--
________________________________
Kulkin
Sent: Tuesday, September 27, 2005 6:16 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Opinions on laparoscopy (long)
We used to leave 1L of fluid or more in the pelvis for "floatation
effect" to avoid adhesion formation so i don't think leaving her a bit
wet was an issue. Clearly, some type of physiologic/ anatomic issue
here. If she started to diurese, her fluid was somewhere to be
mobilized back to the intravascular space so I'm doubting the ascites is
urine---unless we have a bladder injury with resultant illeus which may
be associated with ascites. Would like to know why this healthy, young
women would third space at all? Would have expected her to be febrile
with abowel injury -yousaid her h/h was stable. What about her white
count?
Jay
Jay M. Kulkin, MD MBA FACOG
Women's Institute For Health PC
975 Johnson Ferry Road
Suite 460
Atlanta, Georgia 30342
Ph: 404.832.0300
Fax: 404-832-0070
http://www.wifh.com
> ----- Original Message -----
From: Lynn D. Montgomery, M.D. <mailto:apgar10@montanadsl.net>
To: Multiple recipients of list OB-GYN-L
<mailto:ob-gyn-l@dns.obgyn.net>
Sent: Tuesday, September 27, 2005 12:53 PM
Subject: RE: Opinions on laparoscopy (long)
Should be able to perform electrolytes on the aspirated fluid to
determine if indeed it is urine.
Sounds like a urinoma. I believe your ascites is urine.
Was the CT with kidney contrast? And was the radiologist thinking
urine in abd. I have seen this picture that radiologists (good ones)
missed. All you see is a cloudy abd pix. If no contrast given, you may
want to redo the study.
________________________________
________________________________
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On
Behalf Of Elrod Darryl G MAJ 48 MDOS/SGOBO
Sent: Tuesday, September 27, 2005 12:16 PM
To: Multiple recipients of list OB-GYN-L
Subject: Opinions on laparoscopy (long)
Last week I operated on a 23 yo G0, young healthy active
duty woman. She had previously had laparoscopy for pelvic pain where
they fulgurated endometriosis. By her op pictures, the implants were
located in the posterior cul de sac across both uterosacral ligaments
and between them over the upper vagina and rectum. There did not appear
to be much in the anterior cul de sac. Prior to me seeing her, she had
also gone through 6 months of Depo Lupron with add back.
My approach was going to be excision of peritoneal
implants rather than recauterizing implants.
Surgery was fairly uneventful. I was able to use sharp
dissection to peel away most of the peritoneum from the posterior
culdesac and both ovarian fossas. Both ureters were seen before and
after the dissection. I had a rectal probe in the rectum and a sponge
stick in the vagina to be able to locate these. Blood loss was about
100ml. I tried not to burn much so I left it a bit 'oozy' but by no
means actively bleeding.
In PACU her pain wasn't well controlled and she couldn't
void. She was then admitted.
Serial H/H over the next 24hrs were stable. VS
initially were stable as well. She was able to void 100-200ml at a
time. Pain was still an issue so she stayed.
On POD 2 now, she became hypoxic with desats to the 80s
on RA. O2 was added and she came back up to normal. At the same time
she became tachycardic with HR to 130s. EKG, CXR and KUB were orderd.
EKG-sinus tach
CXR-right pleural effusion
KUB-dilated large bowel with all bowels apparently
pushed to the midline, with presumptive diagnosis of ascites.
Days begin to get fuzzy at this point, but over the next
several days the following happen.
Foley gets put in with 1000ml out, grossly infected and
subsequently grows out E coli. Cipro started.
BUN/Cr bump to 25/2.5 IVF changed and within a day
renal function normalizes. Renal ultrasound normal. Ascites confirmed.
Pt still is not passing flatus nor tolerating any clears.
By POD 5-6 pt begins to diurese well, begins to have
some liquid stool but still vomiting.
Last night, NG tube placed with 950ml out. Today pt
vomits NG out.
CT scan today shows clearance of pleural effusions,
large amount of ascites but no dilated bowels or signs of abscess. Labs
show electrolyte disturbances (low K, low phosp, low magnesium) all
being replaced.
Pericentesis just done with clear fluid noted. Cell
count, gram stain and culture all pending.
Can anyone make sense of a plausible cause for this? As
I've read some things on Endometriosis Zone on obgyn.net it seems all
I've done previously with simple fulguration of endometriosis isn't
really doing anything to treat the disease. So I tried to expand my
thinking and skills and do a more aggressive excision. Now I'm stumped
and not sure I did the right thing by this patient.
I appreciate the help
Glen
//SIGNED//
D. Glen Elrod, Maj., USAF, MC
Obstetrician/Gynecologist
Chief of Obstetrics
48 MDOS/SGOBO
RAF Lakenheath, England
Telephone DSN: 314-226-8130
Comm: +44 (0) 1638 52 8130
Notice of Confidentiality
Under the Privacy Act of 1974, you must safeguard all
information reflected on this e-mail and, if applicable, all
attachments. Disclosure of information is IAW AFI 33-119, AFI 33-127,
AFI 37-131, AFI 37-132, AFI 33-219, and PL 93-579"
This e-mail message including any attachments is for the
sole use of the intended recipient(s) and may contain confidential and
privileged information. Any unauthorized review, use, disclosure or
distribution is prohibited. If you are not the intended recipient,
please contact the sender by reply e-mail and destroy all copies of the
original message. Any questions pertaining to disclosure should be
directed to the privacy officer.
