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Surgical Rounds

Lumbar Sympathetic Nerves

     Everybody knows a fitness program can improve one's health and well-being, but The Net Worth Workout (AMACOM; 2006) provides an exercise      regimen for your wallet, not your waistline. Written by Susan Feitelberg,      your "financial fitness trainer," this book offers helpful      exercises to shape up your finances so you can enjoy a healthy and happy      retirement. When you consider that the average American retires with less      than a year's living expenses in his or her savings account, the need      to whip your funds into shape before your twilight years becomes clear.      Feitelberg merges her experience as a triathlete with her expertise as a      financial advisor for JPMorgan Chase to develop a monetary regimen that      focuses on positivity and discipline. Chock full of fitness allegories, The      Net Worth Workout relates four areas of physical health to financial health:      earning equals metabolism, spending equals calorie intake, saving equals      strength training, and investing equals cardio fitness. This easy-to-read      financial tome bills itself as a powerful conditioning      program for your finances; try turning the      pages of The Net Worth Workout while turning miles on your stationary      bike.  

Are college endowments going to good use? 

     When it comes to      charitable giving, many surgeons spread their wealth to their alma mater,      but your contribution may be getting tossed on a growing stockpile of money      that the school isn't using. According to the Wall Street Journal,      higher education receives around $24 billion in donations each year, yet      most wealthy colleges spend less than 5% of that amount. The endowment      surplus of Harvard University alone is nearly $26 billion, with $590      million more accumulated during 2005. In their defense, schools insist that      they must be cautious with spending this money for the sake of future      generations in the event of an economic downturn. They also state that the      funds go toward student grants, funding beneficial research, and expanding      their undergraduate student body. Still, the mammoth surpluses of these  schools have some cynical donors giving their money to causes they deem more "in need."

Retirement savings     personalities, in color

     Maybe you're a worrier who wonders if you will      have enough money for retirement yet didn't think twice when      purchasing a new widescreen projection high-definition television. Or      perhaps you epitomize the eternal optimist, believing you will effortlessly      accumulate ample money to fund your golden years. According to InvestmentNews,      either personality trait will land you in the same financial boat: not      enough cash for retirement. Allstate Insurance Company's      "Retirement Reality Check" survey of 1,600 people found five      different retirement savings personalities. People in the red group, which      includes 13% of respondents, believe they will have to work past retirement      age. Orange respondents, making up 21%, are pessimistic worriers whose      reckless spending leads them to regret purchases, neglect savings, and then      spend more money to feel better. The largest group is the underachieving      blues, at 27%, who know they should save but consistently fall short of      their goals. Only 20% of respondents will transition smoothly into      retirement. These make up the green group, which has the fiscal smarts to      stick to a budget, invest with discipline, and monitor savings. One      personality type that will be surprised to find themselves on the road to      financial hardship is the 19% who qualify as optimists. These individuals      are generally aged 45 and older with less than $100,000 in savings, yet      they believe everything will come up roses in retirement and aren't  the least bit worried that they may reap weeds instead.

Social Security maximum earnings outpace CPI 

     Despite a 3.5% inflation rate, the maximum earnings      subject to Social Security tax rose 4.7% in 2006. Ac?cording to the Wall      Street Journal, the federal government derives this percentage from changes      in wages as measured by a national index?not the Consumer Price Index      (CPI), which tracks the prices of all goods and sets the rate of inflation.      Social Security tax previously applied only to the first $90,000 in      annual income but is now capped at $94,200.      If you earn more than $94,200, you will pay      $5,840 in Social Security taxes this year and your employer will pay the      same. In addition, a 1.45% Medicare tax applies to both employee and      employer. For self-employed surgeons, the tax rate is still capped at the      annual earnings amount of $94,200, but as employer and employee, a 12.4%      tax rate applies, which can be offset by tax provisions. The Medicare tax      rate for the self-employed surgeon is 2.9%. Unlike the Social Security tax,      the Medicare tax is not capped. A self-employed surgeon who earns $150,000      maxes out the employee Social Security tax contribution at $5,840 ($11,680      total) and will pay an additional $4,350 in Medicare tax.   

Will you get over your fear of the mouse? 

     Are you still licking stamps? Maybe 2006 will be the      year that you join the 27 million Americans who pay their bills      online?up from 10.6 million in 2001. According to US News and World      Report, most large banks and credit unions offer the service for no fee,      while services such as Check?Free.com and PayTrust.com charge. Aside      from the ease of completing money transactions with the click of a mouse,      paying your bills on time is the biggest benefit. You can arrange automatic      and recurring payments, such as for your mortgage or car loan, and credit      card companies can alert you when you are dangerously close to missing your      payment due date. You can also transfer money between checking and savings      accounts at any time. Convenience does come with risk, and many people are      wary about the very real threat of identity theft and question the safety      of conducting financial transactions over the Internet. Although any Web      site that involves banking transactions takes the highest level of      precautions to ensure security, an online thief needs only a username and      password to access your information. Federal banking laws stipulate that      consumers are responsible for no more than $50 of unauthorized online      transactions, provided they report the incident within 2 business days. If      you bank or pay bills via the Internet, check your online statements often      and watch for suspicious transactions. More importantly, every time you pay      a bill or conduct a financial transaction via the Web make sure that the      URL reads "https" instead of "http." Another      safeguard is to look for the tiny padlock that should appear at the bottom      of your screen; this icon ensures the identity of the particular Web site      as well as its safety.  

     A recent Federal Reserve study found that Americans      extracted $600 billion in cash from their homes in 2004. The upsurge in      home values has prompted many owners to sell their house and capitalize on      their investment. Thinking of putting a for sale sign on your front lawn? Bottom      Line/Personal reminds surgeoninvestors that generating a large profit      will trigger capital gains taxes. If you are married and file jointly,      profits up to $500,000 from the sale of a primary residence are excluded      from capital gains taxes. If you are single, profits up to $250,000 are      tax-exempt. After that, homeowners may pay as much as 15% in federal taxes,      in addition to state taxes. While paying $60,000 in taxes on a $550,000      capital gain may seem steep, parents and grandparents could do a lot of      good for the next generation by investing a portion of those proceeds into      a 529 college savings plan. And what if you don't sell your home? If      you or your spouse is suddenly without a job and your emergency fund has      run out, for example, your home can be used as collateral to obtain a home      equity line of credit usable for any purpose. Rather than taking on the long-term interest payments associated with a second mortgage, a credit line can give you  the help you need with an interest rate well below that of a credit card.

     Emotionally, you may have been ready for retirement      years ago. But do you have what it takes financially? To see where your      finances stand, check out Vanguard's retirement tools at      

 (click on the personal investing portal and then      "IRAs, 401(k) rollovers, retirement investing").      Vanguard's calculators and worksheets can help you discover your      asset allocation and determine the best retirement vehicle, including IRAs      and annuities. You can also determine whether you are on the right track or      discover how much more you need to allocate to retirement savings. Simply      input your salary, retirement goals, current savings balance, and projected      investment returns, and the calculator will reveal your retirement asset      needs, the total value of your current assets, and the percentage of annual      income you should save to meet your goals. Ac?cording to the Web site,      a 27-year-old who earns $100,000 per year and wants to retire at age 67      needs to save 13% of his or her income each year for the next 40 years,      assuming he or she will survive 25 years post-retirement. A 37-year-old      with no retirement savings must save 21% over 30 years, and a 47-year-old      would have to squirrel away 36% of income over the next 20 years to retire.      The 47-year-old would have to save $23,000 more than the 27-year-old each      year in order to retire with enough money, which illustrates the importance      of early planning and saving.   

     Retailers return billions of dollars worth of      brand-name electronics and appliances to manufacturers each year. Sometimes      an item is damaged or defective, and other times a customer has simply      changed his or her mind. Either way, once an item is returned to the store,      retailers can no longer legally sell it as new,      according to Bottom Line/Personal. In the past, opened returns were destroyed or sold to      liquidators. Now, with an increasingly competitive market, manufacturers      market repaired and repackaged items as refurbished. DVD players, digital      cameras, televisions, computers, golf clubs, and office equipment are some      examples of what you can find. Surgeons can save up to 80% off retail      prices and buy a great deal for their home or practice if they know what to      look for. No federal regulations exist that define the language of      "refurbished" versus "factory reconditioned" or      simply "open-box," but many sellers will tell you, if asked.      The best refurbs are items that were returned unused, functional items with      minor cosmetic damage, and overstock items that may be last year's      model. Try to avoid demonstration units, which have substantial wear from      use in stores and trade shows, and defective products that may or may not      have been repaired. Also look for a good warranty and return policy and      make sure the product includes all components, such as cables, software,      and headphones. These retailers provide refurbished      products at big discounts.

74%?Percentage of      Americans who say the US economy was strong in      2005. (

72%?Percentage of      Americans who said that the US economy would be even better in 2006. 

 55%?Percentage growth in spending for online advertising in the third quarter  of 2005. (

 50%?Percentage of electronics pur?chases made by women. (

 33%?Percentage of baby boomers who volunteered  at an organization at least once in the past year. (

 $1.13 trillion?Total net worth of  America's 400 wealthiest people. (

 $4.3 billion?Amount that Ameri?cans will  pay to withdraw cash from ATMs in 2006. (

 $520 million?Annual revenue of the online  dating industry. (

 270 million?Cases of wine bought in the United States in 2004.  (

 20?Average number of hours work?ed by high school students, at a rate of $6 per hour. (

Mistakes to avoid when headed for bankruptcy 

     As if declaring bankruptcy isn't bad enough,      there are still slip-ups you can make during the process that will deepen      your troubles. Bankrate.com advises you to steer clear of the following      bankruptcy blunders:  

     Not disclosing a previous personal bankruptcy      is a big mistake, because the court can easily find out about previous      filings.  

      Not disclosing all of your assets to your      attorney or the court or trying to hide an asset by transferring it out of      your name puts your bankruptcy petition in jeopardy of being refused and      puts you at risk for additional legal trouble.  

      Employing a paralegal to handle your case is a      bad idea, because it's not a paralegal's job to supply reliable      legal counsel. Hire a reputable attorney who understands the ins and outs      of the new bankruptcy laws.  

       Using your credit cards heavily or taking out a cash      advance in the 3 months before filing for bankruptcy puts you at risk for      having to return some or all of the money for the charges and could trigger      creditor challenges to your bankruptcy.  

Tip for exemplary      service, not expectations 

     While most patrons agree that the wait staff member      who attends to your every need throughout a meal merits a 15% to 20% tip,      many consumers are up in the air as to how much other food service      employees should be tipped?or whether they should be tipped at all. The      Wall Street Journal offers guidelines on how to show your gratitude in      other restaurant situations. Your sommelier, who recommends a perfect wine      pairing to your duck, may garner a tip of 8% of the cost of the wine,      although etiquette expert Emily Post recommends 15% to 20%. Because sushi      chefs handle food and not money, you should not tip, even if your tuna roll      was extra spicy and plated with an extra curl of ginger. When picking up      takeout food, leave 10% to 15% if you are a regular and the establishment      tosses in extras, like fortune cookies or fresh bread. When a coffee house      worker serves your coffee in espresso time, toss a little change in his or      her tip jar. Of course, not everyone feels obligated to do so. According to      a survey on EmilyPost.com, 70% do not tip at      counter service establishments.  

     Surgeons from the baby boom generation may soon be      faced with a difficult decision: finding a safe facility to care for aging      parents. According to Forbes, assisted living remains a popular choice for      older adults who do not yet need nursing care, which costs 50% to 60% more.      For an average of $2,500 per month, residents receive private rooms, meals,      housekeeping services, and activities. Trained professionals help with      daily living tasks, and medical help is nearby. Finding a good facility is      difficult because no federal standards exist for assisted living centers      and no database is available. So how do you find a safe place that your      parents can call home? Many nursing centers have assisted living facilities      attached or right next door. While assisted living is unregulated, nursing      homes must be inspected at least every 15 months, and you can obtain      nursing home records from your state health department. Once you decide      which facilities to visit, ask residents about the quality of medical care      they receive. Look for facilities that have at least one nurse on staff at      all times. Make sure units have safety bars in the bathroom and panic      buttons throughout the apartment to alert staff in case of a medical      emergency. Good facilities will have a daily check-up system in place in      which residents must go to the lobby and flip a switch to notify staff that      they have received their mail; otherwise, they receive a phone call or      visit from a staff member. And don't forget about transportation. The      facility should assist residents with doctor appointments and shopping,      providing van service to off-site locations.   

Surgeon's Bulletin Board

A Morgagni hernia is a rare diaphragmatic hernia.      Laparoscopic repair has been shown to provide successful treatment. The      authors report a case of Morgagni hernia and provide a review of the      literature, highlighting the 44 reported cases involving laparoscopic      repair. A prosthesis was used in 65% of these cases. When should prosthetic      material be used? Although there are no controlled studies, the authors      provide a convincing case for using prosthetic material to repair a      diaphragmatic hernia. The recurrence rate is not known for primary repair      of diaphragmatic hernias larger than 4 cm. Extrapolation of data      from studies evaluating the use of prosthetic material for ab&shy;dominal      wall hernias larger than 4 cm may not necessarily be applicable to      diaphragmatic hernias. With these shortcomings in mind, I favor the      authors&#8217; recommendation for more frequent use of prosthetic material      in repairing diaphragmatic hernias, especially those that are congenital.      The hernia sac should also be excised whenever possible. Sharma and      colleagues provide an excellent review of laparoscopic diaphragmatic hernia      repair. Better follow-up studies evaluating recurrence rates of      diaphragmatic hernia repair are needed. 

Series    Guest Editor Professor and Chairman

 Medical  College of Georgia Augusta, GA 

             Fellow in Cardiothoracic Surgery 

             The Heart, Lung, and Esophageal Surgery Institute 

             The University of Pittsburgh Medical Center 

             Clinical Professor of Surgery 

             Tufts University School of Medicine 

             The Lahey Clinic Medical Center 

             Assistant Professor of Surgery 

Morgagni hernia is a rare      form of diaphragmatic hernia with an overall incidence of 1% to 3%.

 The      foramen of Morgagni is a space that can arise from a defect in the retro-xiphoid sternocostal hiatus through which herniation of omentum, colon, stomach, or other viscera may      occur.

 Morgagni hernias most often present later in life as a result of      progressive attenuation of the diaphragm. The diagnosis of such hernias warrants operative repair. Conventionally, surgeons have treated this defect using an open approach via the thorax or by laparotomy.

 Recently, successful      repair using a laparoscopic approach has been validated. We report a case      of a retrosternal hernia of Morgagni in a      77-year-old woman who presented with intestinal obstruction. We      describe our repair technique and provide a review of the literature with      regard to laparoscopic repair in adults.      

     A 77-year-old woman with a history of rheumatoid      arthritis, hypothyroidism, gastroesophageal reflux disease, and congestive      heart failure presented to the emergency department because of epigastric      abdominal pain associated with nausea and vomiting. She had experienced      this pain intermittently over the 2 months before her admission. Plain radiographs and computed tomography (CT)      scans of her chest and abdomen showed a right parasternal defect with      dilated stomach and transverse colon herniating      intrathoracically (Figures 1 and 2). The patient subsequently      underwent a laparoscopic repair.  

     Under general endotracheal anesthesia, a      supraumbilical incision was made and the abdomen was entered under direct      vision. Four additional ports were placed into the abdomen after      insufflation with carbon dioxide to a pressure of 15 mm Hg. The      patient&#8217;s abdomen was examined and found to have the transverse colon      and distal stomach incarcerated within an anterior lateral diaphragmatic      hernia. The contents were reduced without difficulty (Figure 3). The      peritoneal lining of the hernia sac was then excised using sharp      dissection. The defect measured 6 x 8 cm, which was too large to repair      primarily without undue tension. Therefore, a      dual-sided polytetrafluoroethylene/expanded polytetrafluoro&shy;ethylene (PTFE/ePTFE) mesh, which was approximately 8 x 12 cm and      elliptical, was introduced into the abdomen. It was secured to the      diaphragmatic musculature at either end with two interrupted 0-braided      polyester sutures. The mesh was then fixed into place with running No. 1 polybutylate-coated polyester sutures posteriorly to the edge of the diaphragm and anteriorly to the      anterior chest wall. In addition, 5-mm spiral tacks were placed      circumferentially, pinning the mesh into the xiphoid and costal cartilages      superiorly and into the diaphragm inferiorly (Figure 4). The patient      recovered without event and was doing well with no signs of recurrence at      6-month follow-up.   

     Retrosternal hernia of Morgagni is a rare form of      diaphragmatic hernia that re&shy;sults from a congenital failure of the      diaphragm&#8217;s septum transversum to fuse with the costal arches.

 The      anatomical defect is usually located on the right, at the level of the      seventh rib on either side of the xiphoid, in a space where the superior      epigastric vessels pass; however, defects may also occur on the left, at      the midline, or bilaterally. A hernia through the right sternocostal hiatus      is referred to as a Morgagni hernia, whereas a hernia through the left      hiatus is named a Larrey hernia.

 The differential diagnosis includes      pleuropericardial cyst, pleural mesothelioma, pericardial fat pad,      mediastinal lipoma, tumor or cyst of the diaphragm, thymoma, and anterior      chest wall tumors.

     Morgagni hernias are thought to result from an      inheritable condition and may be associated with congenital abnormalities      such as Down syndrome, pentalogy of Cantrell, Noonan syndrome, Prader-Willi      syndrome, and Turner syndrome.

 Most Morgagni hernias present later in life      as a result of progressive attenuation of the diaphragm from aging and      changes in intra-abdominal pressure caused by pregnancy, obesity, and      trauma.

Patients may be asymptomatic or present with cardio&shy;pulmonary      symptoms due to compression of the thoracic organs or pulmonary infection.      They may also experience gastrointestinal symptoms due to visceral      herniation. Morgagni hernias are of the direct type and are composed of a      sac that may contain omentum, transverse colon, stomach, other segments of      intestine, or liver.

     Diagnosis can be established with routine imaging      studies, including plain radiographs, CT scanning, contrast studies, or magnetic resonance imaging. Once this condition is diagnosed, surgical treatment is warranted      even for patients who do not have symptoms because intestinal      incarceration, strangulation, or both, may ensue.

 Operative intervention      may be deferred only in the rare circumstance of an asymptomatic elderly      pa&shy;tient who would not tolerate the risks of surgery. Open repair of      Morgagni hernias through the abdomen and chest has been successful.

      Minimally invasive techniques provide a means to repair these defects while      minimizing the morbidity of open surgery. Our review of the literature up      to 2005 showed 44 patients (27 men, 11 women, and 6 patients whose sex was      not specified) with a mean age of 50 years (range, 17&#8211;85 years) had      undergone laparoscopic repair (Table).

Most patients (80%) had      colon within the hernia sac, 13% had omentum, 5% had either small intestine      or stomach, and only 3% had either liver, round ligament, or the falciform      ligament contained with&shy;in the sac.  

     Considerable controversy exists re&shy;garding the      need for sac excision and whether prosthetic material should be used.      Primary suture repair of the defect assumes that the apposable tissues are      of good quality; however, Morgagni hernias are predicated on the fact that      the diaphragmatic musculature is weak and attenuated. Therefore, we think      that even if the defect may be closed primarily without tension, use of a      suitable prosthesis should be considered. Although no recurrences are      reported in the literature, patients may have had a failed primary repair      and remained asymptomatic or did not undergo radiological monitoring.      Prostheses were used in 28 of 43 cases reviewed (65%) and included      polypropylene mesh and a variety of composite prostheses such as ePTFE and      hydrophilic resorbable film. We prefer to use dual mesh, which allows      the closure of large defects while minimizing the risks of adhesions to the      prosthetic surface.  

     The direct hernia sac was excised in 15 of 41 patients      (37%). Although some authors report that sac excision is unwarranted      because of the unacceptable risk of massive pneumomediastinum and damage to      the pericardium or mediastinal structures,

 excision of the sac may have      the following advantages: (1) reduction of tissue trauma because only the sac is manipulated      (rather than its contents) in cases where the colon or stomach are      contained within the sac and the possibility for transmural visceral      in&shy;jury or neurovascular injury exists; (2) decreased chance for      symptomatic fluid collection since the serous lining membrane is removed;      and (3) sac excision negates the chance that the sac itself can act as a lead point for recurrent herniation.  

     In a prospective study, Edye and colleagues reported      no cases of early reherniation in patients whose hernia sac was excised.

 Although this paper fo&shy;cused on sac      excision during paraesophageal hiatal hernia      repair, we think the aforementioned arguments are valid for Morgagni      herniorrhaphy and recommend excision of the sac. Laparoscopic hern&shy;i&shy;orrhaphy is the preferred method to repair      defects in the retroxiphoid sternocostal hiatus.      The hernia sac should be removed when technically safe. More&shy;over, a      prosthesis must be used when the defect&#8217;s size precludes tension-free      repair.    

     1. Contini S, Dalla Valle R, Bonati L, et al.      Laparoscopic repair of a Morgagni hernia: report of a case and review of      the literature.

     2. Comer TP, Clagett OT. Surgical treatment of hernia      of the foramen of Morgagni. 

     3. Ketonen P, Mattila SP, Mattila T, et al. Surgical      treatment of hernia through the foramen of Morgagni.

     4. Lev-Chelouche D, Ravid A, Michowitz M, et al.      Morgagni hernia: unique presentations in      elderly patients. 

     5. Gilkeson RC, Basile V, Sands MJ, et al. Chest case      of the day. Morgagni&#8217;s hernia. 

     6. Honore LH, Torfs CP, Curry CJ. Possible association      between the hernia of Morgagni and trisomy 21. 

     7. Rau HG, Schardey HM, Lange V. Laparoscopic repair      of a Morgagni hernia. 

     8. Saltzstein HC, Linkner LM, Scheinberg SR.      Sub&shy;cost&shy;ernal (Morgagni) diaphragmatic hernia; report of a case of      hernia containing stomach, transverse colon, and omentum, with review of      the literature. 

     9. Puri P. Congenital diaphragmatic hernia. 

     10. Kuster GG, Kline LE, Garzo G. Diaphragmatic hernia      through the foramen of Morgagni: laparoscopic repair case report. 

     11. Rau HG, Schardey HM, Lange V. Laparoscopic repair      of a Morgagni hernia.

     12. Newman L 3rd, Eubanks S, Bridges WM 2nd, et al.      Laparoscopic diagnosis and treatment of Morgagni hernia. 

     13. Smith J, Ghani A. Morgagni hernia: incidental      repair during laparoscopic cholecystectomy. 

     14. Fernandez-Cebrian JM, De Oteyza JP. Laparoscopic      repair of hernia of foramen of Morgagni: a new      case report. 

     15. Huntington TR. Laparoscopic transabdominal      preperitoneal repair of a hernia of Morgagni. 

Mahesh S. Sharma, Fellow in Cardiothoracic  Surgery, The Heart, Lung, and Esophageal Surgery Institute, The University of Pittsburgh Medical Center, Pittsburgh, PA; Desmond H. Birkett, Clinical Professor  of Surgery, Tufts University School of Medicine, Staff Surgeon, The Lahey Clinic Medical Center, Boston, MA; Paresh C. Shah, Staff Surgeon, Department of Surgery, Lennox Hill Hospital, New York, NY; David M. Brams, Assistant Professor of Surgery, Tufts University School of Medicine, Staff Surgeon, The Lahey Clinic Medical Center, Boston, MA

Laparoscopic repair of retrosternal hernia of Morgagni

   Providence Hospital and Medical Centers    

Intussusception is a rare complication following        gastric surgery and is estimated to occur in 0.1% of patients. The authors        describe a case of retrograde intussusception after Roux-en-Y        gastrojejunostomy that was initially diagnosed as pancreatitis because the        classic symptoms of intussusception were absent. Computed tomography        scanning of the abdomen and pelvis showed a dilated duodenum and proximal        jejunum, raising suspicion of intussusception. Surgical treatment included        manual reduction with resection of the gangrenous bowel segment. It has        been suggested that retrograde intussusception may be an extreme form of        the Roux stasis syndrome.

     Intussusception is a rare      complication in patients who have undergone previous gastric surgery.      It was first reported in 1917, 30 years after the first gastrojejunostomy.      An estimated 0.1% of patients who have had Billroth II reconstruction or      Roux-en-Y reconstruction will de&shy;velop adult intussusception.

 Je&shy;junogastric intussusceptions after Billroth II are typically categorized according to four      anatomic variants: afferent (type 1), efferent (type 2), combined      (type 3), and side-to-side jejunojejunal anastomosis (type 4). This      classification system is difficult to apply to the anatomy of a Rouxen-Y.      We present a case of retrograde intussusception that occurred years after      distal gastrectomy with antecolic Roux-en-Y gastrojejunostomy.  

     A 49-year-old man presented to the emergency      department with a 36-hour history of acute periumbilical pain accompanied      by nausea and vomiting. The pain was relieved by upright fetal positioning.      His surgical history was significant for gastric resection 5 years earlier,      which was performed because of peptic ulcer perforation. An edematous      pancreas was the only significant finding on ultrasonography. Amylase and      lipase levels were elevated to 1,972 IU/L and 6,510 IU/L, respectively. A      preliminary diagnosis of acute pancreatitis was made, and the patient was      admitted to the hospital. Physical examination of the abdomen revealed      marked distention and tenderness on palpation, but no abdominal mass. A      nasogastric tube was placed, which drained 750 cc of coffee-ground blood.      The patient was febrile and had leukocytosis, with a white blood cell count      of 27.8 x 103/µL. A subsequent computed tomography (CT) scan of the abdomen      and pelvis demonstrated gastric dilatation with distinct proximal small      bowel air fluid levels (Figure 1).   

     After intensive fluid and electrolyte resuscitation,      the patient underwent ex&shy;ploratory laparotomy, which showed his      previous surgery was a subtotal gastrectomy and antecolic Rouxen-Y      jejunogastrostomy. He had developed a retrograde jejunojejunal      intussusception involving the distal end of the Roux limb, which led      to complete obstruction of the jejunum below the jejunojejunostomy site      (Figure 2). The duodenal loop was distended to a diameter of 10 cm, causing      its contents to reflux into the gastric lumen. The intussusception was      reduced manually, a 25-cm segment of gangrenous intussuscepted bowel was      resected, and a successful primary anastomosis was performed. Thorough      gross inspection of the resected specimen showed no evidence of an      intraluminal, intramural, or extraluminal lesion, which could have acted as      a nidus for the intussusception and subsequent ischemia. The patient      tolerated the surgery well and improved exponentially. His serum amylase      and lipase levels returned to normal, and he was discharged to home in      excellent condition on postoperative day 8.  

     Postoperative intussusception is a rare complication of gastric surgery. The reported incidence      is approximately 0.1%.

 In 2004, Goverman and      colleagues reported two cases of retrograde      intussusception out of more than 600 Roux-en-Y gastric bypass procedures in      their experience, which confirms the rarity of this disease.

Symptoms      of mechanical obstruction can be delayed from 2 weeks to as long as 20      years in adults with postoperative intussusception. Patients may present      with an acute surgical emergency or chronic postprandial pain. The      literature reports pain, a palpable abdominal mass, and rectal      bleeding as a classical triad of symptoms indicating intussusception,      al&shy;though this triad is rarely seen. The constellation of symptoms is      easily confused with those caused by postoperative ileus and abdominal      adhesions, and it is difficult to find distinctions because there are no      pathognomonic symptoms to rely on. As evidenced by our patient,      intussusception can have a similar presentation to pancreatitis occurring      secondary to afferent loop syndrome.   

     A preoperative diagnosis of intussusception can      be made radiologically through the use of an upper gastrointestinal study,      ultrasonography, and CT scanning. Endoscopy may be performed if there is a      high index of suspicion. Ultimately, intussusception must be confirmed by      laparotomy. A retrospective review of our patient&#8217;s CT scan suggests      that the original evaluation did not appreciate the target-like concentric      circles that strongly suggest an intussusception. Radiologic demonstration      of a dilated proximal segment of small bowel in a patient with a history of      gastrectomy should lead the surgeon to consider postoperative      intussusception in the differential diagnosis.

             The pathogenesis of intussusception in a patient with      a history of gastric surgery with either Billroth II or Roux-en-Y      jejunostomy remains debatable. In the case of Billroth II anastomosis, the      most commonly accepted theory postulates that antegrade or retrograde      peristalsis in the afferent or efferent limbs may lead to intussusception.      Other possible etiological factors include intestinal luminal prosthesis,      suture or staple approximations, postoperative adhesions, and electrolyte      imbalances.

 In the case presented, no intraluminal, intramural, or      extraluminal cause could be deduced as having led to the retrograde      jejunojejunal intussusception. We strongly agree with other investigators      that the retrograde intussusception in Roux-en-Y anastomosis could be      secondary to Roux stasis syndrome.

 The etiology of this syndrome      results from disruption of myoelectrical activity confounded by the      presence of an ectopic pacemaker distal to the jejunojejunostomy site. The      resulting atony and dilatation of the Roux limb, together with      antiperistaltic contraction at its distal end,      could explain this unusual complication following gastrectomy and Rouxen-Y      gastrojejunostomy. Hocking and colleagues reported the utility of      intraluminal manometry in a patient noted to have recurrent intussusception      after Roux-en-Y gastric by&shy;pass.

 They obtained direct evidence of      abnormal intestinal motility in that patient, which pointed toward abnormal      motility as the etiology of the pathologic process.   

     The development of an uncut Roux operation that allows for the propagation of normal pacesetter      potentials may prevent this type of intussusception; however, this      technique may not prevent other forms of jejunogastric intussusception.      This is because the uncut Roux operation is somewhat similar to Billroth II      reconstruction, with additional jejunal occlusion at the afferent limb and      creation of the jejunojejunostomy between the afferent and efferent limbs.      Long-term observation is required before the benefits of an uncut Roux      operation can be assessed.   

     One of the most important      decisions in performing a Roux-en-Y reconstruction is whether to bring the      Roux limb behind (retro) or in front of (ante) the transverse colon. In      performing the gastrectomy for benign disease, there is no clear evidence      that this makes any difference. For malignant disease, it has generally      been held that the retrocolic position may be predisposed to obstruction      owing to the enlargement of lymph nodes or serosal implants in the      transverse mesocolon. Whether or not this predisposition exists,      positioning the jejunal limb in front of the colon requires a somewhat      longer mesentery. As long as the anastomosis will not be under tension, the      antecolic position will permit emptying as effectively as that through a      retrocolic anastomosis.   

     In an acute presentation of intussusception, surgery is the treatment of choice. Early diagnosis is critical be&shy;cause mortality rates      increase abruptly if surgery is delayed. The reported mortality rate ranges      from 10% for treatment within the first 48 hours to 50% with a 96-hour      delay.

 After the diagnosis is made, surgical findings guide the operative      procedures performed. In cases of intussusception after Roux-en-Y gastric      bypass, surgeons familiar with bariatric procedures should be consulted for      both the operative and perioperative management of such patients.

     1. Jang WI, Kim ND, Bae SW. Intussusception into the      enteroanastomosis after Billroth II gastric resection: diagnosed by      gastroscopy. 

     2. Wheatley MJ. Jejunogastric intussusception      diagnosis and management. 

     3. Goverman J, Greenwald M, Gellman L. Antiperistaltic      (retrograde) intussusception after Roux-en-Y gastric bypass. 

     4. Ozdogan M, Hamaloglu E, Ozdemir A. Antegrade      jejunojejunal intussusception after Roux-en-Y esophagojejunostomy as an      unusual cause of postoperative intestinal obstruction: report of a case.

     5. Loizou MC, Koundourakis SS, Kollias VD.      Jejunojejunal intussusception after Roux-en-Y gastrojejunostomy: a rare      cause of postoperative bowel obstruction in an adult. 

     6. Hammond N, Miller FH, Dynes M. Intussusception into      the enteroanastomosis after Billroth II gastrectomy and Roux-en-Y      jejunostomy: sonographic and CT findings. 

     7. Gerst PH, Iyer S, Murthy RM. Retrograde      intussusception as a complication of Roux-en-Y anastomosis.

     8. Hocking MP, McCoy DM, Vogel SB. Antiperistaltic and      isoperistaltic intussusception associated with abnormal motility after      Roux-en-Y gastric bypass: a case report. 

     9. Walstad P, Ritter J, Arroz V. Delayed jejunogastric      intussusception after gastric surgery: an ever-present threat. 

Kongkrit Chaiyasate, Surgical Resident; Melhem  Solh, Surgical Resident; Sumet Silapasvang, Surgical Attending; Vijay Mittal, Program Director, Department  of Surgery, Providence Hospital and Medical Centers, Southfield, MI

Intussusception After Roux-en-y Gastrojejunostomy: Sequela of the Roux Stasis Syndrome?

   Colorado Pathology Consultants, PC    

Gastric glomus tumors are      considered rare, but the clinical presentation of these tumors has been      well documented.

Despite this documentation, we could not find one      report in the literature that included their clinical presentation,      preoperative endoscopic and biopsy findings, preoperative radiologic      imaging findings, operative management, and histologic characteristics.       In our report on the case of a gastric glomus tumor in a 33-year-old      woman, we discuss each of these topics and provide a brief review of the      literature. 

     A 33-year-old woman who was 5 weeks postpartum      presented to the emergency department of an urban Colorado teaching      hospital. She had been experiencing dizziness, weakness, coffee-ground      emesis, and melena. Her hemato?crit was 17.8%. After the patient was      stabilized, an esophagogastroduodenoscopy was performed. Her      esophagus appeared normal until the scope was advanced through the      esophagogastric junction to the antrum, where a 2-cm, well-circumscribed,      exophytic mass was observed (Figure 1). Several biopsies were taken from      the mass.  

     Histologically, the tumor was composed of a      proliferation of uniform round cells with centrally placed, darkly staining      nuclei, and a small amount of clear to eosinophilic cytoplasm (Figure 2).      The tumor cells were arranged around vascular spaces, which were lined by      bland endothelial cells. There was no evidence of significant cytologic      atypia, and mitotic figures were not seen.      Im?mun?o?histochemical staining for smooth muscle actin and      vimentin were strongly positive, while cytokeratin, chromogranin, and c-Kit      (CD117) were not detected (Figure 3). The      histologic appearance and immunohistochemical      profile of the mass in our patient supported the diagnosis of a glomus      tumor. Preoperative computed tomography (CT) scanning revealed a      subtle, hypodense, intraluminal mass in the prepyloric region measuring 2.9      cm (Figure 4). There were no inflammatory changes or significant adjacent      adenopathy. Because frozen-section diagnosis during surgery may not allow      glomus tumors to be differentiated from other smooth muscle tumors, it is      beneficial to diagnose a benign glomus tumor of the stomach preoperatively.      A rare tumor such as this can present a diagnostic dilemma, and every      possible step in the diagnostic armamentarium should be utilized.      Immunohistochemical staining is the most sensitive and specific tool for      diagnosing these tumors and is often necessary to make a definitive      diagnosis. Because immunohistochemical staining takes 1 to 2 hours to      complete, stains available for use during an operation are limited. Given      the rarity of the tumor, the diagnostic dilemma faced, and the logistics      and timing of making the diagnosis, preoperative diagnosis is vital so that  more extensive surgery can be avoided.

Based on our preoperative diagnosis, the patient was      taken to the operating room and explored through a midline incision with      plans to proceed with localized excision of the tumor. The tumor was      visualized along the greater curvature of the stomach in the region of the      pylorus. It did not appear to penetrate through the wall of the stomach,      and no enlarged lymph nodes were detected. A limited distal gastrectomy and      gastroduodenostomy were performed.  

     On gross pathology examination, a gelatinous, dark      red, ulcerated mass was identified on the mucosal surface of the antrum,      which extended to a depth of 3.5 cm. The tumor was histologically      identical to that of the previous biopsy specimen. Although there was tumor      within the muscularis propria, it did not extend to the serosal surface.      The proximal and distal margins were clear. The two included lymph nodes      showed only reactive changes.  

     Glomus tumors are mesenchymal tumors made up of      modified muscle cells arising from glomus bodies.

 Glomus bodies are      arteriovenous communications that help regulate the body's skin      temperature.

 Glomus tumors most commonly occur in the peripheral soft      tissues.

 Several cases of glomus tumors of the gastrointestinal tract have      been reported, and glomus tumors of the stomach      have also been described in the literature, although rarely.

 Our review      of the literature failed to identify any cases of gastric glomus tumors      that were evaluated using all of the diagnostic tools currently available,      including eso?phago?gastroduo?denoscopy, CT scanning, and      histologic and immunohistochemical staining.  

     Gastric glomus tumors are generally considered      solitary, benign lesions

; however, cases of multiple glomus tumors of      the stomach and a case of a large glomus tumor of the stomach that      metastasized to the liver have been reported.

 In addition, Folpe and      colleagues reported a series of 52 cases of atypical or malignant glomus      tumors.

     Clinically, glomus tumors may cause local      gastrointestinal irritation, including hemorrhage or even obstruction.

     Patients may have melena and abdominal pain. Gastric perforation has      also been reported.

 The CT findings of a gastric glomus tumor have      been described as peripheral nodular or homogeneous strong enhancement      in the arterial phase and prolonged enhancement in the delayed phase.

     Histologically, the main characteristics of glomus      tumors are glomus cells and irregular vascular channels.

 Most tumors      are composed of multiple cellular nodules that are often separated and      surrounded by gastric smooth muscle cells. In addition, a capsule-like rind      of connective tissue is often seen on the serosal and mucosal surfaces of      the tumor.

The most recent development in the diagnosis of glomus      tumors is the use of immunohistochemical staining, which can make an often      difficult pathologic diagnosis easier.  

     Glomus tumors may be confused with other tumors      because they appear histologically similar to these lesions, which include      gastrointestinal stromal tumors (GISTs), carcinoid tumors, paragangliomas,      and lymphomas.

 Historically, differentiating glomus tumors from GISTs has      been difficult

; however, the difference between these tumors is      readily apparent with immunohistochemical staining. GISTs almost always      stain positive for c-Kit (CD117) and 70% of the time stain positive for      CD34. In contrast, glomus tumors are consistently negative for c-Kit and      are rarely positive for CD34.

 GISTs are also generally negative for smooth      muscle actin, which is almost always positive in glomus tu?mors.

     Carcinoid tumors are differentiated from glomus tumors by their positive      staining for cytokeratins such as chromogranin and synaptophysin. These      cytokeratins are rarely seen in glomus tumors.

 Paragangliomas, like      carcinoid tumors, can be differentiated from glomus tumors by their      positivity for chromogranin and synaptophysin.

 Finally, lymphomas      (specifically gastric mucosa-associated lymphoid tissue) can be      definitively differentiated from glomus tumors by leukocyte-specific      markers such as CD20 and CD45.

The overall immunohistochemical profile of glomus      tumors includes positive staining for smooth muscle actin and vimentin.      Glomus tumors are negative for c-Kit, cytokeratin, and chromogranin, which      generally distinguishes these lesions from GISTs and epithelial cell      tumors, such as paragangliomas and carcinoid tumors, respectively (Table).      By examining the immunohistochemical profile of a given tumor, a definitive      diagnosis can be made.  

     Gastric glomus tumors are rare and generally benign.      By using different diagnostic      tools including esophago?gastroduo?denoscopy, CT scanning, and histologic examination (specifically immuno?histo?chemical staining), a correct diagnosis can be made and      suitable treatment provided. Benign glomus      tumors are treated with focused, local excision.   

     1. Almagro UA, Schulte WJ, Norback DH, et al. Glomus      tumor of the stomach. Histologic and ultrastructural features. 

     2. Caccamo D, Kaneko M, Gordon RE. Glomus tumor of the      stomach. 

     3. Chang SM, Ho WL. Glomus tumor of the stomach: a      case report. Zhonghua Yi Xue Za Zhi      (Taipei). 1993;52(4):276-279.  

     4. Chng SP, Chung AY, Ng SB, et al. Glomus tumor: the      other umbilicated lesion of the stomach. 

     5. Haque S, Modlin IM, West AB. Multiple glomus tumors      of the stomach with intravascular spread. 

     6. Kim JK, Won JH, Cho YK, et al. Glomus tumor of the      stomach: CT findings. 

     7. Miettinen M, Paal E, Lasota J, et al.      Gastrointestinal glomus tumors: a clinicopathologic, immunohistochemical,      and molecular genetic study of 32 cases. 

     8. Park SH, Han JK, Kim TK, et al. Unusual gastric      tumors: radiologic-pathologic correlation. 

     9. Folpe AL, Fanburg-Smith JC, Miettinen M, et al.      Atypical and malignant glomus tumors: analysis of 52 cases, with a proposal      for the reclassification of glomus tumors. 

Christopher M. Larson, General Surgery Resident, Department of Surgery Education, Exempla Saint Joseph Hospital; Erick R. Ratzer, General Surgeon, Department of Surgery Education, Exempla Saint Joseph Hospital; Janet K. Stephens, Staff Pathologist, Colorado Pathology Consultants, PC, Exempla Saint Joseph Hospital; Stephen Kel Muckleroy, General Surgeon, Colorado Permanente Medical Group, Exempla Saint Joseph Hospital, Denver, CO

Glomus tumor of the stomach

     Brooke Army Medical Center Fort Sam Houston, TX          

Fournier&#8217;s gangrene is a life-threatening        bacterial infection of the skin that affects the genitals and perineum. It        is much more common in men, especially the elderly. The authors report the        case of a 70-year-old man who went to the emergency department after        falling in the shower. His evaluation and workup re&shy;vealed synchronous        sigmoid and rectal cancers, which presented as Fournier&#8217;s gangrene.        The authors discuss this rare 

case and provide a        review of the literature

     Fournier&#8217;s gangrene,      a necrotizing fascitis involving the male genitalia, is a life-threatening      infection that requires prompt diagnosis and surgical intervention. It was      first described in 1764 by Baurienne and has since been widely reported and      well documented in the medical literature.

We present a case of      synchronous rectal and sigmoid carcinomas that presented as      Fournier&#8217;s gangrene with nontraumatic subcutaneous emphysema. The      patient required extensive debridement of the pelvic floor, rectum, and      perineum. This case demonstrates an uncommon presentation of a relatively      common disease. When a diagnosis of Fournier&#8217;s gangrene is made, the      underlying pathology must be evaluated. If perineal subcutaneous emphysema      is found, the presence of a perforated hollow viscus must be investigated.        

     A 70-year-old man presented to the emergency      department after falling in the shower. The initial examination was      performed by the internal medicine service and revealed he was      normotensive, afebrile, and had an irregular heart rhythm. The patient      reported no medical or surgical history and had not seen a physician in 20      years. A review of systems was positive for melena for at least 4 weeks and      loose bowel movements for the past 1

 years, which had increased in intensity and volume over the past      4 weeks. He also had an unintentional weight loss of 40 pounds during the      previous year. A physical examination noted that the patient was pale, had      a tense, rigid abdomen that was nontender to palpation and tympanitic to      percussion, and the presence of significant scrotal edema. His admission      history and physical ex&shy;amination write-up recorded no digital rectal      examination. Laboratory evaluation showed a hematocrit of 14% and a white      blood cell (WBC) count of 33,000/mm

. The patient was admitted to the      intensive care unit (ICU) for resuscitation and a blood transfusion.      Further workup at this time was directed towards the etiology of his      diarrhea and significant anemia. The ICU attending physician&#8217;s note      described scrotal trauma with suprapubic crepitus, which was attributed to      hematoma and the possibility of a perforated hollow viscus.   

     The following morning, a gastroenterologist examined      the patient and observed an increasing amount of scrotal edema. There was      surrounding erythema and an area of black and green discoloration, which      was not present upon admission to the hospital. An abdominal examination      found crepitus and that his abdomen had become tender to palpation. It was      recommended that a computed tomography (CT) scan be performed to rule out      perforation of a hollow viscus and that a regimen of broad-spectrum      antibiotics be initiated. While the CT scan was being performed, a      urologist was consulted to evaluate the patient&#8217;s increasing scrotal      edema. His scrotum and perineum were noted as markedly edematous, with      focal areas of necrosis and a generalized rubor extended throughout      the perianal region, up the abdomen, and down to his thighs (Figure 1).      Marked crepitus was palpated over his inguinal ligaments and scrotum.      Moreover, he had become more somnolent. At this point, a presumptive      diagnosis of Fournier&#8217;s gangrene was made based on the physical      examination findings of frank cutaneous necrosis and subcutaneous      emphysema.   

     The CT scan of the patient&#8217;s abdomen and pelvis      showed a 7-cm, anular, constricting lesion consistent with malignancy in      the distal descending colon and a rectal constricting lesion with a      transition point seen at the distal sigmoid colon, consistent with      synchronous malignancies. The CT scan also showed extensive      perineal, scrotal, and anterior abdominal wall subcutaneous emphysema, with      fluid and air adjacent to the rectal mass (Figure 2).   

     Given these findings, the patient was taken to the      operating room for emergency debridement of his perineum and colectomy.      Laparotomy revealed an extensive infection that tracked from the      patient&#8217;s perineum to the rectal tumor, completely obliterating the      anal canal, distal rectum, and pelvic floor (Figure 3). A digital rectal      examination found a fixed rectal mass approximately 3 cm above the anal      verge that completely obstructed the rectum. The tissues surrounding the      perineum, however, ap&shy;peared viable and healthy with no fascial      involvement.   

In subsequent surgeries, the patient&#8217;s testicles      were placed into thigh pouches for preservation and serial topical negative      pressure dressings were applied to his perineum to promote wound healing      (Figure 4). Cultures from the initial de&shy;bridement showed multiple      enteric or&shy;ganisms, including 

     The sigmoid tumor measured 6 cm, invaded the pericolic      adipose tissue, and was metastatic to four of six regional lymph nodes,      showing evidence of lymphovascular invasion. The rectal tumor, which was      only partially resected, was metastatic to one of three lymph nodes and      showed evidence of lymphovascular invasion. The sigmoid tumor was staged as      T3 N2 MX (stage IIIC) and the rectal tumor was staged as T4 N1 MX (stage      IIIB). The patient was discharged to a rehabilitation center on      postoperative day 26 and referred to oncology for palliative neoadjuvant      and radiation therapy. Two years after his initial presentation, the      patient was receiving hospice care due to his end-stage disease.   

     Our patient had a rare presentation of a common      disease. A 1988 case study of 35 patients with colorectal cancer and      spontaneous gangrene revealed five cases of rectal cancer and three sigmoid      cancers that developed nontraumatic gas gangrene, but none of which      presented with Fournier&#8217;s gangrene.

 An extensive search of the      literature found only four previously reported cases of Fournier&#8217;s      gangrene that resulted from rectal or sigmoid adenocarcinoma.

 Of these      four cases, one was a stage II (T3 N0 M0) lesion, the others Dukes&#8217; B      and Aston Collier C2, and the fourth case had no staging reported.

 Our      case was a stage IIIC/IIIB, more advanced than the cases previously      reported.  

              Fournier&#8217;s gangrene is typically de&shy;scribed      as a polymicrobial disease that allows a synergistic necrotizing infection      to invade the tissues of the scrotum, perineum, and perianal region.

 It is      frequently caused by perineal injury from instrumentation or trauma and is      often associated with comorbid diseases, most notably diabetes, and other      immunosuppressed states.

 Fournier&#8217;s gangrene can also be caused by      perianal infection, perirectal abscess, skin infection, urethral stricture,      indwelling catheters, penile intravenous drug use (injection of drugs into      the corpus cavernosum), hidradenitis, and      balanitis.

     The initiating event in Fournier&#8217;s gangrene from      an anorectal source is penetration of the anal sphincter muscles by a deep      infection. The infection then has two avenues of opportunity: it may track      up Colles&#8217; fascia to involve the tunica dartos, or it may spread      through the Retzius space and down the spermatic cord.

 Fournier&#8217;s      gangrene from a penile source occurs when the infection penetrates      Buck&#8217;s fascia and spreads along the shaft of the penis into the      scrotum, up along Scarpa&#8217;s fascia and by way of Colles&#8217; fascia      into the perineum.

     The bacteria typically associated with      Fournier&#8217;s gangrene are 

 with an    average of at least three bacteria cultured from each patient.

 Even with      such extensive infections, one review showed that blood cultures were      positive in only one third of cases.

     Fournier&#8217;s gangrene usually presents with      itching and edema as well as perianal or perineal pain that is      disproportionate to findings on physical examination.

 The clinical disease      becomes more evident with worsening of the subcutaneous infection and      inflammation that culminates in frank necrosis of the skin as the blood      vessels thrombose.

     Fournier&#8217;s gangrene is diagnosed clinically and      should be evident from a prompt and thorough patient history, review of      systems, and physical examination. If the diagnosis is questionable, some      imaging modalities are useful in evaluating the acute scrotum.      Ultrasonography of the scrotum can help visualize subcutaneous      emphysema and reportedly has shown subcutaneous gas prior to it being found      during physical examination.

 Ultrasound findings consistent with      Fournier&#8217;s gangrene include normal testes, a thickened scrotal wall,      and subcutaneous gas that lies parallel to the transducer head.

 Plain      abdominal radiographs and CT scanning can assist in early visualization of      subcutaneous emphysema and help identify the source of infection.

     Nontraumatic, nongangrenous, subcutaneous emphysema of      the lower extremities is documented as being associated with      gastrointestinal (GI) perforations.

 A 1995 review reported 36 cases of      subcutaneous emphysema originating from GI tract perforations.

 This      report suggests that subcutaneous emphysema of GI origin depends on three      factors: (1) perforation of the bowel; (2) an adequate pressure gradient      between bowel lumen and subcutaneous space; and (3) the anatomic site      of the perforation.

 Studies have shown that gas pressures in the      intestinal lumen may rise to more than 60 cm H

O, while soft tissue pressures are about 5 cm H

 It is thought      that the gas gains access to the lower extremities anteriorly under the      inguinal ligament or posteriorly across the sciatic foramen.

 Often,      subcutaneous emphysema without gas gangrene will be the manifestation of      the perforation and is commonly misdiagnosed as gas gangrene.

 Subcutaneous      emphysema as the result of a perforated hollow viscus can occur anywhere      from the neck to the lower extremities.

 Whether subcutaneous emphysema is      mere&shy;ly the manifestation of a perforated hollow viscus or from      spontaneous nontraumatic gas gangrene can be difficult to determine because      in either case, the patient may present toxic and in extremis.      Spontaneous nontraumatic gas gangrene is usually accompanied by other      findings on physical examination, such as erythema, skin necrosis, and      progressive deterioration of the patient&#8217;s clinical condition. Gas      gangrene should always be high in the differential diagnosis and      immediately excluded. A tissue biopsy will provide conclusive      information if the diagnosis is still in doubt after a careful physical      examination is performed and a thorough patient history is obtained.

      The pitfall would be to delay prompt surgical management at the expense of obtaining a definitive diagnosis.   

     Managing Fournier&#8217;s gangrene requires      prompt diagnosis, antibiotic therapy, and surgical debridement to limit morbidity and mortality.      During exploration, the surgeon may not      have the luxury of imaging studies to assist in diagnosis and should be      prepared for both urinary and fecal diversion, extensive debridement,      and laparotomy.

 Before de&shy;bridement, rigid proctoscopy should be      performed to evaluate sphincteric involvement. After debridement      and once the patient has been brought through the acute phase, the      remaining defects can be allowed to heal by secondary intention.

     Mortality from Fournier&#8217;s gangrene is variable      and ranges from 0% to 75%.

 A study that examined which factors predicted      mortality showed that on admission, advanced age, anemia, elevated blood      urea nitrogen (BUN), hypocalce&shy;mia, hypoalbuminemia, increased alkaline phosphatase, and low cholesterol predicted a poor outcome. The same study showed that 1 week      after admission, an elevated WBC count, thrombocytopenia, hypokalemia, low      bicarbonate, elevated lactate dehydrogenase,      and elevated BUN predicted a poor outcome.

     Our case was similar to others in the literature      involving patients who presented with advanced colorectal carcinoma and      other comorbidities, such as diabetes and alcoholism, which predisposed      them to this manifestation of their underlying pathology.

 The other      cases were managed similarly, with extensive debridement, resection of the      cancer, and fecal diversion. Only one case had a positive culture for Clostridium; most had      mixed enteric flora.

     It is probable that the large amount of subcutaneous      emphysema seen on our patient&#8217;s CT scan resulted from the perforated      rectal cancer. Of special interest regarding this patient is the failure of      several experienced physicians to diagnose the infectious process correctly      on presentation and subsequent examinations. The differential diagnosis made by the ICU attending and      gastroenterologist addressed the possibility of a perforated hollow viscus      as the etiology of the subcutaneous emphysema. Given the overall clinical      picture of the patient (scrotal edema, subcutaneous emphysema, cutaneous necrosis, and elevated WBC count), it is unfortunate that the possibility of necrotizing      Fournier&#8217;s gangrene was never contemplated because an earlier      diagnosis of the underlying disease process would have led to prompt      intervention, allowing more limited debridement. The finding of      subcutaneous emphysema should have automatically triggered a consultation      for surgical evaluation. Fortunately, the      organisms iso&shy;lated from this infection      were not gas-forming Clostridia but were instead less virulent anaerobes.      Fournier&#8217;s gangrene is a true surgical emergency where life-saving,      definitive treatment is provided in the operating room.   

Neil R. McMullin, General Surgery Resident; Scott Gering, Colorectal Surgeon; Thomas Levoyer, Surgical Oncologist, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX

June 2006

Lumbar Sympathetic Nerves

Surgeon's Bulletin Board

Laparoscopic repair of retrosternal hernia of Morgagni

Intussusception After Roux-en-y Gastrojejunostomy: Sequela of the Roux Stasis Syndrome?

Glomus tumor of the stomach

Necrotizing Fournier's Gangrene From a Perforated Rectal Carcinoma

Intravenous revolution

Massive Pneumoperitoneum From Pulmonary Barotrauma: a Rare Complication