far. If the participant withdraws and does not 
demand the deletion of data, the data collected up to that point will be anonymised and used 
for the statistical analysis. 
9.4 
Registration 
The study is registered at ClinicalTrials.gov: NCT03469609 
9.5 
Record Retention 
The original study documents wil be stored in an archive of the participating study site for at 
least 10 years after the final study report. 
9.6 
Financing 
The clinical trial is funded by public funds through the German Research Foundation. 
9.7 
Patient Involvement 
The steering committee of the patient organization “Das frühgeborene Kind e. V.” is aware of 
the study. This organization consists of parents of former preterm infants and also actively 
involved in other scientific studies in Germany. Regular telephone conferences with this 
organization will be held to exchange information, and a representative is invited to the 
investigator meetings. The PIs are available for consultations by the patient organization 
concerning mucous fistula refeeding and will update the steering committee on recent 
publications and evidence-based recommendations. 
 
10 
HANDLING OF BIOMATERIAL 
 
Biomaterials in the main study include the analyses of sera, plasma and urine, rectal stool and 
the use of enterostomy stool for MFR. Sera, plasma and urine will be collected and analyzed 
using the current concepts of each department. Therefore, no additional trauma will be present. 
Enterostomy losses will be collected in strict intervals [1x (continuous refeeding) or 3x 
(separated refeeding every 8 hours) daily] for the refeeding. Stool will not be stored for the 
MFR. The necessary amount will be transferred and the surplus will be thrown away.  
 
 
 

 
 
 
 
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11 
PUBLICATION 
 
After completion of the trial, data analyses will be performed by the Institute of Biostatistics 
(MHH). The results and the study protocol including all data used to perform MFR will be 
published. If the results of this study show significant differences between the intervention 
group and controls, MFR will become the new standard of care for neonates with 
enterostomies. In Germany, the current national guideline for neonatal and surgical treatment 
of necrotizing enterocolitis (NEC) is currently in revision [Leitlinie 024-009: Nekrotisierende 
Enterokolitis (NEK)]. One of the principal investigators of the trial (Prof. Dr. Martin Lacher) is 
co-author of this guideline (Delphi method). If the current trial proves the hypothesis that MFR 
is beneficial for these infants, it may not only change the national guideline for the best 
treatment after enterostomy creation in Germany, but also in other countries. 
 
 
 

 
 
 
 
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