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Fri Nov 6 12:16:36 GMT 2009

Errington:

Yes, I do recall that...I apparently missed the bit about the mini  
thoracotomy being to place *external* pacer leads on the heart. my bad.

and even if I never had a chance to watch one, I am aware of Kocher's  
procedure to reflect the duodenum to the left in order to get better access. I  
stopped and looked it up just to make sure that the comment would be  
appropriate...but I guess you don't recall Dr. Clay's old joke about asking for  a 
particular toothed clamp while doing a choley with Dr.  Oschner...Which 
goes to show just how much influence Dr. Oschner had on medical  education in 
Louisiana.

and while you didn't specify your relationship to the patient initially, I  
also remember how you were willing to dig a bit more on your patients to 
get the  best background possible, so I figured that you might have found some 
preop  films to compare to the findings on CT. Considering the number of 
unilaterally  elevated hemi diaphragms I've seen in the ED in 'virgin' 
patients, I was not  willing to assign the blame for the paralyzed muscle to the 
operation without  some evidence that it was NOT present preop.

ck

In a message dated 11/6/2009 06:01:32 Central Standard Time,  
errington at erringtonthompson.com writes:

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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