John Bundrick MD has published the following case in Mayo Clinic Proceedings (2011): CASE 3: A 26-year-old woman presents with right upper quadrant abdominal pain of 18 months' duration that began after an episode of self-limited viral gastroenteritis. She describes it as a sharp, burning discomfort that is well localized and continuous.
This is a case of well-localized abdominal wall pain, with no symptoms of an acute abdomen - where the MD reader is supposed to get that you diagnose non-acute abdominal wall pain with a simple no-brainer maneuver, and thereby reassure the patient without scaring them into an unnecessary procedure. But this is not what really goes on at Mayo Clinic - where patients get railroaded to surgery before John Bundrick ever knows they are there - the surgical option to ACNES = anterior cutaneous nerve entrapment syndrome. [continued below]....
..... This surgical option should have been 'gone' at the latest in 1972 if any surgeon at Mayo Clinic read the surgical literature.
The discussion: This case is classic for chronic abdominal wall pain, an entity first described by the British surgeon J. B. Carnett in 1926 = anterior cutaneous nerve entrapment syndrome (ACNES). Carnett described the maneuver whereby the tender spot is located and then patients are asked to raise either their legs or torso (thus tensing the abdominal muscles). Crunch maneuver in jock lingo. If the pain does not decrease (and especially if it increases) during the maneuver, then it is very unlikely to be from a visceral source and may reliably be localized to the abdominal wall muscles.
False-positive Carnett maneuvers occur infrequently (<5% or so), almost always in the setting of acute appendicitis (due to irritation of the adjacent parietal peritoneum). Chronic abdominal wall pain is typically described by the patient as being constant in nature and may worsen slightly after eating (abdominal distention). In reality, the Mayo surgeons don't take that much of a history - just you need to pick a resident - and there's no reassurance - just the 'scare' that they need to cut you open because they 'are' Mayo Clinic = the Mayo delusional disorder. And Sarr tells parents that he 'IS' the Mayo Clinic.
The Carnett maneuver is not only useful in diagnosis, but is also helpful in educating and reassuring patients as to the true source of their pain and therapeutic- it reduces herniation of the neurovascular bundle (prevents the pseudoneuroma). But the surgeons at Mayo Clinic don't do the Carnett maneuver; while Dr. Bundrick is educating the world, he has not educated his own staff - and patients are paying dearly with obsolete neurectomy procedures 'for the money.'
Surgically-speaking, no alternatives are offered, not even Bundrick consultations. And the Mayo Clinic has been told to stop this for at least 15 years - the Legal Counsel Jill Beed-Smith defends neurectomies with deforming mass closures - she hasn't heard of the Carnett maneuver. There's no reassurance if you get near a Mayo surgeon such as Dr. Sarr - he takes muscles & nerves and leaves no prisoners - he's not reassuring or gentle.
But the Mayo Clinic advises per John: Local heat or ice treatments, sometimes accompanied by gentle stretching of the abdominal muscles, have been tried with variable success. With a conservative approach, about 50% of patients will improve over several months of follow-up. Trigger point injections provide relief in about two-thirds of patients. In all cases, the diagnosis helps to provide reassurance, while avoiding unnecessary expense, testing, and confusion. The emphasis is on 'gentle,' and no one has seen this kinder gentler Mayo Clinic.
In this case, the pain is too constant and prolonged to represent biliary colic, and the elevated ALT is compatible with fatty liver. Earth to John: Most don't get an ALT before surgery, especially the women. The features are not compatible with gastroesophageal reflux, and upper endoscopy did not show any gastritis or ulceration, making it unlikely that a trial of a proton pump inhibitor would be of benefit. The patient does not have atrial fibrillation and is far too young to have (and does not have the pattern to suggest) symptomatic atherosclerosis (the most common conditions associated with mesenteric ischemia). So you don't have to call Warner Andrew Oldenburg MD.
Clinical Pearl: The Carnett maneuver can be very useful in both diagnosing chronic abdominal wall pain and reassuring patients who receive that diagnosis. Clinical Paradox: the Surgical Service at Mayo Clinic does not use this maneuver - so it can't be useful.
The problem is that Mayo Clinic staff are not doing the Carnett maneuver - and don't read John Bundrick - but they are probably reading 'GONE GIRL.' Mayo Clinic is still railroading women patients into PAINFUL next day neurectomy surgeries - before John Bundrick can do a consult. The Surgical Services at Mayo Clinic don't do Carnett's and pooh-pooh this maneuver, injections, and anything but surgery. The patients don't consent and get the neurectomy - the Mayo signature deformity. Dr. Sarr has a complete 'menu' of neurectomies.
These neurectomies are being done without consent or discussion - the patient will think that it's scar tissue, or retained appendectomy suture materials, pressing on nerves - the surgeons get in and find a swollen nerve and pretend this is 'foreign material.' The OR Reports are enlightening reading as to the rationalizations of non-thinking surgeons. And the surgeon will have been told to 'not touch the nerve.'
No injections of any anesthetic agent are offered on the surgical service until the patient is scheduled - then they are injected with an unconsented IV drug so that they don't walk - as they realize what Dr. Sarr really intends. It's like out of Robin Cook 'Coma,' where the woman MD gets an unnecessary appendectomy - it's not one bit assuring.
But the worst of it - is the using of these patients to practice Mayo signature COMMON MASS CLOSURES. Common mass closures are where the surgeons cuts all the abdominal muscles, and the nerves are above one of the muscles, to sew them all together with one suture pack - it's a guy challenge like chasing a whiskey with a beer - the 'whiskey' being the nerve removal, and the 'beer' being the common mass closure = the Mayo surgical 'cocktail.'
John Bundrick needs to put into practice what he preaches - it's not a woman MDs job to be telling the Mayo Clinic to stop this for the last 15 years - sending Dr. Sarr articles about Carnett's and requesting that all common mass closure deformities are undone, and that Mayo stop the incidental accidental neurectomies. Jill Beed-Smith has continued to whitewash neurectomies - the Surgical Services call abdominal cutaneous nerve entrapment syndrome (ACNES) = 'neuroma;' they can't tell this entity from a 'neuroma' from a previous surgery. So please enlighten your own staff John Bundrick MD - not to touch the nerves.
But the real problem is the doing of common mass closures - which further deform and irritate the abdominal wall muscles and other nerves - causing more ACNES. They have to be undone, and no one wants to undo Dr. Sarr's common mass closures - because they don't understand why they were done in the first place, ie why he cuts the transversus - or any of the muscles - as Mayo Clinic has endoscopes and intraoperative ultrasounds literally littering the ORs in Rochester. And Mayo Clinic should have OR 'help' able to use them - not 3-month wonder interns and black medical students imported from God-only-knows-where. But you also have to have a SURGICAL CONSENT to operate on ACNES. And you have to tell Dr. Sarr that if the pain goes away with a 2% lidocaine injection, then it was not a 'neuroma.' Mayo Clinic has John Bundrick but the neurectomies haven't stopped; there are probably some scheduled for today's OR - under 'neuroma.' Check the schedule.
Removing abdominal nerves is painful, not reassuring, and causes skin atrophy and loss of sensation in areas of the body where people like to exercise their 50 SHADES options. The common mass closure is so deforming, and painful, that you have to wear loose clothing - it takes all the swimming suit options. It makes you ashamed of your body, ashamed that you fell for this 'take,' and ashamed to be a woman - where guys would try this. Where is the Renaissance man?
John Bundrick MD -- you are not correctly managing ACNES at Mayo Clinic. You need to undo all the common mass closure deformities done for obsolete neurectomies because your Surgical Service can't tell a 'neuroma' from an entrapped nerve, and can't do a Carnett's test - and you need to keep these patients out of the OR by correct triage. Plastics can't be turfing ACNES to Dr. Sarr.
This wouldn't be so bad except that it occurs so commonly. Carnett, in the early 20th century, claimed to have seen three patients per week with this diagnosis, and as many as three per day in consultations sessions - the problem is that when Dr. Sarr sees these patients, he schedules them for his suddenly available OR slot and painfully deforms them with an obsolete procedure - they are not urgent procedures - or procedures to 'get in' before the next flight out.
This 'practice' should have gone out in the early 20th century - and still is going on in the early 21st century at Mayo Clinic. Dr. Bundrick looks the other way for this quota procedure, while an objecting woman MD gets served 'defamation' suit papers from Dr. Sarr & Mayo Clinic. Dr. Bundrick doesn't answer his mail, nor arrange for the Surgical Services to stop the butchery - Sarr charges about $1000 to remove a nerve and practice a common mass closure. And the sadistic surgical resident staff love the practice - they don't know a Carnett's test from a Kocher maneuver.
When a patient is seen for abdominal pain without other clinically significant symptoms, ACNES should be high on the list of likely diagnoses - the nurses should be able to triage this at Mayo. But a woman patient shouldn't have to diagnose herself, inject herself - or deal with the ignorant Sarrisms.
Complete relief of the pain by the anesthetic agent establishes the diagnosis and is therapeutic - doesn't deform the abdominal wall further to create more ACNES. Almost everyone who has written about abdominal wall pain overlooks the diagnosis . . . but that does not excuse the ignorance or the anachronistic surgical behaviors at Mayo continuing long past the early 20th century. This wouldn't be on ripoff if John Bundrick would answer his mail, and assure that no women is in the Rochester St. Mary's OR this morning for a neurectomy with common mass closure.