Presentation on theme: "11/22/2008 Mike D'Orazio, ET1 Weird or Arcane Ostomy and Other Info Some myths, some facts and some things to ponder courtesy of Mike ET."— Presentation transcript:
11/22/2008 Mike D'Orazio, ET1 Weird or Arcane Ostomy and Other Info Some myths, some facts and some things to ponder courtesy of Mike ET
Mike – Ostomate – ET 11/22/2008 Mike D'Orazio, ET USN ET – WOCN Conf.
11/22/2008 Mike D'Orazio, ET3 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.
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. 11/22/2008 Mike D'Orazio, ET4
11/22/2008 Mike D'Orazio, ET5 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?
11/22/2008 Mike D'Orazio, ET6 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?
11/22/2008 Mike D'Orazio, ET7 “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?
Bowel nerves book references 11/22/2008 Mike D'Orazio, ET8
11/22/2008 Mike D'Orazio, ET9 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
11/22/2008 Mike D'Orazio, ET10 Muc = mucosa SM = submucosa CM = circular muscle MP = myenteric plexus Lm = longitudinal muscle John B. Furness, Wolfgang A. A. Kunze and Nadine Clerc. Am J Physiol Gastrointest Liver Physiol 277: , 1999.
11/22/2008 Mike D'Orazio, ET11 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
11/22/2008 Mike D'Orazio, ET12 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.
11/22/2008 Mike D'Orazio, ET13 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: , John B. Furness, Wolfgang A. A. Kunze and Nadine Clerc. page G924
11/22/2008 Mike D'Orazio, ET14 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.
11/22/2008 Mike D'Orazio, ET15 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.
Parastomal hernia 11/22/2008 Mike D'Orazio, ET16
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 Apr;145: /22/2008 Mike D'Orazio, ET17
11/22/2008 Mike D'Orazio, ET18 Arcuate line anatomy 1. Posterior wall of rectus sheath 2. Arcuate line 3. Linea alba 4. Rectus abdominis 5. Inferior epigastric vessels coursepages/M1/anatomy/htm l/atlas/abdo_wall61.html Accessed 10/25/2008
11/22/2008 Mike D'Orazio, ET19 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!
Osmosis: The Goldilocks Principle Hypertonic is too much Isotonic is just right! Hypotonic is too little 11/22/2008 Mike D'Orazio, ET20 nr/cells/cell%20pics/osmosisMicrogra phs.jpg
Diffusion: The Nose Knows 11/22/2008 Mike D'Orazio, ET21 I hope this doesn’t smell like my ostomy bag!!
11/22/2008 Mike D'Orazio, ET22 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 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 centimeter.
11/22/2008 Mike D'Orazio, ET23 Vitamin B 12 concerns The terminal 18” (≈ cm) of the ileum is critical for vitamin B 12 (cobalamin) and bile acid absorption. It is prudent to reassess B 12 levels for any suspect patients since it takes 2-4 years to deplete B 12 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.
11/22/2008 Mike D'Orazio, ET24 Fecal diversions and urinary stones 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): Accessed 10/16/2008
11/22/2008 Mike D'Orazio, ET25 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.
11/22/2008 Mike D'Orazio, ET26 Gas, flatulence or farts Subject condition Number of daily farts Approx. daily volume in liters Swallowed air/gas Gut produced gas – non smelly Smelly component of gas Normal10 +/- 12 N 2 (16%) O 2 (3%) CO 2, (10%) H 2, (9%) CH 4 (18%) Sulfur groups H 2 S <1% Lactose intolerant (osmosis also at work here) 19 +/- 2.4 ↑ (diarrhea also increases) ↔↑? SIBO small intestinal bacterial overgrowth ↑↑↔↑ Sulfur & other gases ↑
11/22/2008 Mike D'Orazio, ET27 Odoriferous flatus: women’s curse SubjectsTotal vol. per passage H 2 S conc. µmol/L MES conc. µmol/L DMS conc. µmol/L Total conc. µmol/L Odor intensity scale: 0 (no odor) to 8 (very offensive) Judge 1 Judge 2 All Men N = Women N = N.B.: H 2 S = 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
11/22/2008 Mike D'Orazio, ET28 Stool odor relief “Bismuth is supposed at times to relieve diarrhea by combining with the H 2 S 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 H 2 S release. The ability of bismuth subsalicylate to dramatically reduce H 2 S could provide a clinically useful means of controlling fecal odor and / or flatus and of decreasing the putative injurious effects of H 2 S on the colonic mucosa.” Fabrizis, Suarez, Furne, Springfield & Levitt: Bismuth Subsalicylate Markedly Decreases Hydrogen Sulfide Release in the Human Colon. Gastroenterology 1998; 114: Bismuth subgallate (C 7 H 5 BiO 6 ) is found in Devrom ®.
Pee Break 11/22/2008 Mike D'Orazio, ET29
11/22/2008 Mike D'Orazio, ET30 Pee break: Ureterosigmoidostomies AuthorYearEvent John Simon1851First urinary diversion Thomas Smith1878First direct ureterointestinal implantation Karl Maydl1892Implantation of the trigone into the sigmoid George Fowler1896First antireflux ureterointestinal implantation Robert Coffey1911First successful antireflux ureterointestinal implantation Wyland Leadbetter1951First 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.
11/22/2008 Mike D'Orazio, ET31 Pee break: Cutaneous Ileal conduits Eugene Bricker established the use of the ileal conduit in 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.
11/22/2008 Mike D'Orazio, ET32 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
11/22/2008 Mike D'Orazio, ET33 Hautmann, R E; Stenzl, A; Studer, U E; Volkmer, B G Methods of Urinary Diversion. Deutsche Arzteblatt 2007; 104(16): A 1092–7
11/22/2008 Mike D'Orazio, ET34 Hautmann, R E; Stenzl, A; Studer, U E; Volkmer, B G Methods of Urinary Diversion. Deutsche Arzteblatt 2007; 104(16): A 1092–7
11/22/2008 Mike D'Orazio, ET35 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:
11/22/2008 Mike D'Orazio, ET36 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:
11/22/2008 Mike D'Orazio, ET37 Urinary reflux and stenosis Oosterlink W. Lobel B, Jakse G, Malstrom PU, Stoeckle M, Sternberg C. Guidelines on bladder cancer. Eur. Urol 2002; 41:
11/22/2008 Mike D'Orazio, ET38 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 / 3 πr 3 C *..plasty = changing shape of an organ
Detubularized diversions 11/22/2008 Mike D'Orazio, ET39 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.
11/22/2008 Mike D'Orazio, ET40 Pouch wear times (50 years ago) Number of daysNumber of respondents < weeks48 >2 weeks19 Lenneberg and Rowbotham The Ileostomy Patient: A Descriptive Study of 1425 Persons published by Charles C. Thomas of Springfield, Illinois in Page 45. Essentially, this book describes their targeted research on pouch wear times and reasons for changes for ileostomates from the period of and comprises the tabulated results of 1355 ileostomy only participants.
11/22/2008 Mike D'Orazio, ET41 Pouch wear times (today 2008) Stoma typeNumber of participants PercentAverage wear time Colostomy Ileostomy Urostomy Total n = 551 JWOCN Vol 35/No 5 September/October 2008 Richbourg et al, page 507
11/22/2008 Mike D'Orazio, ET42 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.
Historical – Koenig & Orowan 11/22/2008 Mike D'Orazio, ET44
Coloplast Conseal Plug-1980s 11/22/2008 Mike D'Orazio, ET45
11/22/2008 Mike D'Orazio, ET46 Historical turning points - pouches
Ostomy pouch oddities 11/22/2008 Mike D'Orazio, ET47 7/you-crocheted-what.html
Davol pouch in use 11/22/2008 Mike D'Orazio, ET48
Davol pouch – before, during, after 11/22/2008 Mike D'Orazio, ET49
11/22/2008 Mike D'Orazio, ET50 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 O 2 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
11/22/2008 Mike D'Orazio, ET51 Czechoslovakian father of loop colostomy (12/28/1883) Karl Maydl Oliver Pfaar. Karl Maydl. Dis Colon Rectum 2001; 44(2):
11/22/2008 Mike D'Orazio, ET52 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!!!
Bowel Surface Area 11/22/2008 Mike D'Orazio, ET /image/villi.jpg&imgrefurl=http://www.colorado.edu/intphys/Class/IPHY /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
11/22/2008 Mike D'Orazio, ET54 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 m 2 (an adult body skin surface area ranges from 1.5 to 2 m 2, typically 1.75m 2 ).” Max E. Valentinuzzi. Understanding The Human Machine: A Primer for Bioengineering. World Scientific, New Jersey, page 152. N.B. a tennis court is approximately 228 m 2,and not much larger than the area of the intestine. Accessed 10/17/2008
11/22/2008 Mike D'Orazio, ET55 Comparative surface areas Lung area Skin area Intestinal area Accessed 10/17/2008
11/22/2008 Mike D'Orazio, ET56 Skin graphic
11/22/2008 Mike D'Orazio, ET57 Skin has layers
Skin layers lost to tape removal trauma 11/22/2008 Mike D'Orazio, ET58
11/22/2008 Mike D'Orazio, ET59 Skin: peristomal contours
11/22/2008 Mike D'Orazio, ET60 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?
11/22/2008 Mike D'Orazio, ET61 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
11/22/2008 Mike D'Orazio, ET62 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.
11/22/2008 Mike D'Orazio, ET63 ICD versus ACD ICDACD Diseased skinAll exposed areasOnly sensitized areas Concentration dependency Dose effect & duration “all or nothing” Subjective qualitiesBurning, stingingItching Objective qualitiesErythema, edema, bulla, necrosis, desquamation Erythema, papule, vesicle Diagnosis (dx)No dx testPatch test Gebhardt, Elsner & Marks. Handbook of Contact Dermatitis. Martin Dunitz, London, table 4.1
Dermatitis book references 11/22/2008 Mike D'Orazio, ET64
11/22/2008 Mike D'Orazio, ET65 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!
11/22/2008 Mike D'Orazio, ET66 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 ;year=2004;volume=70;issue=3;spage=187;epage=189;aulast =Thappahttp://www.ijdvl.com/article.asp?issn= ;year=2004;volume=70;issue=3;spage=187;epage=189;aulast =Thappa. Accessed 10/23/2008 * Isomorphic = different ancestry but same appearance
Koebner = Psoriatic flare 11/22/2008 Mike D'Orazio, ET67
11/22/2008 Mike D'Orazio, ET68 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. accessed 10/23/2008
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, ET69
11/22/2008 Mike D'Orazio, ET70 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!
11/22/2008 Mike D'Orazio, ET71 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!
11/22/2008 Mike D'Orazio, ET72 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!!
11/22/2008 Mike D'Orazio, ET73 The Art of Ostomy Potty Once Upon A Throne
11/22/2008 Mike D'Orazio, ET74 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)
11/22/2008 Mike D'Orazio, ET75 Potty Patterns B.O. (Before Ostomy)
11/22/2008 Mike D'Orazio, ET76 Potty Patterns P.O. (Post Ostomy)
Toileting survey asks Front facing sitters? Rear facing sitters? Side saddle aficionados? Kneelers? Stand ups? Slobs? Neat freaks? Procrastinators? Expediters? 11/22/2008 Mike D'Orazio, ET77 my preference
11/22/2008 Mike D'Orazio, ET78 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?
11/22/2008 Mike D'Orazio, ET79 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