--
Larry R. Glazerman, MD
Ob-Gyn at Trexlertown, PC
610-402-0161
l.glazerman@rcn.com
_____
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Elrod
Darryl G MAJ 48 MDOS/SGOBO
Sent: Wednesday, September 28, 2005 4:13 AM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Opinions on laparoscopy (long)
WBC was initially around 11-12 now fairly constant at 7. Bladder injury
would have nearly been impossible since there wasn't any obvious disease in
the anterior culdesac and I stayed well away from the bladder.
New this morning is her C diff is positive.
I can't wait to dictate this discharge summary.
Glen
_____
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Jay 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. <mailto:apgar10@montanadsl.net> Montgomery, M.D.
To: Multiple <mailto:ob-gyn-l@dns.obgyn.net> recipients of list OB-GYN-L
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
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