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Fri Nov 6 11:59:07 GMT 2009

Chuck - 

As you recall, the phrenic nerve lies lateral on the heart. It is very easy
to get it caught up in some sutures while placing external pacer leads. (see
photo)

Also, the Kocher maneuver is where you free up (mobilize) the duodenum from
its posterior attachments. 

Finally, I didn't order any of this patient's tests. He is going to another
MD and contacted me for a second opinion. 

E

Errington C. Thompson, MD, FACS, FCCM
Trauma/Critical Care
Talk Show Host - WPEK 880 AM
www.whereistheoutrage.net

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Krin135 at aol.com
Sent: Thursday, November 05, 2009 8:25 AM
To: trauma-list at trauma.org
Subject: Re: gastric issue

chuckle...ET might want to use Oschner's clamps in his procedure rather  
than Kocher's...

but I agree...time for a test of Bard Parker on the patient, and get that  
gut tied back into the proper position.

ET: were you suspicious that the diaphragm was paralyzed *before*  the 
pacer was placed (excessively elevated left hemi diaphragm on a pre op CXR)?
I 
can't think of any simple way that a pacer placement could cause the  
paralysis you mentioned.

ck

In a message dated 11/5/2009 07:02:38 Central Standard Time, nappio at aol.com 
 writes:

Sounds  like intermittent gastric volvulous exacerbated by the diaphragm 
eventration  and high duodenal bulb.  Kocherize the duodenum and throw in a 
temporary  g-tube to tether it down. Possibly laparoscopically.dn
------Original  Message------
From: Errington Thompson
Sender:  trauma-list-bounces at trauma.org
To: 'Trauma-List [TRAUMA.ORG]'
ReplyTo:  Trauma-List [TRAUMA.ORG]
Subject: RE: gastric issue
Sent: Nov 5, 2009  07:11

Gallbladder is normal size on CT and there is no fluid around  the
gallbladder. Liver looks good. No inflammatory changes anywhere in  the
abdomen. 

Thanks. 

Errington C. Thompson, MD, FACS,  FCCM
Trauma/Critical Care
Talk Show Host - WPEK 880  AM
www.whereistheoutrage.net

-----Original Message-----
From:  trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]
On  Behalf Of Krin135 at aol.com
Sent: Wednesday, November 04, 2009 10:34  PM
To: trauma-list at trauma.org
Subject: Re: gastric issue

what's  his gall bladder status? Does he have anything that might make you  

think of a small perforating ulcer that got wrapped up in the omentum?  
what 
you  are describing sounds like a traction torsion due to an  adhesion. 
Since

your  patient is a male, Fitz-Hugh Curtis syndrome  is unlikely, and 
there's 
not that  much else up there in a virgin  belly....

ck

In a message dated 11/4/2009 21:24:07 Central  Standard Time,  
errington at erringtonthompson.com writes:

I have  a  60 year old male whose only previous operation was  a
mini-thoracotomy for  pacemaker lead placement. For the last 6 - 8  months 
(3
years after the  pacemaker), the patient has been unable to  eat as much as 
he
normally did.  He has lost weight because he  can't eat like he should. He 
has
lost about  50 lbs (he is now  down to 250lbs). He got an upper GI which 
shows
the  distal  portion of his stomach flipped up on top of the proximal   
portion
causing a pseudo-obstruction. The dye does pass thru the  stomach  slowly 
and
into the duodenum. CT of the abd - reveals the  same thing.  Nothing else. 
He
also had a snuff test which was done  under flouro which  shows that his 
left
hemidiaphragm is paralysed.  

Any  thoughts?

Errington C. Thompson, MD, FACS,  FCCM
Trauma/Critical  Care
Talk Show Host - WPEK 880   AM
www.whereistheoutrage.net

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