DEAR READER:
The heart is enclosed in a two-layered sac-like structure called the pericardium. Pericardial effusion occurs when extra fluid gathers in between the two layers. Typically there is a small amount of fluid but damage, injury, inflammation and more can cause the amount of fluid to increase. As the fluid increases, it restricts the heart’s ability to pump efficiently.

Symptoms of pericardial effusion include shortness of breath, cough, fainting, dizziness, painful breathing, chest pain, rapid heart rate, low-grade fever, sense of weakness and more. In some cases symptoms may not be noticeable or present at all. This is especially true in individuals in whom the fluid has gradually increased due to certain disorders.

There are several causes including infection, cancer, autoimmune disorders, hypothyroidism, radiation, HIV, chemotherapy, trauma, some prescription medications, kidney failure and more. In some cases, the cause cannot be identified.

Treatment varies from person to person depending on the amount of fluid, the cause, and whether or not it is or could cause decreased heart function. Common treatments include anti-inflammatory medications and various procedures. These can include needle aspiration to remove the fluid, open heart surgery (primarily for bleeding into the space), sealing the two layers together, and removal of all or part of the pericardium.

If your friend is displaying symptoms and has recurrent effusion, he needs to follow his cardiologist’s advice. Severe or repeated episodes can cause heart weakening, heart failure and death if not properly treated.

To give you related information, I am sending you copies of my Health Reports “Coronary Artery Disease” and “An Informed Approach to Surgery”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 per report to Newsletter, PO Box 167, Wickliffe, OH 44092.

My question to you is, what do I do now?

DEAR READER:
Abdominal aortic aneurysms (AAA) are potentially fatal areas of bulging or ballooning of the large blood vessel that supplies the abdomen, pelvis and legs. They can occur in anyone but are most common in males over 60 with one or more risk factors.

Those factors include emphysema, smoking, high blood pressure, obesity, high cholesterol, being male, and certain genetic factors. There is no known cause.

In most cases, the aneurysm is found during routine screening tests or imaging studies for other conditions. Most aneurysms do not cause symptoms. They usually develop slowly over time but occasionally expand rapidly leading to rupture, dissection (bleeding from the inner wall into the outer wall of the vessel) or other symptoms. All aneurysms carry risks but small ones generally go unnoticed. Large aneurysms are more serious and are more likely to rupture spontaneously and cause symptoms.

Symptoms are usually the result of rupture or dissection and include nausea, vomiting, back or abdominal pain, anxiety, clammy skin, an abdominal mass, abdominal rigidity, rapid heart rate upon standing, a pulsating sensation in the abdomen, and shock. Rupture is a medical emergency and immediate attention is necessary.

Treatment is available. Small, non-symptomatic aneurysms should be monitored on a yearly basis to check for expansion. If the aneurysm causes symptoms, rapidly expands, or is larger than 5.5 centimeters, surgery is often done to prevent complications such as leaks or rupture.

There are currently two types of surgery available. The first is a traditional version which involves making a large incision. The damaged vessel is then replaced with a synthetic material. The second is called endovascular stent grafting which uses several smaller incisions in the groin to access the vessels. The grafting material is then snaked up the artery and put into place in the abnormal area. This type of surgery may have a faster healing time but is not recommended for every sufferer.

If surgery is successfully performed before rupture, the outcome is generally favorable. However, if rupture occurs, less than 40% of patients survive.

I urge you to follow your surgeon’s advice. If you smoke, are overweight or have other risk factors, take steps to reduce or eliminate them. If you are still concerned, request a referral for another opinion.

To give you related information, I am sending you copies of my Health Reports “An Informed Approach to Surgery” and “Blood — Donations and Disorders”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 per report to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title(s).

To date I still have a seroma which must be drained once a month and now my surgeon wants to do another surgery to see what is wrong. Have you ever heard of this problem?

DEAR READER:
A seroma is simply a build-up of fluid that usually follows surgery, especially mastectomy (breast removal). In most cases it disappears on its own. Some seromas may need to be drained, occasionally more than once.

In your case, your seroma has failed to be reabsorbed back into the body and continues to accumulate fluid which, I assume, is causing pain, discomfort or annoyance that necessitates its repeat drainage. It has been more than three years, making this a highly unusual case.

I suggest you take your surgeon’s advice and have the surgery to investigate what is causing the seroma to “stick around” for such a long period of time. He or she can then advise you what to do next to ensure that the seroma does not return.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

Before had the surgery, my left knee cap would slide to the left and lock. The doctor told me to should be replaced. Now, after the surgery, it continues to do the same thing. I often have to take my hand and push it back into place. It happens a lot when I go up and down stairs. Does this sound right to you?

DEAR READER:
I am not an orthopedic knee surgeon. You were told you needed a knee replacement because of a problem with your knee cap, yet after the surgery you still have the same problem. This to me suggests that something was not done correctly.

I recommend you return to the surgeon who operated on you and ask why you had the knee replaced if it did not fix the problem. You are entitled to answers. If your surgeon refuses to help, ask for a copy of your medical and surgical records so that you can take them to be reviewed by a second orthopedist who may be able to tell you what is happening and if it was a problem with the surgery, the prosthetsis or something else.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

In April 2005 I had an abdominal aortic aneurysm which burst while I was on the operating table. Against the odds I lived.

In July 2005 I developed two hernias which were treated non-invasively. In April 2006, I developed three hernias which were again treated non-invasively.

In May of 2006 I had surgery on my left carotid artery because it was 95% blocked. I was fine until March 2008 when I had to have surgery for another hernia. I have enclosed the hospital papers with this letter for your review.

Aug 2008 I returned to the same hospital because of more hernias. The doctor said they could not operate and that I would have to be seen by a specialist at a nearby medical university hospital or the Mayo Clinic. He said they couldn’t do the repair because any further operation might cause me to lose part of my stomach and/or large intestine. I have been wearing an abdominal binder but the bulges are very prominent and painful, especially when I cough which was often since I have COPD.

DEAR READER:
Thank you for sending some back up material as it was helpful in coming up with my answer.

Based on the report, all of your hernia problems have come from your abdominal aneurysm repair. The surgical incision has weakened in several areas allowing the hernias to form. During the first surgical repair, mesh was put in place to prevent further weakening of the area. During the second surgical repair, a new hernia occurred just on the edge of the old mesh and that the old mesh has grown into the flesh. You also had several severe adhesions (areas where two organs fuse together inappropriately). The adhesions where removed, as was the old mesh. A new, larger piece of mesh was put in place and the hernia repaired. At the same time, your umbilicus (belly button) was removed because it had adhered to the mesh.

All of this means that your while your first surgery successfully fixed the hernia, it eventually led to several potentially serious conditions caused by the healing process. Adhesions are essentially a buildup of scar tissue and in your case, this occurred between your stomach, small and large intestine and the surgical mesh. Your body healed too well which led to the problem.

Based on the findings of the second surgery and your current situation, it seems to me that you will continue to have issues with hernias. I am unsure of the cause of this, however, can understand the physician’s stance. Based on your last surgery, the hospital and surgeons are expecting more of the same. Even if your adhesions and hernias are less severe than the previous ones, damage has been done.

Removal of part of the stomach and intestine is major and can lead to complications. I agree with his recommendation to see super specialists at a teaching hospital or the Mayo Clinic. The physicians and surgeons here have access to the newest procedures and protocols. Perhaps they will be able to fix your hernias and prevent them from returning.

I urge you to make an appointment at one of the facilities for a consultation. Be sure to bring your medical records for review as they may play a crucial role in determining your next course of action.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped envelope number 10 and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

Six months ago I had the same procedure. Three months later I had a hernia operation. I recovered with no complications. I was 89 at the time of both surgeries and just had my 90th birthday. I am in good health and enjoy life.

I look forward to reading your column every day. Keep up the good work.

DEAR READER:
Since that particular article came out, I have received hundreds of letters similar to yours. It would appear this “consumer advocate” is not well liked by the consumers. Perhaps he or she should find another profession.

Thank you for writing and sharing your experience with me and my readers.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

I’m 60 years old and carried mail for 34 years. I retired at the age of 55. I don’t know if my occupation has anything to do with my weak stomach lining or not.

My questions are, should I change doctors? Is there any other new procedure besides mesh? Does wearing a truss help any, and how many surgeries can be done on a stomach without causing further damage?

DEAR READER:
Hernias occur when soft tissue protrudes through a tear or weakened area of the lower abdominal wall. This can occur because of strenuous activity, coughing that accompanies smoking, or when muscles weaken later in life.

While some hernias go unnoticed, don’t cause any problems and aren’t discovered until physical examination, others cause great discomfort and are quite painful.

While anyone of any age — including infants and pregnant women — can develop hernias, they are more common in men. One reason might be that with the male fetus, the testicles form within the abdomen and proceed down the inguinal canal into the scrotum. After birth, the canal tightens, leaving adequate room for the spermatic cord to pass through, but inadequate room for the testicles to move back into the abdomen. A weakened area develops when the canal fails to close properly.

There are numerous reasons for a hernia to develop including obesity, chronic coughing or sneezing, straining during defecation or urination, and lifting heavy objects.

The most common, successful hernia repair performed today is hernioplasty, where a physician inserts synthetic mesh into the abdomen to cover the weakened spot. The mesh patch is secured with staples, clips or sutures. It is often done using a laparoscope so the surgeon can make several small incisions rather than one large one. This allows the patient to heal faster with less discomfort and to return to normal daily living sooner.

I cannot say if your 34 years as a mail carrier is the cause for your multiple hernia sites. Perhaps you returned to normal function too quickly, strain too often, or have other reasons for your many hernias. I must admit I have never heard of anyone who has had eight hernias and six surgical repair procedures.

In terms of wearing a truss, this is probably not in your best interests. Some surgeons recommend wearing them once a hernia is discovered until a surgical procedure can be coordinated, but they aren’t recommended for daily use.

I suggest you return to your surgeon and present your list of questions to him or her. If you don’t receive the appropriate answers, go back to your primary care physician and ask for referral to another surgeon. A second opinion is often the appropriate way to go.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped, number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

I am a 74-year-old man. I currently take one Ultram tablet three times a day and one Lyrica tablet twice a day. I have also had two hip replacements in the past 20 years.

When I get up in the morning, my left leg feels like someone has attached an electric wire to it. I also have a great deal of pain in my shoulders. The electrical feeling in my leg and the pain in my shoulders last until I take the Ultram but then I still have some trouble standing or walking for too long. The Lyrica seems to help because by about 10 am I am able to get up and move around somewhat better.

Because of all the pain, I tried a pain clinic where I was prescribed gabapentin three times a day. I later stopped it because I felt very confused; I didn’t know who or where I was. Quality of life is important to me. They also tried giving me an epidural block which did not work.

My primary care physician told me that I would have to have surgery when my bowels become involved. I feel that I am getting too old to have surgery and knowing what I have told you and your past dealings with similar patients, I would like to know what your opinion is. Should I live with the pain or take a chance with surgery?

DEAR READER:
You have enclosed the results of your MRI which shows severe degenerative disc disease in several areas of your spine. The report recommends surgical decompression should other, non-invasive treatments work. I believe that you have reached that stage.

Surgery is a final option for most conditions. Spinal surgery is especially worrisome. Despite its vast advances over the years and its relatively low incidence of serious side effects, most people are uncomfortable with it. All surgery has risks but spinal surgery is perhaps the second most detrimental (following brain surgery) including permanent nerve damage which may result in loss of feeling, paralysis and more. Fortunately, with modern techniques, the chance of adverse effects is drastically reduced.

I suggest you speak with a neurosurgeon or orthopedic surgeon who specializes in the spine. These specialists can answer any questions you may have, calm any concerns and give you a realistic picture of what to expect. It is your choice to have surgery or not, but before you can make that decision you must be completely informed. As you stated above, quality of life is very important but you do not seem to have good quality now. If you are otherwise healthy, perhaps surgery is your best option.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery. Other readers who would like a copy should send a self-addressed, stamped envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

During her follow-up visits after the surgeries she was told that because of her persistent pain that she is in the 25% of patients who have chronic pain because of adhesions and scar tissue build-up at the incision site. The excess tissue is also causing parts of the intestine to collapse, leading to periodic blockages and pain that are treated with IV antibiotics and pain medication in the hospital.

Because I hate to see my lovely wife suffering so much, I have done my own research on her situation. I found an article about bowel obstruction on www.WebMD.com and it mentioned something called a stent. I asked her surgeon about this but he said she is not a candidate because she is otherwise healthy and that stents are only used as last resorts for short periods of time in terminally ill patients.

I want to know if this is a correct analysis of the situation. Is it common to use stents only in the terminally ill? It doesn’t seem logical to me that someone dying should be a candidate but not a healthy person.

DEAR READER:
Let me start by saying I am not a surgeon and cannot give more than general information regarding your wife’s situation.

You have kindly included the article and a list of your wife’s surgery from January 2006 to February 2008. She has had a colostomy, colostomy removal, four scar tissue/adhesion removals, and a colonoscopy. I also note that you have included hospital charges for most of the procedures which total up to more than $200,000. I would imagine with the missing charges and the doctor’s fees this easily adds up to more than $300,000 which is more than staggering. However, I will save the healthcare cost rant for another column.

I will start with the reason your wife had the initial surgery: bowel obstruction. A bowel obstruction exists when the intestine becomes twisted, knotted, pinched or otherwise blocked preventing its contents from passing through and leaving the body. Blockages can be complete or partial. Complete blockages can be especially dangerous because of the risk of intestinal rupture due to increasing pressure caused by the backed up fecal matter. If rupture occurs, the contents spill into the abdominal cavity and if left untreated can cause infection, sepsis and death. Partial blockages generally are not as dangerous but must be taken care of immediately to prevent complete obstruction.

Because your wife required surgery, I assume she had a complete blockage. During surgery the blockage is removed and if necessary the intestine is repaired or part of it is removed. A colostomy is put in place to allow proper healing.

Most gastroenterologists place stents in the bowel because of an oncologist’s recommendation. This translates into most individuals who receive bowel stents because they have some form of intestinal cancer. However, given your wife’s continuing difficulties, I recommend you get a second opinion. This will bring a new perspective to the situation and perhaps new treatment options.

Adhesions are painful buildups of scar tissue often at or near a surgical incision. Scar tissue is necessary for proper healing because it joins the two sides of the incision, closing the wound. However, when this process occurs abnormally, too much scar tissue is made and not only closes the wound but also pulls on surrounding healthy tissues adhering them together which often causes pain. Ironically, the only treatment I am aware of is surgery to remove the excess tissue and separate the abnormally joined areas. Some individuals then develop more adhesions from the removal surgery, as is (I assume) the case with your wife.

When you see the second specialist, I urge you to ask about any new treatment options for the adhesion as well, which, if eliminated, may resolve the continuing bowel obstruction problems, too.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

By the way, I am an 80-year-old female.

DEAR READER:
Balloon kyphoplasty is a relatively new procedure used to correct painful compression fractures of the vertebrae. These fractures are often the result of osteoporosis.

The procedure is done through a small incision near the vertebrae. A small, deflated orthopedic balloon is then guided into the fracture site where it is then inflated. This pushes the bone back into a more normal alignment. The balloon is then deflated and removed which creates a hole that is then filled with a special bone cement to ensure the bone stays in the corrected position. To ensure that the vertebrae are repaired correctly and put back into as close to a normal configuration, the procedure is done on both sides of the bone. Balloon kyphoplasty generally takes less than an hour to complete and may need a short hospital.

According to the Kyphon website, most patients have complete pain relief. Those who don’t, usually experience a vast improvement. Narcotic pain medication can be eliminated in most cases and there are very few, if any, procedure-related complications.

Anyone interested in learning more about this procedure should check out the website www.kyphon.com. You can even find a physician who does the procedure in your area.

Thanks for writing to share your experience. I hope this helps others in a similar situation.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.