Patient Case Study for Bowel Continuity Testing
This case report details the use of The InsidesTM Systemfi to prepare “Mary”1 for reversal of her double-barrel ileostomy, formed as a part of her care pathway to treat multiple internal fistulae secondary to Diverticular disease2.
Mary is a 75-year old female patient with a history of complicated Diverticular disease. She has had previous colovaginal3, colovesical4, and coloenteric5 fistulas secondary to Diverticular disease.
On the 19th of February 2020, Mary underwent a laparotomy, low anterior resection, small bowel resection, and fistulotomy of her coloenteric, colovesical, and colovaginal fistulas. A double-barrel ileostomy was formed as a result of these procedures.
A contrast computed tomography (CT) performed on the 28th of May 2020 which showed the anastomosis from the low anterior resection to be widely patent
The Insides Company was contacted by Mary’s colorectal surgeon to use The InsidesTM Systemfi to rehabilitate her distal bowel, test functional continence, and allow Mary to simulate intestinal continuity.
Mary was consulted by a stomal therapist (STN) a week before being set up with The InsidesTM Systemfi to discuss usage of the device. Mary was advised to maintain a low residue diet to achieve the appropriate chyme consistency for The InsidesTM Pumpfi to work properly6.
During the consultation, Mary also mentioned a small parastomal hernia she had. Mary’s hernia was evaluated by the STN, where it was determined that the parastomal hernia would not affect the set-up and use of The InsidesTM Systemfi.
On the 22nd June 2020, the STN completed the installation of The InsidesTM Tubefi, and the set-up, education and troubleshooting of The InsidesTM Systemfi at Mary’s home, which took approximately an hour.
Mary was taken through the care of The InsidesTM Tubefi, and how to change her ostomy appliance and The InsidesTM Pumpfi every three days, as well as troubleshooting if The InsidesTM Pumpfi became blocked. She was advised to slowly increase the frequency of refeeding to build tolerance to chyme reinfusion, as well as to minimize lower abdominal discomfort from introducing food to the previously defunctioned distal intestine.
Rehabilitating the distal limb of an ileostomy is uncomfortable because the stretch of the luminal walls from reintroducing chyme downstream generates a diffuse discomfort across the lower abdomen. The longer a person has been defunctioned, the longer it will take to increase their tolerance to reinfusing their entire daily output. Mary had been defunctioned for four months, so it took six days for her to become established with no lower abdominal discomfort.
Follow up care:
The STN followed up with Mary the day after installation, and at the end of the week to ensure she was reinfusing her output and mitigating any issues that arose. The main concern for Mary was keeping her output thin enough for it to be pumped through by The InsidesTM Pumpfi. Mary found that drinking another two glasses of water per day kept her output thin enough for reinfusion.
Mary refed 50ml on the first day, 50ml twice the following day, and gradually increased the frequency and amount over the next four days until she was refeeding 85% of her output (day-6). Mary also established her first bowel movement (Bristol 5) on day-6.
Mary continued to refeed 85-90 % of her output throughout the remainder of her therapy with minimal issue. The 10-15% that was not refed was the early morning output that had been sitting within the stoma appliance overnight (for close to 8-hours), and therefore needed to be discarded.
Mary had also established a routine that entailed refeeding around her many social events and family gatherings and was able to have a formed bowel movement every alternate day for the following 35 days of therapy.
The STN followed up with Mary via weekly phone calls and had a face to face visit every fortnight; this ensured Mary felt supported, and any issues could be immediately remedied.
The STN removed The InsidesTM Tubefi the day before Mary’s planned reversal on the 29th July 2020. Mary had an uneventful surgery where her double-barrel ileostomy and parastomal hernia were reversed and repaired. She started passing flatus within 6 hours post-reversal and passed a formed bowel movement at 72 hours post-reversal. She stated that she only required paracetamol for pain within 36 hours postoperatively. Mary was successfully discharged day four post-operatively
Image Left - Patient with Ostomy Appliance
Image Right -InsidesTM Tubefi inserted into the patient's distal bowel
1 Alias used to protect patient privacy
2 Diverticular disease: A condition in which small, bulging pouches develop in the digestive tract.
3 Colovaginal Fistula: A fistula (abnormal connection) between the colon (large intestine) and the vagina
4 Colovesical Fistula: A fistula (abnormal connection) between the colon (large intestine) and the bladder
5 Coloenteric Fistula: A fistula (abnormal connection) between the colon (large intestine) and the small intestine
6 The InsidesTM Driverfi has five power settings designed to pump across a range of chyme consistencies. However, it is advised for the patient to avoid fibrous and stringy foods that may clog The InsidesTM Pumpfi.
Individual results may vary; testimonials are not claimed to represent typical results. All testimonials are received from real patients via text, verbally or video submission, and may not reflect the typical patient’s experience, nor intended to represent or guarantee that anyone will achieve the same or similar clinical results. Each patient’s condition is unique to their physiology and health status. Thus, the testimonials shared by The Insides Company may not reflect the typical patients’ experience.