Transcript author / owner - Wound/Ostomy Related Documents

Weird or Arcane Ostomy
and Other Info
Some myths, some facts and
some things to ponder
courtesy of
Mike ET
11/22/2008
Mike D'Orazio, ET
1
Mike – Ostomate – ET
1963 - USN
1970 - ET
1985
2006 – WOCN Conf.
11/22/2008
Mike D'Orazio, ET
2
A priori housekeeping concerns
Ostomies are trade offs!
Disease vs. non disease & ↑problems vs.
↓problems
Potty: Defecation and excretion are dynamic
processes that flow in a net unidirectional way
(mouth to anus and kidney to urethra) and any
event that impedes such homeostatic flow is
troublesome in the long run.
Ostomy diversions, continent or other wise, may
well perturb the natural cephalad to caudad order
of things.
In other words, anatomic, metabolic & stasis
concerns can arise!
Skin: Is a chronic concern for all as we age, with
or without an ostomy.
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Mike D'Orazio, ET
3
Ostomies as tradeoffs
How are ostomies or other diversions
presented to prospective patients?
Do the ostomies live up to the hype?
Is there a balance point?
For some, ostomy is a blessing, early on.
For others the ostomy is less well received.
Time and comprehensive assessment of
experiences (a.k.a. lived experiences) are
the best arbiters of ostomy outcomes.
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Mike D'Orazio, ET
4
Let’s query the audience
Stomas and nerves?
Anatomy & hernia risks?
Bowel physiology?
Adequately hydrated?
Gas and odor issues; a gender issue?
Pee breaks?
Pouch wear times?
Historical tidbits?
Is your skin in the game?
Defunctionalized organ behaviors?
Pharmacy in the loop?
Are you a boy/girl scout?
The Art of Ostomy Potty?
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Mike D'Orazio, ET
5
Do stomas have nerve endings?
What say you?
What say the medical folks?
How can we know for ourselves?
What makes it tick?
What makes it move?
What makes it pee & poop?
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Mike D'Orazio, ET
6
“Stomas have no nerve endings”
This is a bald-faced lie!
It is also a myth that will not die!
Until now, hopefully!
Okay, smarty, how do we clarify?
What say you?
What say I?
11/22/2008
Mike D'Orazio, ET
7
Bowel nerves book references
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The nerve of that stoma!
“There are more than 100 million nerve
cells in the human small intestine, a
number roughly equal to the number of
nerve cells in the spinal cord. Add in the
nerve cells of the esophagus, stomach,
and large intestine and you find that we
have more nerve cells in our bowel than in
our spine. We have more nerve cells in
our gut than in the entire remainder of our
peripheral nervous system.”
The Second Brain by Michael Gershon, M.D. page Xiii
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Mike D'Orazio, ET
9
Muc = mucosa
SM = submucosa
CM = circular muscle
MP = myenteric plexus
Lm = longitudinal muscle
11/22/2008
John B. Furness, Wolfgang A. A. Kunze
and Nadine Clerc. Am J Physiol
Gastrointest Liver Physiol 277:922-928,
1999.
Mike D'Orazio, ET
10
The nerve of that stoma!
“The discoveries of the Law of the
Intestine by Bayliss & Starling in 1899 and
the Peristaltic Reflex by Trendelenberg in
1917 describe the pressure induced
propulsive (mouth to anus) activity of the
gut, which is not dependent upon any
connection to the brain or spinal cord, i.e.,
a completely autonomous ‘local nervous
mechanism’ which is now known as the
enteric nervous system (ENS) of the gut.”
The Second Brain by Michael Gershon, M.D. page 3
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11
The nerve of that stoma!
So, why is it that the stoma feels
no pain when cut or cauterized?
This is the question and
observation that has contributed
to the erroneous statement that
the stoma has no nerve endings.
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The nerve of that stoma!
“…most of the information carried by
gastrointestinal primary afferent neurons is
not consciously perceived. This is nicely
demonstrated by tests on fistula patients
who report no sensation when the healthy
stomach is probed or in patients that have
had the intestinal lining cut to take a
biopsy.”
Am J Physiol Gastrointest Liver Physiol 277:922-928, 1999.
John B. Furness, Wolfgang A. A. Kunze and Nadine Clerc. page
G924
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13
Alas, stomas do have nerves!
So, now let us put to rest the misstatement
about the bowel and nerves.
There are nerves; but the sensory nerves
of the bowel between the esophagus and
the rectum, for certain types of painful
stimuli, such as cutting or cautery, are
either very low in number and caliber or the
brain is not readily able to perceive the
pain.
Of course, one can still be a pain in the
ass; however, this is a topic for other times
and places.
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Mike D'Orazio, ET
14
Arcuate line vs. parastomal hernias?
The arcuate line is a defined anatomical landmark
that shows the demarcation of the various
abdominal wall layers from fully layered to partially
layered as one examines the length of the anterior
abdominal wall fascial layers. The other interesting
finding is that this line is not universally positioned
across or among all patients.
Above the arcuate line, the rectus abdominis (the
“six pack” muscle group) is surrounded by an
anterior layer of the rectus sheath and a posterior
layer.
Thus, it begs the question whether or not
parastomal hernias would be affected by location
of stomas above or below the arcuate line.
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Mike D'Orazio, ET
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Parastomal hernia
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Variations of the rectus sheath
“In a study of 40 cadavers… the shape and
position of the arcuate line were neither
symmetrical nor constant, and neither was
the arrangement of the nerve supply to the
rectus abdominis muscle or to the overlying
skin.”
Monkhouse WS, Khalique A. Variations in the
composition of the human rectus sheath: a
study of the anterior abdominal wall. J Anat.
1986 Apr;145:61-6.
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Arcuate line anatomy
1. Posterior wall of
rectus sheath
2. Arcuate line
3. Linea alba
4. Rectus abdominis
5. Inferior epigastric
vessels
http://www.med.umich.edu/lrc/
coursepages/M1/anatomy/htm
l/atlas/abdo_wall61.html
Accessed 10/25/2008
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Physiology
Osmosis
When two aqueous solutions of unequal
concentrations are separated by a membrane
permeable only to water, the water migrates
through the membrane to equalize the
concentrations of the two solutions. Osmosis
describes the net water flux.
Think diarrhea associated with lactose
intolerance, and making urine!
Diffusion?
High to low concentration migration of gases.
Think farts and other odors!
It is why, along with the olfactory nerves, we
can smell!
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Osmosis: The Goldilocks Principle
Hypertonic
is too
much
Isotonic is
just right!
http://campus.queens.edu/faculty/jan
nr/cells/cell%20pics/osmosisMicrogra
phs.jpg
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Hypotonic
is too little
Mike D'Orazio, ET
20
Diffusion: The Nose Knows
I hope this
doesn’t smell
like my
ostomy bag!!
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21
Water & electrolyte absorption
The duodenum & jejunum are the major sites of
water absorption, which can be explained by the
relatively large pore size (8 angstrom radius) and
consequent low flow resistance to water
movement across the mucosa, whereas water
movement across the ileum is more restricted due
to smaller pores (4 angstrom).
Clinical Gastrointestinal Physiology by Granger, Barrowman &
Kvietys. W.B. Saunders, Phila 1985. page 151
The total daily water load (1-1.5 liters ingested & 6
– 7 liters from secretions of salivary glands,
stomach, pancreas, liver and intestine) presented
to the small intestine is roughly 8 liters &
approximately 80% is absorbed.
N.B. An angstrom is the unit of measure of wavelengths; one
one-hundred-millionth of a centimeter or 10-8 centimeter.
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Vitamin B12 concerns
The terminal 18” (≈ 50 - 60 cm) of the ileum
is critical for vitamin B12 (cobalamin) and
bile acid absorption.
It is prudent to reassess B12 levels for any
suspect patients since it takes 2-4 years to
deplete B12 reserves in the liver.
Trading off some measure of continence
with urinary or fecal reservoirs at the
expense of some loss of essential nutrient
absorption.
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Fecal diversions and urinary stones
http://www.urostonecenter.com/evaluation.asp
Accessed 10/16/2008
11/22/2008
Compared with controls,
ileostomy and J-pouch
patients had significantly
lowered urinary volumes and
pH, higher concentrations of
calcium and oxalate, and an
increased risk of forming uric
acid stones.
Christie PM, Knight GS,
Hill GL. Comparison of
relative risks of urinary
stone formation after
surgery for ulcerative
colitis: conventional
ileostomy vs. J-pouch. Dis
Colon Rectum 1996 Jan;
39 (1): 50-4.
Mike D'Orazio, ET
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The air we breathe – including farts
Fart recognition cycle
Air – gas – fart – noise (Fx restriction & pressure)
Tight or stenotic stomas are more likely to make louder noises
Think of the balloon letting out air
Laplace’s Law: Tension = Pressure x radius (restriction) or P = T/r
Two essential ingredients tend to give us away
– smelly and noisy farts.
Ladies take no solace because your farts tend
to stink more than men’s; even though men
tend to fart more in volume.
Ostomy bags can be helpful hiding us.
Until we either open up the bag or the filter fails
to do its job.
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25
Gas, flatulence or farts
Subject
condition
Number of
daily farts
Approx.
daily
volume in
liters
Gut
produced
gas – non
smelly
Smelly
component
of gas
O2 (3%)
CO2, (10%)
H2, (9%)
CH4 (18%)
Sulfur
groups H2S
<1%
↔
↑
?
Swallowed
air/gas
N2 (16%)
Normal
Lactose
intolerant
(osmosis also
at work here)
10 +/- 1
19 +/- 2.4
2
↑
(diarrhea also
increases)
SIBO
small
intestinal
bacterial
overgrowth
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↑
↑
↔
Mike D'Orazio, ET
↑
Sulfur &
other gases
↑
26
Odoriferous flatus: women’s curse
Subjects
Odor intensity scale:
Total vol.
per
passage
H2S
conc.
µmol/L
MES
conc.
µmol/L
DMS
conc.
µmol/L
Total
conc.
µmol/L
All
107
1.06
0.21
0.08
1.35
3.3
5.6
Men
N = 10
119
0.59
0.19
0.08
0.86
2.8
5.1
Women
N=6
88
1.77
0.24
0.07
2.08
4.2
6.7
0 (no odor) to 8 (very
offensive)
Judge 1
Judge 2
N.B.: H2S = hydrogen sulfide (rotten egg smell), MES = methane thiol or methyl
mercaptan (rotten cabbage), DMS = dimethyl sulfde (characteristic cabbage like
smell & “the smell of the sea”) Info obtained via Google search on 10/19/2008.
table extracted from: F Suarez, J Springfield, and M Levitt
Gut 1998 July; 43(1): 100–104
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Stool odor relief
“Bismuth is supposed at times to relieve diarrhea
by combining with the H2S which is irritating to the
bowel.”
An Introduction to Gastroenterology. Walter C. Alvarez, Paul B.
Hoeber, Inc, 1940
“Treatment of subjects with bismuth subsalicylate
(Pepto-Bismol® or Kaopectate®) produced a >95%
reduction in fecal H2S release. The ability of
bismuth subsalicylate to dramatically reduce H2S
could provide a clinically useful means of
controlling fecal odor and / or flatus and of
decreasing the putative injurious effects of H2S on
the colonic mucosa.”
Fabrizis, Suarez, Furne, Springfield & Levitt: Bismuth Subsalicylate
Markedly Decreases Hydrogen Sulfide Release in the Human Colon.
Gastroenterology 1998; 114: 923-929
Bismuth subgallate (C7H5BiO6) is found in Devrom®.
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Pee Break
http://images.google.com/images?hl=en&q=little+boy+eeeing&btnG=Search+Images&gbv=2
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Pee break: Ureterosigmoidostomies
Author
Year
Event
John Simon
1851
First urinary diversion
Thomas Smith
1878
First direct ureterointestinal
implantation
Karl Maydl
1892
Implantation of the trigone into the
sigmoid
George Fowler
1896
First antireflux ureterointestinal
implantation
Robert Coffey
1911
First successful antireflux
ureterointestinal implantation
Wyland Leadbetter
1951
First ureterointestinal implantation
avoiding reflux and stenosis
The History of Urinary Diversion. D.T. Basic, J. Hadzi Djokic, I. Ignjatovicl.
Urological Clinic, Clinical Center Nis. Institute of Urology and Nephrology,
Clinical Center of Serbia, Belgrade Serbia.
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Pee break: Cutaneous Ileal conduits
Eugene Bricker established the use of the ileal
conduit in 1950. However, the first ileal conduit
was performed by Heinz Haffner from Bricker’s
group. Afterwards, Bricker reported a series of 307
patients, with lethality rate of 12.4% and only 3.4%
related to procedure. Since the metabolic
shortcomings associated with the
ureterosigmoidostomy have been overcome,
Bricker’s technique became the gold standard for
the next 35 years, without substantial changes
until today.
The History of Urinary Diversion. D.T. Basic1, J. Hadzi Djokic, I.
Ignjatovicl. Urological Clinic, Clinical Center Nis. Institute of Urology
and Nephrology, Clinical Center of Serbia, Belgrade Serbia.
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Hautmann, R E; Stenzl, A; Studer, U E; Volkmer, B G
Methods of Urinary Diversion. Deutsche Arzteblatt 2007; 104(16): A 1092–7. Mansoura is in Egypt &
Lund is in Sweden
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Hautmann, R E; Stenzl, A; Studer, U E; Volkmer, B G
Methods of Urinary Diversion. Deutsche Arzteblatt 2007; 104(16): A 1092–7
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Hautmann, R E; Stenzl, A; Studer, U E; Volkmer, B G
Methods of Urinary Diversion. Deutsche Arzteblatt 2007; 104(16): A 1092–7
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Metabolic abnormalities continent urinary diversion
Metabolic and
histological
complications in ileal
urinary diversion:
Challenges of tissue
engineering technology
to avoid them. C.
ALBERTI, European
Review for Medical and
Pharmacological Sciences
2007; 11: 257-264
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Metabolic abnormalities continent urinary diversion
Metabolic and
histological
complications in ileal
urinary diversion:
Challenges of tissue
engineering technology
to avoid them. C.
ALBERTI, European
Review for Medical and
Pharmacological Sciences
2007; 11: 257-264
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Urinary reflux and stenosis
Oosterlink W. Lobel B, Jakse G, Malstrom PU, Stoeckle M, Sternberg
C. Guidelines on bladder cancer. Eur. Urol 2002; 41: 105-12
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Detubularized diversions
J-pouch, neobladder, coloplasty*, etc…
Detubularized or reconfigured diversions
for urine or stool suffer similar trade offs.
Achieving “continence” with internal reservoirs
results in lower pressure systems, which may
benefit the continence and storage aspects at the
expense of increased residual or incomplete
emptying aspects.
Pressure = tension/radius (Laplace’s Law)
Volume of sphere = 4/3πr3C
* ..plasty = changing shape of an organ
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Detubularized diversions
Laplace's Law
The larger the vessel radius, the larger the wall tension
required to withstand a given internal fluid pressure.
For a given vessel radius and internal pressure, a spherical
vessel will have half the wall tension of a cylindrical
vessel.
http://hyperphysics.phy-astr.gsu.edu/Hbase/imgmec/lapl1.gif
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Pouch wear times (50 years ago)
Number of days
Number of respondents
<1
67
1
253
2
252
3-5
499
6-7
167
1-2 weeks
48
>2 weeks
19
Lenneberg and Rowbotham The Ileostomy Patient: A Descriptive Study of 1425
Persons published by Charles C. Thomas of Springfield, Illinois in 1970. Page 45.
Essentially, this book describes their targeted research on pouch wear times and
reasons for changes for ileostomates from the period of 1958-1962 and comprises
the tabulated results of 1355 ileostomy only participants.
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Pouch wear times (today 2008)
Stoma type
Number of
participants
Percent
Average wear
time
Colostomy
203
36.9
4.55
Ileostomy
238
43.3
5.01
Urostomy
109
19.8
5.02
Total n = 551
JWOCN Vol 35/No 5
September/October 2008 Richbourg et al, page 507
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Pouch wear times assessed
It would appear that the durability of the average
pouch wear times has held relatively constant over
a half century, and, in fact, the Lenneberg study
was much more useful since it limited its study to
only drainable ileostomy pouch wearers, and also
identified reasons for complete appliance removal
from skin during pouch changes.
The Richbourg study included all ostomy types
and failed to distinguish between closed end or
drainable pouches, one piece or two piece, wafer
vs. pouch changes and also failed to identify
reasons for changes.
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Historical turning points
Incontinent Stomas
Brooke , Crile & Turnbull - early 1950s
Reusable Pouches
Strauss/Koenig – 1936
Gricks – 1939
Orowan – 1963 (convexity)
CIRA > UOA >ETs > WOCNs >UOAA
Disposable Pouches (1950s onward)
Coloplast (Sweden) - one piece adhesive & Conseal Plug
(1980s)
Marsan - multi piece adhesive or karaya wafer
Hollister - all-in-one pouch & karaya wafer
E.R. Squibb – Orahesive® dental bandage > Stomahesive®
Continent Outcomes (with and without stomas)
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Historical – Koenig & Orowan
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Coloplast Conseal Plug-1980s
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Historical turning points - pouches
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Ostomy pouch oddities
http://monstercrochet.blogspot.com/2005/0
7/you-crocheted-what.html
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Davol pouch in use
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Davol pouch – before, during, after
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Historical tidbits – outer space
No astronaut has defecated on the moon;
however, urine was left in the lunar module
descent stage on the moon’s surface.
In a closed cabin, flatus was annoying; however,
the Apollo crews took out their emergency O2
masks and used them frequently for protection
against the obnoxious odor.
In the Gemini flights a small fecal bag with an
attached finger cot on the side was adhered to the
perineum.
Lomotil® became the drug of choice to minimize
stooling.
Gemini XII flight and Gemini Program Summary. Fact
Sheet 291-1, NASA, Dec. 1966.
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Czechoslovakian father of loop
colostomy (12/28/1883)
Karl Maydl 1853-1903
Oliver Pfaar. Karl Maydl. Dis Colon Rectum 2001; 44(2): 280-283.
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Quiz time, again
Which organ system has the greatest
exposure to the outside elements?
Is it the skin?
Are you sure of your answer?
Or, is it the GI tract?
Drum roll, please…
GI tract!!!
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Bowel Surface Area
http://images.google.com/imgres?imgurl=http://www.colorado.edu/intphys/Class/IPHY3
430-200/image/villi.jpg&imgrefurl=http://www.colorado.edu/intphys/Class/IPHY3430200/020digestion.htm&h=371&w=660&sz=97&hl=en&start=1&usg=__DcANUpgpWvK
QCxiheQK9vC1LJwc=&tbnid=q2tm0ZmML9B65M:&tbnh=78&tbnw=138&prev=/images
%3Fq%3Dneural%2Banatomy%2Bof%2Bthe%2Bintestine%26gbv%3D2%26hl%3Den
%26sa%3DG. Accessed 10/29/2008
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Speaking of skin…
“The intestinal surface area is approximately 100
times the skin body surface area, that is, it is in the
order of 200 m2 (an adult body skin surface area
ranges from 1.5 to 2 m2, typically 1.75m2).”
Max E. Valentinuzzi. Understanding The
Human Machine: A Primer for Bioengineering.
World Scientific, New Jersey, 2004. page 152.
N.B. a tennis court is approximately 228 m2,and
not much larger than the area of the intestine.
http://en.wikipedia.org/wiki/Tennis_court
Accessed 10/17/2008
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Comparative surface areas
Skin area
Lung area
Intestinal area
http://www.vendian.org/envelope/dir2/lungsout.html
Accessed 10/17/2008
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Skin graphic
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Skin has layers
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Skin layers lost to tape removal trauma
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Skin: peristomal contours
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Some more skin questions
Why do some barriers irritate more so
than others?
ICD (irritant contact dermatitis) vs.
ACD (allergic contact dermatitis)?
How to decide rigid vs. flexible
selection?
Why does scratching cause a skin
flare?
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Some skin answers
Why do some barriers irritate more so than
others?
Idiopathic predilection (behavioral & genetic)
Barrier ingredients
Mechanical & related factors:
Pressure
Friction
Duration
Too wet or too dry skin state
pH – alkalinity increases risks
Age
Cleansing and prepping products & techniques
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Some more skin answers
Traumatic or irritant adhesive dermatitis
The greatest number of skin reactions which
are observed in relation to the wearing of
adhesive tapes or barriers are of a mechanical
nature.
Shearing at the tape-skin interface & edges
Plugging of follicles and sweat pores
The dermatitis caused by trauma usually
remains strictly localized to the site of contact
with the adhesive, while allergic reactions tend
to spread beyond the area of actual contact.
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ICD versus ACD
ICD
ACD
Diseased skin
All exposed areas
Only sensitized
areas
Concentration
dependency
Dose effect &
duration
“all or nothing”
Subjective qualities
Burning, stinging
Itching
Objective qualities
Erythema, edema,
bulla, necrosis,
desquamation
Erythema, papule,
vesicle
Diagnosis (dx)
No dx test
Patch test
Gebhardt, Elsner & Marks. Handbook of Contact Dermatitis. Martin
Dunitz, London, 2000. table 4.1
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Dermatitis book references
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Rigid versus flexible pouch/wafer
This is more art than science
Many factors to consider
Body habitus and lifestyle concerns
Comfort level or perceptions
If peristomal skin planes are very
challenging then skillful assessment is
needed, and flexible or rigid may be in
order – there are no hard and fast
rules here!
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Scratch an itch and make it worse
Note that some people are itchers while
others are not
Koebner’s Phenomenon
The Koebner phenomenon is the development of isomorphic*
pathologic lesions in the traumatized uninvolved skin of patients
who have cutaneous diseases. It refers to the fact that in
persons with certain skin diseases, especially psoriasis,
trauma is followed by new lesions in the traumatized but
otherwise normal skin, and these new lesions are clinically and
histopathologically identical to those in the diseased skin.
http://www.ijdvl.com/article.asp?issn=03786323;year=2004;volume=70;issue=3;spage=187;epage=189;aulast
=Thappa. Accessed 10/23/2008
*Isomorphic = different ancestry but same appearance
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Koebner = Psoriatic flare
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Scratch an itch and make it worse
Lewis wheal effect
Sir Thomas Lewis, in 1927, described the triple response
to a blunt instrument, such as the handle of a reflex
hammer, being pulled firmly across the skin: a relatively
narrow red streak develops in the path of the instrument,
followed by a red flare extending several centimeters out,
and finally elevation of the skin (wheal formation). The
elements of the triple response involve respectively
capillary dilation, arteriolar dilation, and exudation into
the extravascular space as histamine is released from
mast cells and basophils. In so many words, the firm
pressure on the skin produces an acute inflammatory
response.
http://findarticles.com/p/articles/mi_qa3841/is_/ai_n9138879.
accessed 10/23/2008
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tape > irritant contact dermatitis (ICD) > severe
itching > aggressive scratching + pouch > maceration
> contributes to yeast overgrowth + Skin Prep® wipes
> increased chemical sensitization > vicious cycle of
trauma and insult (Lewis Wheal effect)!!!
11/22/2008
Mike D'Orazio, ET
69
Diverted or bypassed organs
Although an ostomy diversion now
functions for the detoured GI or
urinary tract, any remnant structures
will likely still produce their own
accumulating physiological debris,
such as mucus, blood and other
shedding cells.
E.g., do not be alarmed if you still feel
the urge to take a poop or a pee as
before!
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Pharmacists need to be your ally
The complexities of an altered GI & GU
tract and the myriad advances and
characteristics of medicines really demand
a close liaison with you, the prescriber and
the knowledgeable pharmacist.
You must take the initiative to inform about
your ostomy circumstances and work with
the prescriber and the pharmacist – they
do not read minds!
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Mike D'Orazio, ET
71
Ostomates’ motto
Borrow the wisdom of the scouts and
always plan ahead and be prepared for all
possible contingencies.
Back up supplies readily available?
Murphy’s law accounted for?
Have extra supplies, will travel?
Comfortable in your ostomy role?
Others know what to do for you?
Now, get on with pottying as well and as
normally as you can!!
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Mike D'Orazio, ET
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The Art of Ostomy Potty
Once Upon A Throne
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Mike D'Orazio, ET
73
Foreground (pre ostomy) check
Toilet – check!
Cleanliness – check!
Location – check!
Toilet paper – check!
Wash up – check!
Out of here – ASAP! (unless you use
the throne for secondary gains)
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Mike D'Orazio, ET
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Potty Patterns B.O. (Before Ostomy)
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Potty Patterns P.O. (Post Ostomy)
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Mike D'Orazio, ET
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Toileting survey asks
Front facing
sitters?
Rear facing sitters?
Side saddle
aficionados?
Kneelers?
Stand ups?
Slobs?
Neat freaks?
Procrastinators?
Expediters?
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Mike D'Orazio, ET
my preference
77
Toilet police wants to know
How much toilet paper?
How many flushes?
Do low flush toilets work well for fecal
ostomates?
Who fits or not upon the throne?
Who whistles?
Who hums?
Who’s uptight?
Who’s carefree?
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Mike D'Orazio, ET
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Remember, Ostomy = tradeoff
I hope this little presentation helped
enlighten and entertain you and brought
additional insights to aid your
understanding of ostomy tradeoffs.
Thank you, and continued ostomy potty
success!
Mike ET
11/22/2008
Mike D'Orazio, ET
79