Prior to reinfusing with The Insides System

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Contrast Imaging of Distal Intestinal Tract

Prior to commencing chyme reinfusion therapy the patient’s distal intestine must be checked to ensure patency. A method of doing this is contrast imaging.

  • Chyme reinfusion therapy may not be appropriate for patients with a distal stenosis from inflammatory bowel disease.
  • Patients with a distal stenosis from other aetiology can be dilated before starting chyme reinfusion therapy if safe to do so.
  • During installation of a tube, do not advance the tube if there is significant resistance, or if advancement causes the patient to experience pain.

 

Selecting the Correct Tube Size

The Insides System contains two sizes of The Insides Tube, 28 Fr and 22 Fr. As a general guide:

  • The 28 Fr is suitable for most enterostomy patients within six months of enterostomy formation.
  • The 22 Fr is suitable if the patient has:
    • been defunctioned for over six months, or
    • an enteroatmospheric fistula (EAF)

If the Clinician determines that neither the 28 Fr or 22 Fr tube sizes are appropriate, a minimum 20 Fr balloon retained tube is recommended. Please note, a balloon retained tube with an ENFitTM connection does not couple with The Insides Pump.

The Insides Tube 28Fr tube is recommended when applicable. If the 28Fr does not fit, smaller tubes can be used to reinfuse small boluses to rehabilitate the intestine. After a short period of intestinal rehabilitation, the patient may be able to transition to a version of The Insides Tube or transition from the 22 Fr to the 28 Fr Tube.

 

Parastomal Hernia

If a patient has a parastomal hernia, caution is needed when inserting the tube. Possible bowel kinking can prevent the tube from being inserted and can create a risk of perforation. The increased external length of bowel can prevent the tube from being positioned and anchored correctly. Digitally palpating the distal tract will indicate the direction of distal limb, any narrowing or kinking, and the distance to fascia.

  • The tube should not be advanced against any resistance or if advancing the tube causes the patient to experience pain. Chyme reinfusion therapy with The Insides System is not indicated if tube intubation is unsuccessful or tube placement causes pain.
  • If the distance to the fascia is greater than 70 mm, consider using a straight balloon retained tube that has no retention sleeve/cuff that can reach the fascia safely. The longer tube should not be advanced against resistance or if advancement causes the patient to experience pain.
  • Ensure that there is suitable facial opening so that the tube does not migrate into the distal intestine.

 

Prolapsed Distal Limb

If the patient has a prolapsed distal limb of their enterostomy or enterocutaneous fistula (ECF), caution is needed when inserting the tube due to the extended, unsupported length of intestine that is external to the body. The Insides Tube is not suitable for this type of patient.

  • Carefully consider whether the clinical benefit of chyme reinfusion therapy balances the increased risk of a potentially difficult tube insertion.
  • Consider using a straight balloon retained tube that has no retention sleeve/cuff. The full length of the balloon retained tube may need to be inserted into the limb which means when The Insides Pump is attached, it may sit close to the outlet of the distal limb.
  • The longer tube should not be advanced against significant resistance or if advancement of the tube causes the patient pain.
  • Modifying an enteral feeding tube may cause the tube to migrate into the distal intestine.

 

Enterocutaneous Fistulas

If a patient has an ECF, caution and careful clinical decision making are required when selecting the correct tube to use for the patient. Patients may have little or no fascia around the location of tube insertion. Consequently, a retention sleeve or cuff may not prevent the migration of the tube into the distal intestine as it matures. An appropriate tube should be selected and monitored to ensure the migration does not occur.

 

Ostomy Appliance Selection

The Insides Tube can be used with any ostomy appliance. Initially, it is recommended the patient use a clear ostomy appliance, so it is easy to watch chyme move up the tube and see the volume in the ostomy appliance decreasing. If a tube, other than The Insides Tube, is required initially, then this tube and pump must fit comfortably within the ostomy appliance without any pressure exerted on the tube and The Insides Pump.

 

Basic Stomal Therapy Principles

The installation of a feeding tube into the patient’s distal limb may increase the size of the stoma on the abdomen. Consequently, it is recommended that the patient’s template on the base plate of the ostomy appliance, is re-measured. This is to ensure there is a clearance of 2 – 3 mm between the enterostomy and the edge of the base plate. This allows for peristalsis and the natural movement of the enterostomy and tube complex to prevent the risk of mucosal erosion due to rubbing on the side of the base plate. It is best to re-measure the patient’s template periodically. The base plate should also be re-measured if there have been any changes as a result of weight gain, weight loss, herniation, or prolapse.

 

Commencing Treatment with The Insides System

When starting therapy with The Insides System, the patient will spend a short period of time increasing their tolerance to chyme reinfusion therapy, rehabilitating their distal bowel, and slowly introducing oral food. During this period, it is recommended to keep the patient’s parenteral nutrition prescription and anti-motility medication at the same dose. This will allow the patient to become independent with The Insides System and not become overwhelmed with the increase in their output from weaning the anti-motility medication. This will also maintain their nutrition while they are transitioning to reinfuse all of their output and ensure their nutrition is optimised.

 

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