Articles

Surgical Rounds

Transposition of the Great Vessels

Eversion carotid endarterectomy (ECEA) has been used for some time as a method for preventing stroke. Numerous groups have adopted this technique. In particular, The Vascular Group, PLLC, in Albany, New York, has written extensively on ECEA, pointing out its numerous advantages. One of the obvious advantages is speed. Because ECEA is technically a faster operation to perform, the question of shunting usually becomes secondary. This technique is also beneficial for patients who do not want to use a synthetic patch following the procedure. By performing an ECEA, the internal carotid artery serves as the patch. As Saratzis and colleagues indicate, another advantage of ECEA is that it addresses the long tortuous or kinked carotid artery, making it easy to foreshorten this vessel. Although ECEA is not commonly used in the United States, surgeons who perform carotid surgery should be familiar with this technique because it may be necessary at certain times. 

Carotid endarterectomy      (CEA) is a well-established method for preventing stroke and is recognized      as the gold standard for both symptomatic and asymptomatic patients with      high-grade extracranial carotid artery stenosis.

 The two methods of CEA include conventional and eversion      carotid endarterectomy (ECEA).      Conventional CEA involves longitudinal      arteriotomy of the internal carotid artery (ICA), removal of any plaque,      and closure of the arteriotomy using a continuous simple suture, a      patch made from synthetic material, or an autologous vein graft. Although      conventional CEA is the most frequently employed technique, ECEA is a good      alternative. ECEA involves complete transection of the ICA at its origin,      removal of the atheroma while the adventitia of the ICA is everted, and      reimplantation of the ICA on the common carotid artery (CCA). ECEA can      prove useful in cases with carotid elongation and should be incorporated in      the armamentarium of every vascular surgeon.

     During the past several years, open carotid surgery has      been sidelined in favor of less invasive techniques such as carotid      angioplasty and stenting

; however, carotid stenting should be avoided in cases of      severe carotid elongation because a nonflexible metal stent can cause      severe kinking of an elongated and tortuous vessel. In such cases, ECEA      should be the method of choice. We detail the steps of an ECEA and include      a series of figures for further clarification.   

     The patient is placed supine on the operating table      with the head hyperextended and turned to the opposite side. A 5- to 6-cm      incision is made parallel to the anterior border of the sternocleidomastoid      muscle. Electrocautery is used to incise the platysma muscle. The      sternocleidomastoid muscle is retracted laterally, and after division and      ligation of the facial vein, the carotid bifurcation is exposed.   

     The CCA, external carotid artery (ECA), and ICA are exposed and      clamped. Systemic heparinization is      necessary. A right-angled bulldog clamp should control the ICA well beyond      the distal end of the atheromatous plaque (Figure 1).   

     The CCA is entered with a scalpel. Using angulated      Pott's scissors, the arteriotomy is extended in a distal direction      towards the fork of the carotid bifurcation (Figure 2). The incision should      be made precisely parallel to the axis of the ICA. A common pair of      scissors is then used for complete transection of this vessel (Figure 3).      The transection permits complete mobilization of the artery. Additional      traction downwards offers further length of exposure.  

     Endarterectomy is started at the stump of the ICA, and      the plane is developed between the outer layers of the media and the      adventitia (Figure 4). Fine atraumatic vascular forceps are used to      circumferentially separate and detach the atheroma, while the outer layer      of the vessel is everted (Figure 5). The eversion progresses distally, and      the atheroma is detached like a cast (Figure 6). Gentle traction is used to      completely remove the atheromatous core, leaving a thin, tapering end point      (Figure 7). While the atheroma is removed, the luminal surface and the      transition between the endarterectomized and the      nonendarterectomized segments of the ICA are carefully assessed. The field      is flooded with copious quantities of heparinized saline to remove intimal      or medial debris. Flaps or loose residuals are removed gently by      circumferential traction because cephalic traction can cause inadvertent      intimal dissection of the ICA end point.   

     Next, endarterectomy of the ECA and CCA is attempted.      The plaque is mobilized circumferentially using the closed jaws of a      dissector (Figure 8). After proximal division of the plaque, the      endarterectomy is carried out into the ECA orifice as distally as      possible.   

The arterial wall of the ICA is drawn proximally, and      the surgeon initiates reimplantation of the artery to its normal position.      The anastomosis is started at the bifurcation fork, using a simple,      running, 6-0, synthetic monofilament suture. The posterior wall is      reconstructed first, with tiny suture bites (Figure 9). Before completing      the anterior wall of the anastomosis, each clamp is removed sequentially to      allow back bleeding and to wash out any thrombogenic debris. At this stage      of the procedure, the extracranial segment of the ICA may be dilated using      appropriately sized dilators measuring up to 4.5 mm in diameter (Figure  10). 

Angioscopy may be used to verify the anatomic result. Angioscopy      provides excellent visualization of the whole endarterectomized luminal      surface and the end point of the ICA (Figure 11). In case of incomplete      endarterectomy or an unsatisfactory anatomic result, intraoperative stent      deployment can be used to secure the distal end of the intima (Figure 12).   These defects may be well documented using intraoperative completion      arteriography. After the anastomosis is completed, blood flow is restored      first to the ECA and then to the ICA. In some complex cases, when the inner      surface of the ICA is unsmooth and friable after the ECEA or the plaque is      extended distally, it may be necessary to replace the ICA using a graft. In      such cases, interposition of synthetic or saphenous vein grafts may be used      (Figure 13).   

     The concept of ECEA was first reported by DeBakey and      associates in 1959.

 The technique involved complete transection of the CCA at      the bifurcation level, followed by ECEA of both the ICA and ECA. Since      these divided arteries remained and were joined in a bi-furcation,      adequate eversion of the ICA and visualization of the distal plaque end      point were almost impossible. As a result, this method was not widely      accepted. In 1989, Kasprzak and Raithel presented a modification of the      technique, involving oblique transection of the ICA at the bifurcation,      which allowed complete cephalad mobilization of this vessel and excellent      visualization of the end point.

 Moreover, an elongated ICA could be resected at the desired      length and reimplanted at the carotid bulb.   

     ECEA has several advantages over conventional CEA. The      longitudinal arteriotomy of the ICA is avoided, and, subsequently, the      suture line does not interfere with the small distal lumen of the vessel.      The anastomosis is reconstructed at the carotid bulb and is rather large in      diameter (2?3 cm). As demonstrated by Koskas and colleagues, this may      be associated with avoidance of neointimal hyperplasia at the distal ICA      and a lower restenosis rate than observed with conventional CEA.

     EVEREST (EVERsion carotid Endarterectomy versus      Standard Trial) evaluated the feasibility and durability of ECEA. A total      of 1,353 patients with surgical indications for carotid stenosis were      randomly assigned to undergo ECEA (n = 678) or conventional CEA (n =      675). The groups had similar rates of perioperative major stroke and death      (1.3 for each study group) and a similar incidence of early carotid      occlusion (0.6% for ECEA versus 0.4% for conventional CEA). No significant      differences were found between ECEA and conventional CEA with respect to      incidence of perioperative transient ischemic accident, minor stroke,      cranial nerve injuries, neck hematoma, myocardial infarction, or surgical      defects. Overall 30-day events occurred in 13.3% of ECEA patients and 11.4%      of conventional CEA patients. At a mean follow-up of 14.9 months, 16 (2.4%)      restenoses occurred in the ECEA group and 28 (4.1%) occurred in the      conventional CEA group.

     An advantage of ECEA is that it does not require use      of a patch, even in patients with small arteries (particularly women).      Closure is also technically easier and quicker. Radak and associates      reported the mean clamping time for ECEA at 13.5 minutes versus 19.9      minutes for conventional CEA.

 ECEA is a highly effective method for correcting      coiling, kinking, or tortuosities of the ICA in the presence of      arteriosclerotic lesions. After completing the ECEA, an appropriately sized      segment of the ICA is resected and the vessel is reimplanted.  

     Over the past decade, our center has performed ECEA on      278 patients. Restenosis occurred in 3 cases and 2 patients experienced an      intraoperative stroke. These results and those      of others, such as the EVEREST, indicate that ECEA is a feasible and safe      technique for managing extracranial carotid arteriosclerosis. Major      advantages of this technique are that it allows for optimum correction of      an elongated ICA, has lower restenosis rates, and does not require patch      material for arteriotomy closure.   

     1. North American Symptomatic Carotid Endarterectomy      Trial Collaborators. Beneficial effect of carotid endarterectomy in      symptomatic patients with high-grade carotid stenosis. 

     2. d'Audiffret A, Desgranges P, Kobeiter H, et      al. Technical aspects and current results of carotid stenting. 

     3. DeBakey ME, Crawford ES, Morris GC Jr, et al.      Surgical considerations of occlusive disease of the innominate, carotid,      subclavian, and vertebral arteries. 

     4. Kasprzak P, Raithel D. Eversion endarterectomy of      the internal carotid artery [in German]. 

N. Saratzis, Assistant Professor of Vascular Surgery;            A. Saratzis, Resident; S. Miliaras, Senior Lecturer in Surgery; G. Ginis, Resident; N. Melas, Resident;            A. Lioupis, Resident; D. Lycopoulos, Resident;            J. Lazarides, Senior Lecturer in Vascular Surgery;            D. Kiskinis, Professor, Head of Department, First Department of Surgery, Papageorgiou General Hospital, Aristotle University Medical School, Thessaloniki, Greece

Eversion Carotid endarterectomy illustrated: Tips and tricks of the procedure

Zero to Zillionaire: 8 Foolproof Steps to      Financial Peace of Mind 

     Bookstores offer consumers a deluge of personal      finance books on  how one can become wealthy or      self-help books on how to be rich at heart;      however, finding a book that addresses both issues is like finding a rare      gem. 

(Sourcebooks, Inc;      2006) is not a get-rich-quick scheme or a peprally. Instead, it's a      useful guide with simple tips and powerful strategies that will help you      achieve both wealth and an enriched life. In the first section of the book,      author Chelli? Campbell tackles changing      your mindset, which she feels can help you change your future. The book      helps you assess your past and identify habits      of thought and  behavior, setting a solid foundation to build on with      Campbell's next seven strategies. These      strategies focus on setting goals, actively pursuing those goals, and      creating a framework in your life that consists of people, financial      planning, and personal enlightenment.  "Someone is a      zillionaire," Campbell says, "when      they not only learn how to make a zillion dollars, but learn how to have a      zillion dreams, a zillion friends, and a fun-filled life with zero      worries." Filled with proven principles and successful techniques, 

is relevant      not only for the million-dollar entrepreneur but also for the      small-business owner and the busy professional struggling to maintain a  balanced checkbook.

Private school tuition continues to climb 

     If you're a surgeon who has one or more children      enrolled in a private school, you are likely aware of tuition's      rising costs. A recent article in the 

 cited statistics from the      National Association of Independent Schools (NAIS) showing the national      median tuition for the 2005?2006 school year was $16,970?a      14.5% increase over the 2000?2001 school year?with some New      York City schools topping $30,000 a year. In areas with the highest cost of      living, private schools have begun to rival college costs. NAIS listed the      average tuition of schools based in New York and New Jersey as $23,005 for      grade 12, while schools in the Southeast fall      on the other side of the spectrum at $12,960. Traditionally, private      schools allocated grant money to needier students; now many schools across      the country are trying to increase the amount of aid available for middle- and upper-middle-income families. Parents who gross as much as $250,000 and have two or more  kids in tuition-charging schools may qualify for financial aid.

Help alleviate the stress of your finances 

     As if your duties as a surgeon weren't stressful      enough, there's the added stress of worrying about money. An article      in 

 presents      a simple five-step plan that can help you      combat your financial worries.  

. Write down the important things you      want to accomplish with your money and then calculate how much money      you'll need to achieve those goals. Defining these objectives will      help you curb impulse spending and save money.  

 Make a      budget and stick to it. Write down your monthly expenses and break them      down by day. Once you have accomplished that, cut out what you don't      need.  

e. Online      bill payments are a convenient way to simplify your monthly expenses.      Scheduling your payments to be withdrawn automatically can help prevent      late fees. Just make sure you always have enough money in your account to      cover the expected withdrawals.  

. Keep      a bare minimum of credit cards, and periodically contact customer service      to obtain a better annual percentage rate. Also, limit your card use to      major purchases and pay off your cards in the order of highest interest      rate first.  

. Automate your      saving efforts by having a fixed amount moved from your checking account      each month into an interest-bearing account or mutual fund. Use any      financial windfall you receive (eg, tax returns, inheritance, bonus) toward  paying down your debts and building up your savings.

New home mortgage trends for first-time buyers

   Surgeons who purchased their first home years ago    likely selected a 30-year fixed-rate mortgage with a traditional 20% down    payment, which has been the standard for decades. These days there are many    options available to first-time home buyers, for better or for worse. As    housing prices have gone sky-high in recent years, new homeowners are    finding it difficult to come up with the customary 20% down payment and are    instead opting for no-money-down mortgages. According to 

, a whopping 43% of first-time      home buyers purchased their homes with no money down in 2005, which is up      28% from 2 years ago.  However, financing      100% of your home leads to additional costs, including private mortgage      insurance and a 0.5% premium during the first year of payments. Even worse,      homeowners who opt for no-money-down mortgages usually end up owing more      than their home is worth, and if they sell while the market is in a cool      down, they'll still be left with huge monthly payments. New buyers      should also be cautious of another mortgage trend: interest-only loans. When interest rates are low, signing a low-percentage,      interest-only, adjustable-rate mortgage seems wise, but if rates later balloon, you will find yourself paying  substantially more for your monthly mortgage payment. 

Search overseas for your real estate investments 

     The end of the housing bubble in the United States has      burst the enthusiasm of many surgeon investors involved with the real      estate market. 

 reports that overseas real estate is      fast becoming an attractive option for US investors because of low prices,      diversification, and legal changes that are encouraging the flow of money      into foreign countries. These changes are being enacted to promote the      creation of real estate investment trusts that will interest numerous      investors. A surgeon investor looking to get involved in overseas housing      can choose from a variety of funds that encompass different regions, such      as the Cohen & Steers International Realty      fund, which focuses on Europe, or the      Fidelity International Real Estate fund, which concentrates on Asia and Australia. 

 advises investors to be      cautious of global real estate funds, because they may include investments      in the United States, negating the advantages of foreign real estate  investing.

     It's becoming increasingly more common for      first-graders to accumulate credit card debt of $10,000 and more, but not      because they ran amuck with mom and dad's plastic. Every year, an      estimated 400,000 people under age 18 become victims of identity theft,      according to 

.      The perpetrators target children because a nonexistent credit history is      attractive to thieves looking to establish a falsified line of credit.      Thieves, who range from low-life relatives to computer hackers, obtain the      child's Social Security number and then open credit cards in the      child's name. In the past, people did not get Social Security numbers      until they began working and received a paycheck, but for tax reasons, 90%      of today's newborns leave the hospital already signed up for Social      Security. While children and teens account for only 4% of last year's      10 million cases of identity theft, that number doubled since 2002,  according to the Federal Trade Commission. 

Bird flu pandemic could affect life insurers

     Headlines warning of a possible bird flu pandemic continually resurface, and this has engendered      quite a few "what ifs" on the investment front. While      emphasizing the remote likelihood of a pandemic, the 

 suggests that life insurers would get the short end of the stick.      Four insurance industry giants?MetLife, UnumProvident, StanCorp, and      RGA?claim to have considered the possible risks associated with avian      flu; however, earnings and shareholder equity could take a hit in the event      of increased mortality rates. The 

 quotes the Insurance Information Institute as estimating      that a 1918-style pandemic could cost the industry $133 billion in      additional death claims, and that a more modest outbreak could amount to a      little less than 15% of capital. The 

 suggests a pandemic could also negatively affect all      human-to-human contact sectors, including restaurants, hotels, and the      travel industry. With this scenario in mind, the better sectors to invest  in would be those that skirt face-to-face contact, such as Internet stocks. 

     Many financial experts advise saving as much money for      your nest egg as possible while you are still working. They also recommend      spending conservatively during the early years of retirement to ensure you      do not outlive your funds. But what if future retirees are saving too much      now and can spend more freely during the early years? Ty Bernicke argues      this point in the 

. He is convinced that retirement planners usually      overestimate future needs because of flawed assumptions in regard to      spending. The general consensus among financial advisors is that retirees      will need 70% to 80% of their preretirement income, but Bernicke contends      that an individual's spending decreases even further as he or she      settles into retirement rather than rising with inflation as traditional      belief holds. In a subsequent article, 

 offers an example of Bernicke's theory at work.      Suppose you and your spouse would like to retire at age 62 with an      estimated retirement income of $61,000 a year after taxes. Conventional      planning would factor 3% yearly inflation into the calculations. By the      time you turn 75, your annual after-tax needs would rise to $90,000; however, Bernicke states that people aged 75 and      over spend 25% less than retirees aged 65 to 74, which corresponds with      data collected for the Bureau of Labor Statistics Consumer Expenditure      Survey. As retirees become older and less active, they spend less, so      instead of requiring $90,000 annually at age 75, Bernicke's retiree      will need closer to $54,000. Although Bernicke's "reality      planning" is appealing, 

 warns that you cannot compare the spending patterns or      needs of previous generations with those of future retirees. In addition,      medical advancements and projected longer life spans may allow future  septo- and octogenarians to be more active than in the past.

Hidden moving costs move cash right out of your wallet 

     Moving to a new house is exciting, but the physical      move can be a nightmare, both labor-wise and financially. If you hire a      moving company, a myriad of hidden costs can make your final bill for the      move astronomical. The more stuff you have, the more costs there will      be?something to consider if you're a highly successful surgeon      with a large home. According to 

, moving costs go way beyond employing professional movers      and renting a truck. First of all, supplies have to be taken into account,      including boxes, tape, bubble wrap, packing paper, and more. Unless you      scour local stores for free boxes, you'll spend over $2 a box?a      hefty cost if you need around 100 boxes for your move. If you have large      items to move, such as a piano or car, expect to pay hundreds of dollars      more for their careful transit. Movers may refuse to handle precious and      priceless items such as paintings, antiques, and other family heirlooms,      because those items may not be covered under the movers' insurance.      In that case, you'll need to purchase additional moving insurance or      hire handlers that specialize in moving such items. You'll also pay      significantly more if you're moving a long distance, because the      movers' expenses for gas, lodging, and meals will be added to the  bill.

     With exchange-traded funds (ETFs) tipping the scale      against mutual funds by offering lower costs, surgeon investors may be      drawn in by the scent of a bargain, unaware of possible hidden costs. The      popularity of ETFs has convinced many investors to sell their mutual funds      and transfer the money to a similarly constructed ETF. While this may be a      smart move for some, saving money over time, an article in the 

 stresses      the importance of being aware of any additional costs, which could      potentially outweigh your gains. Hidden fees include the following:  

. These often disappear after a specific      holding period and usually do not exceed 2%.  

 If a mutual fund is owned for      less than 1 year, the tax bill can be as much as 35%.   

 Because ETFs are traded like      stocks, a commission must be paid for each purchase or sale.   

     While switching from a mutual fund to an ETF may prove      beneficial, the cumulation of related expenses may outweigh the benefit of  these lower-cost investments. 

Stock splits don't always equal big profits 

     Surgeon investors tend to get keyed up when a company      announces its stock is splitting, excited by the bullish prospect that      their profits from the investment could take a big leap. But, as 

 points out,      that's not exactly the case these days. Finance investments      strategist William Lefkowitz researched 22 stocks one month after they      split in 2005 and found that while eight gained at least 4%, seven gained      less than 4% and another seven dropped in price. Lefkowitz carried out      similar research in 2004, drawing a similar conclusion: 33 of the 77 split      stocks he studied lost ground immediately after the split. If you find that      a stock you own has split and hasn't immediately made a positive leap      forward, don't cast it out of your portfolio just yet. Consider  staying the course, which remains a successful strategy for the long term.

Three more years until Social Security is tackled 

     The year is 2009; the next president has been elected      and lawmakers are finally buckling down to overhaul Social Security.      That's right; it will be another 3 years before the government      addresses the prospective demise of Social Security as we know it.      According to 

, Finance Committee Chairman Charles Grassley (R-Iowa)      announced that it is unlikely lawmakers can do anything before the end of      President Bush's second term. In October 2005, the president even      stated that Congress was not eager to start such an undertaking. Reasons      for putting Social Security on the back burner include the 2006      congressional elections and the next presidential election. Jim McCrery      (R-Louisiana), head of the House Ways and Means Subcommittee on Social      Security, is optimistic about reform, maintaining that passing legislation      in 2006 or 2007 is possible. Bush asked Congress to establish personal      accounts for individual beneficiaries and make necessary changes to ensure      Social Security's long-term viability, but efforts to form a single      plan of action have yet to be realized. Because of Social Security's      uncertain future, surgeon investors should not factor these once-guaranteed  benefits into their retirement plans.

Surgeons Bulletin Board

Jejunal diverticula are rare and usually occur in the      elderly. The condition is dif

icult to diagnose because patients generally present with      symptoms that mimic other diseases. It is important for clinicians to have      a heightened awareness of jejunal diverticulitis because perforation and      other complications can occur if it is not recognized promptly in      symptomatic patients. The authors report a case of jejunal diverticulitis      that was initially treated with medical management but eventually required      surgical intervention. The perforation was observed during the operation.      The authors also review the literature and discuss the presentation,      diagnosis, and optimal management of this disease. 

     Although diverticular      disease is a common pathology of the colon, diverticulosis of the small      bowel and its complications are relatively rare. As a result, the diagnosis      is often missed,  which can be disastrous. We describe an interesting      case of perforated jejunal diverticulitis. Our      patient was successfully treated and had a      favorable outcome. We also review the literature regarding this rare      condition.   

 A 69-year-old woman presented to the emergency      department with a 36-hour history of left-sided abdominal pain without      nausea or vomiting. On physical examination, she had a temperature of      101?F, pulse of 120 beats per minute, blood pressure of 100/60 mm Hg,      respiratory rate of 20 breaths per minute, and an oxygen saturation of 95%      on room air. The patient's abdomen was soft and nondistended, but a      small mass and tenderness were elicited on deep palpation in the left      mid-abdomen. There were no peritoneal signs and only minimal bowel sounds      on auscultation. The patient's medical history was noncontributory. 

Laboratory studies were significant for an elevated      white blood cell (WBC) count of 16,500/mm

. Computed tomography (CT) scans of the abdomen      revealed a 5-cm, complex, inflammatory mass in the left upper quadrant      adjacent to a loop of small bowel, indicating diverticulitis (Figure 1).      The patient was clinically stable and was admitted to the hospital for intravenous antibiotics, including levofloxacin and metronidazole, and fluid resuscitation.  

     The patient remained febrile, and an upper      gastrointestinal series with small bowel follow-through with barium      revealed several small duodenal diverticula (Figure 2). There was a      tract of contrast arising from the proximal jejunum leading to a mottled      collection of debris and gas in the left upper quadrant. Based on these      findings, a diagnosis of jejunal diverticulitis with abscess was made.       

     The patient was taken to the operating room on hospital      day 6 once her fever had resolved and her WBC count returned to normal. A      midline exploratory laparotomy revealed several small      duodenal diverticula and a large diverticulum arising on the mesenteric      border of the proximal jejunum (Figure 3). There was a small perforation      with a collection of pus near the base of the diverticulum. The bowel      proximal and distal to the diverticular mass was carefully mobilized and      resected using a gastrointestinal anastomosis stapling device. A window was      placed in the transverse mesocolon and the proximal jejunum was      anastomosed to the second portion of the duodenum in a retrocolic      side-to-side fashion. The abdomen was irrigated and a Jackson-Pratt drain      was left near the anastomosis.   

     Pathology revealed a 5-cm segment of small bowel with      a 5.5 x 4.5 x 4.0-cm diverticulum arising from a 2-cm mesenteric defect      along the bowel wall. The diverticular wall consisted only of mucosa,      0.3 to 0.4 cm in thickness. There was no sign of malignancy.  

     The patient did well postoperatively and was discharged      to home on postoperative day 6 tolerating a regular diet. The patient was      doing well at 1-year follow-up.  

     Jejunal diverticulosis was first reported in 1807      by Sir Astley Paston Cooper. Autopsy studies reveal an incidence between      1.3% and 4.6%, whereas radiologic studies show an incidence between 0.02%      and 2.3%.

 Over 80% of jejunal diverticula occur in patients 70 years and      older. Jejunal diverticula make up only 8% of all small bowel diverticula

 and are associated      with diverticula of other areas, with colonic involvement observed in up to 50% of cases.

     Jejunal diverticula are thought to be due to an      acquired disease process. These pulsion-type false diverticula occur along      the mesenteric border of the intestine, where blood vessels pierce the      muscularis layer of the bowel wall, causing weak areas to develop. These      weak areas lead to herniation of mucosa, submucosa, and serosa while      excluding the muscularis layer. Diverticula may be difficult to identify      during laparotomy because they may be hidden by mesenteric fat. Most      jejunal diverticula are asymptomatic; however, a number of acute      complications may occasionally be present.        

     Surgical management of small bowel diverticulosis was      first described in 1906 by Gordinier and Sampson.

 Jejunal diverticulitis      occurs with a frequency of 2.3% in patients with known diverticulosis.

 The etiology is      thought to be secondary to luminal obstruction leading to bacterial stasis      and a localized inflammatory reaction. Diverticulitis may be further      complicated by perforation with peritonitis, mechanical obstruction, or      fistulization. A case of manifestation as an abdominal wall abscess has      also been reported.

 A preoperative diagnosis of jejunal diverticulitis is      rarely made because this condition's presentation is similar      to that of other acute abdominal pathologies, including perforated      ulcer, appendicitis, pancreatitis, and acute cholecystitis.   

     Perforation of jejunal diverticula is uncommon, which      may be related to the low intraluminal pressures within the small bowel.      Instigating factors for perforation were shown to be related to a      necrotizing inflammatory reaction in 82% of cases, followed by blunt trauma      (12%) and foreign body impaction (6%).

 Cocaine sniffing has also been noted as a risk factor.

 Perforation often      occurs into the mesenteric leaves of the jejunum, leading to a mesenteric abscess. Although the perforation may be contained within the mesentery,      preventing leakage into the peritoneal cavity and resultant peritonitis, it      also leads to a delay in diagnosis because the classical physical      examination findings of an acute abdomen are absent, which may prove      disastrous when frail or elderly patients are involved.   

     A review of reported cases showed jejunal diverticula      occur equally in both sexes and that patients have an average age of 62      years on presentation.

 The overall mortality was 24% with survival not      influenced by sex, age, or extent of operation; however, a longer duration      of symptoms marked a poorer outcome. Of patients with perforation, 83% had      multiple diverticula.   

     Jejunal diverticulosis often presents a diagnostic      dilemma. Enteroclysis is thought to be the best diagnostic tool for      visualizing this disease because the positive pressure that results from      instillation of barium and insufflation causes the diverticula in the bowel      lumen to become prominent.

 Standard upper gastrointes-tinal contrast studies may also      be helpful, showing contrast-filled outpouchings characteristic of diverticulosis. Thickened mucosal folds may indicate diverticulitis whereas free      extravasation of contrast indicates      perforation. CT scanning is helpful in      showing acute inflammatory changes, such as mesenteric stranding and      abscess or free air around the diverticular site. Plain upright radiographs      of the abdomen may demonstrate air-fluid levels in the      diverticula. Laboratory studies tend to be nonspecific, but an elevated WBC      count with bandemia can support the diagnosis of diverticulitis or      perforation.   

     Management of jejunal diverticula depends on a      patient's symptoms. It is generally recommended that asymptomatic diverticula found incidentally during laparotomy for      other reasons should be left alone.

 Surgical resection      is the standard of care for symptomatic patients with complicated      diverticula.

 Surgery is required in approximately 8.5% of all patients with      jejunal diverticula,

although it increases to 40% in patients with symptoms      or complications.

 Localization of the diverticula may be difficult      during laparotomy because they are frequently hidden between the mesenteric      leaves. Techniques to facilitate exposure include jejunal insufflation      of air using manual compression and intraoperative endoscopy.    

     Resection of the surrounding small bowel with primary      anastomosis is recommended for complicated diverticula. Some studies      support a laparoscopic approach to exploration and small bowel resection.

 Extensive      resection of multiple diverticula may lead to short bowel syndrome; thus,      resection should be limited only to the diseased segment. Attempts to      resect all portions of the bowel containing diverticula also do not      guarantee that other portions of the bowel will remain free of diverticula.

 Simple      diverticulectomy with oversew is not recommended because it has been linked      to postoperative leakage, sepsis, and death.

     The mortality rate of complicated jejunal disease has      ranged between 21% and 30% over the past 30 years

; however, some reviews      indicate a mortality rate between 0% and 5%.

 These reviews may reflect improvements in intensive care management and antimicrobial treatment. Morbidity and mortality are mostly related to the      obscurity of the diagnosis as well as the advanced age and significant      comorbidities of most patients presenting with complications. Clinicians      should have a high index of suspicion for this disease because early      operative intervention is imperative.  

     Jejunal diverticular disease is a rare clinical entity      that is difficult to diagnose. Although conservative medical management may      be attempted for stable patients, surgical resection of involved bowel      segments is the standard of care for patients with recurrent symptoms who      have undergone unsuccessful medical management or have complications. It is      imperative for general surgeons to be familiar with this entity so that      they can act quickly and contribute to a successful clinical outcome for      their patients.    

     We wish to thank Ms. Sue Shultz, Director of Library      Services, Philip A. Hoover MD Library, York Hospital, for her editorial      assistance; and Dr. Thomas Scott, Director of the General Surgical      Residency Program, York Hospital, for reviewing the contents of this      article.   

     1. Ross CB, Richards WO, Sharp KW, et al. Diverticular      disease of the jejunum and its complications. 

     2. Wilcox RD, Shatney CH. Surgical implications of      jejunal diverticula.

     3. Lee RE, Finby N. Jejunal and ileal diverticulosis. 

     4. Gordinier HC, Sampson JA. Diverticulitis (not      Meckel's) causing intestinal obstruction: multiple mesenteric      (acquired) diverticula of the small intestine. 

     5. Alvarez OA, Mejia A, Ostrower VS, et al. Jejunal      diverticulitis manifesting with abdominal wall abscess. 

     6. Herrington JL Jr. Perforation of acquired      diverticula of the jejunum. Analysis of reported cases. 

     7. Albu E, Parikh V, Alankar S, et al. Perforated      solitary jejunal diverticulum. 

     8. Chendrasekhar A, Timberlake GA. Perforated jejunal      diverticula: an analysis of reported cases. 

     9. Sibille A, Willocx R. Jejunal diverticulitis. 

     10. Rodriguez HE, Ziauddin MF, Quiros ED, et al.      Jejunal diverticulosis and gastrointestinal bleeding. 

     11. Maull KI, Nicholson BW, Mendez-Picon G.      Jejunoileal diverticulosis. 

     12. Cross MJ, Snyder SK. Laparoscopic-directed small      bowel resection for jejunal diverticulitis with perforation.

     13. Brown JE, Vallette R, Brown JE Jr. Recurrent      jejunal diverticulosis. 

     14. Tsiotos GG, Farnell MB, Ilstrup DM. Nonmeckelian      jejunal or ileal diverticulosis: an analysis of 112 cases. 

     15. Akhrass R, Yaffe MB, Fischer C, et al. Small-bowel      diverticulosis: perceptions and reality. 

Parviz Goshtasby, Chief Surgical Resident, Department of Surgery; Vasudevan Tiruchelvam, General Surgery Attending, Department of Surgery; Thomas Nicholson, General Surgery Attending, Department of Surgery,  York Hospital, York, PA

Perforated Jejunal Diverticulitis

Primitive neuroectodermal tumors (PNETs) of the kidneys are      extremely rare and generally occur in young adults. These tumors are      often large and patients present with abdominal or flank pain and      hematuria. Treatment usually includes radical nephrectomy and      postoperative chemotherapy. PNETs are aggressive and prognosis varies.      Long-term survivors have been reported, but few centers have much      experience with these tumors. We report the case of a successfully resected      PNET of the kidney that extended to the renal vein, inferior vena cava,      right atrium, and hepatic veins in a patient with Budd-Chiari syndrome.  

     A previously healthy 17-year-old Filipina girl came to our institution      reporting fatigue and increased abdominal girth of 3 months'      duration. She attributed the swelling to weight gain and began exercising      more. She noted that exercise resulted in an asymmetrical loss of her      abdominal swelling and observed greater protuberance on the right side. She      reported becoming fatigued easily, dyspnea, and palpitations upon minimal      physical activity. One week before admission to the hospital, the      patient experienced fever and chills. She reported no nausea,      vomiting, anorexia, abdominal pain, hematuria, or changes in her bowel      habits. She had no major medical history, but her family history was  notable for gastric carcinoma, diabetes mellitus, and hypertension.

Physical examination revealed abdominal      distension with a fluid wave, massive bilateral lower extremity edema, and      pleural effusions. Her weight gain was 65 pounds from baseline. A computed      tomography (CT) scan showed a large retroperitoneal mass that involved the      right kidney and extended into the renal vein, inferior vena cava, right      atrium, and hepatic veins (Figure 1). She had Budd-Chiari syndrome,      hepatomegaly, ascites, and a bilirubin of 15 mg/dL (Figure 2). An open      biopsy of the renal mass yielded a diagnosis of PNET of the right kidney      with extension into the inferior vena cava and right atrium. Fluorescent in      situ hybridization (FISH) of the tumor showed EWSR gene translocation,      consistent with PNET/Ewing sarcoma.  

The patient was placed on an aggressive neoadjuvant      chemotherapeutic regimen of vincristine, doxorubicin, and cyclophosphamide.      After completing three cycles, she developed a febrile syndrome of unclear      etiology. CT scans demonstrated several new lesions in her left lung. An      abdominal CT scan showed the mass in the retroperitoneum had only a minimal      radiographic response. There was continued involvement of the inferior vena      cava and right atrium, although the liver was not as enlarged and the      ascites had resolved.   

     Resection of the pulmonary lesions showed only chronic      inflammation and fibrosis, with evidence of 

 were identified. Acid-fast staining was negative.          

     Because of the opportunistic infection, chemotherapy      was stopped and the patient was given systemic antifungal therapy.      Five months after the initial diagnosis, she underwent exploratory      laparotomy and median sternotomy with curative intent. Preoperatively,      her laboratory findings included total bilirubin, 7.9 mg/dL; prothrombin      time, 14 seconds; serum albumin, 3.1 g/dL; hemoglobin, 14.6 g/dL; and      creatinine, 1.3 mg/dL. During the operation, a massive, 20 x 20-cm renal      mass with palpable extension into the renal vein, inferior vena cava, and      right atrium was found. After the mass was mobilized, the patient underwent      cardiopulmonary bypass through the femoral vein and superior vena      caval cannulas. Hypothermic circulatory arrest was then initiated to avoid      the risk of tumor embolization. After obtaining vascular control, the lower      inferior vena cava, renal vein, and right atrium were opened simultaneously      and the tumor's intravascular portions were removed. Transesophageal      echocardiography (TEE) was used to guide complete excision of the tumor      from the retrohepatic inferior vena cava and hepatic veins (Figure 3).      After reversing the cardiopulmonary bypass and heparinization, the right      kidney and mass were removed using radical nephrectomy.    

     Pathology revealed PNET/Ewing sarcoma involving the      kidney and perinephric fat with invasion into the renal vein (Figure      4). All margins were clear and there was no nodal involvement. The resected      vena caval tumor contained a blood clot and fibrous      tissue revealing viable PNET/Ewing sarcoma with      necrosis (Figure 5). The patient's postoperative course was notable for mild coagulopathy and pancreatitis, which resolved with conservative treatment. She was discharged from      the hospital on postoperative day 16 and continues her course to recovery.      Her bilirubin levels and abdominal girth are normal, and there is no      evidence of metastatic disease. Additional courses of chemotherapy are      planned.    

     PNETs, in association with peripheral nerves, were      first described by Arthur Purdy Stout in 1918 in a case report that      involved an ulnar nerve tumor.

 These tumors commonly occur in the soft tissues of the      trunk, head, neck, and extremities. PNETs of the kidneys are exceedingly      rare. The exact number of cases is difficult to determine because these      tumors are sometimes not clearly differentiated from extraskeletal      Ewing's sarcomas.

     Macroscopically, PNETs are large, bulky tumors. They tend to be a grayish color, encapsulated, and      contain focal areas of hemorrhage, necrosis, or both. The tumor can be      sharply demarcated from a normal kidney and can present with rupture. PNETs      are categorized as small round cell tumors because, histologically, they      contain small round cells with rounded nuclei and scant cytoplasm (Figure      4). They often exhibit different patterns of rosettes, perivascular      rosettes, and spindle cell elements. A Homer Wright rosette formation      suggests the presence of immature neural tumor cells such as      neuroblastomas, which are also seen in PNETs. Special stains and neural      markers such as CD99, neuron-specific enolase (NSE), and monoclonal      antibodies can be helpful in making the correct diagnosis. CD99 is detected      in PNETs and Ewing's sarcomas. NSE, S100 neurofilaments, and      chromogranin-A can exclude typical and atypical extraosseal Ewing's      sarcomas. Should these prove insufficient for establishing a diagnosis,      electron microscopy, DNA image cytometry, FISH, and molecular      pathology?such as reciprocal translocation of chromosomes 11 and 22       [t(11;22)(q24;q12)]?can be used as confirmatory tests.

Because PNETs are uncommon, the literature consists mostly of case reports, which currently includes      38 cases. PNETs are found equally in both sexes and tend to occur in      relatively young patients. The literature shows an age range from 4 to 69      years, with 33 of the 38 reported cases occurring in patients younger than      42 years. Patients present with flank and abdominal pain, hematuria, or a      palpable mass. Tumors ranged from 4 to 21 cm and exceeded 10 cm in 60% of      cases.

     In the 22 reported cases that included treatment data,      all patients underwent nephrectomy or radical nephrectomy, and 16 received      adjuvant chemotherapy (Table). There were no consistent protocols, and      treatment included various combinations of vincristine, ifosfamide,      doxorubicin, VP16 cyclophosphamide, carboplatin,      paclitaxel, interferon, estramustine, and      etoposide. Four patients received adjuvant radiation therapy, one underwent      radiation for bone metastases, and one had a bone marrow transplant after      chemotherapy.

     Ten patients were reported to have PNETs of the      kidneys that involved a major renal vessel, four of whom had tumors that extended into both the renal vein and inferior vena      cava.

 One of those four patients had extension into the right atrium. A      23-year-old patient from Japan had pulmonary metastases at the time of her      radical nephrectomy and resection of her inferior vena cava thrombus.

 These metastases      apparently regressed after surgery, and she was alive and disease-free      at 12-month follow-up. A 28-year-old patient underwent radical nephrectomy      and inferior vena cava thrombectomy for a 13-cm mass and received adjuvant      vincristine, cyclophosphamide, doxorubicin, and etoposide.

 He was alive      without recurrence at 12-month follow-up. The third patient with venal      caval involvement was a 55-year-old woman whose 5.7-cm mass extended into      the right atrium.

 The mass was resected with radical nephrectomy, inferior vena      caval and right atrial thrombectomy, cardiopulmonary bypass, and deep      hypothermic circulatory arrest. She received adjuvant ifosfamide,      cyclophosphamide, and doxorubicin and was alive 5 months after treatment.      The only reported case to mention Budd-Chiari syndrome involved a      17-year-old girl with a 14-cm mass extending into the renal vein and      inferior vena cava.

 A radical nephrectomy was performed, but the caval      thrombus, which extended from the left renal vein to the retrohepatic      segment of the inferior vena cava, was left behind. The patient died of      Budd-Chiari syndrome and liver failure approximately 5 months after      surgery.  

     In our case, Budd-Chiari syndrome was identified at      the time of diagnosis.  Neoadjuvant therapy with vincristine,      doxorubicin, and cyclophosphamide was used to reduce the size of the tumor,      and the patient subsequently underwent a complete surgical resection. Early removal of the      intravascular tumor component was deemed essential to avoid tumor      embolization. This also served to markedly relieve liver      congestion, which facilitated the radical nephrectomy. Intraoperative TEE was helpful to ensure complete removal and coring out of the      intravascular tumor from the less accessible      retrohepatic inferior vena cava and hepatic veins. Our patient was alive and disease-free 7 months after her condition was initially diagnosed.   

     The literature leaves the prognosis for patients with PNETs difficult to determine. Many studies      suggest PNETs are aggressive, but most of these are case reports with only      limited follow-up. Of the 28 patients whose outcomes were reported, 15      were alive 5 to 64 months after diagnosis and 9 were eventually rendered      disease-free. Recurrences were both local and distant. Although large      studies are not possible for PNETs, aggressive management with both surgery      and chemotherapy may allow long-term survival.   

     1. Stout AP. A tumor of the ulnar nerve. 

     2. Pomara G, Cappello F, Cuttano MG, et al. Primitive      neuroectodermal tumor (PNET) of the kidney: a case report. 

     3. Karnes RJ, Gettman MT,      Anderson PM, et al. Primitive neuroectodermal tumor (extraskeletal      Ewing's sarcoma) of the kidney with venal caval tumor thrombus. 

     4. Friedrichs N, Vorreuther R, Poremba C, et al.      Primitive neuroectodermal tumor (PNET) in the differential diagnosis of      malignant kidney tumors. 

     5. Sivaramakrishna B, Mundada OP, Aron M, et al.      Primary primitive neuroectodermal tumor (PNET) of the kidney with venous      thrombus.

     6. Wada Y, Yamaguchi T, Kuwahara T, et al. Primitive      neuroectodermal tumor of the kidney with spontaneous regression of      pulmonary metastases after nephrectomy. 

     7. Thomas JC, Sebek BA, Krishnamurthi V. Primitive      neuroectodermal tumor of the kidney with inferior vena cava and atrial      tumor thrombus.

     8. Jimenez RE, Folpe AL, Lapham RL, et al. Primary      Ewing's sarcoma/primitive neuroectodermal tumor of the kidney: a      clinicopathologic and immunohistochemical analysis of 11 cases. 

     9. Juan CJ, Wu CJ, Chen CY, et al. Primitive      neuroectodermal tumor of the kidney associated with Budd-Chiari syndrome in      a 17-year-old girl.

     10. Wells J. Primitive neuroectodermal tumor arising      from the kidney.

     11. Marley EF, Liapis H, Humphrey PA, et al. Primitive      neuroectodermal tumor of the kidney?another enigma: a pathologic,      immunohistochemical, and molecular diagnostic study. 

     12. Furman J, Murphy WM, Jelsma PF, et al. Primary      primitive neuroectodermal tumor of the kidney. Case report and review of      the literature. 

     13. Mor Y, Nass D, Raviv G, et al. Malignant      peripheral primitive neuroectodermal tumor (PNET) of the kidney. 

Hong-Ru Chen, Medical Student, University of Hawaii John A. Burns School of Medicine, Honolulu, HI; Sarah Fryberger, Staff, Pediatric Hematology and Oncology, Kapiolani Medical Center, Honolulu, HI; Jeffrey D. Lee, Associate Clinical Professor of Surgery, University of Hawaii John A. Burns School of Medicine, Honolulu, HI; Linda L. Wong, Professor of Surgery, University of Hawaii John A. Burns School of Medicine, Honolulu, HI

Successful resection of a PNET tumor of the kidney with vena caval and cardiac invasion

             Department of Surgery Mount Sinai Medical 

Obturator hernias are rarely suspected because they      are almost never seen and rarely palpated. Although their real incidence is      un?known, these hernias are thought to constitute fewer than 1% of all      hernias world?wide.

 Bjork and colleagues re?ported their incidence at about      0.073% of all hernias repaired at the Mayo Clinic.

     The formation of an obturator hernia is initiated by      preperitoneal fat entering the obturator foramen, the largest and strongest      foramen in the body. Little else is known about predisposing factors, but      weight loss, cachexia, and advanced age contribute.

 Clinically, between 71% and      80% of obturator hernias present as small bowel      obstruction. The most common indicator (found in      40%?50% of pa?tients) is the Howship-Romberg sign, which includes      pain with or without paresthesias felt down the anteromedial thigh to the      knee upon movement of the hip or thigh. Other symptoms include recurrent      attacks of obstruction that resolve spontaneously, weight loss or      emaciation, and, although rarely, a palpable mass.

Treating an obturator hernia varies from reduction of      the hernia while leaving the defect untouched to closing the defect using      sutures, mesh, or a patch. Currently, it is accepted that closing the      defect is essential, although the rate of recurrence without closure is      unknown.

 Bowel resection for ischemia is likely during surgery, and      it is recommended that the hernia be repaired immediately after primary      anastomosis of the bowel.  

     The purpose of this case report is to exemplify the      difficulty in making a preoperative diagnosis of obturator hernia unless      there is a high index of suspicion for this rare entity. Once diagnosed,      treatment is straightforward and the prognosis is generally good.  

     A frail, cachectic, emaciated, 84-year-old white woman      presented to the emergency department reporting abdominal distension,      nausea, emesis, and constipation of 4 days' duration. She was a      nursing home resident, and her medical history was unremarkable and did not      include any previous abdominal surgery. The patient was dehydrated and      tachycardic. There was diffuse abdominal distension and tenderness on      palpation with hyperactive bowel sounds on      auscultation. Initial abdominal radiographs      dem?on?strated dilated loops of small bowel, consistent with  obstruction. She was admitted to the ward for medical management.

     Computed tomography (CT) scans of her abdomen and      pelvis were performed, which were interpreted as showing a partial small      bowel obstruction without an obvious transition point (Figure). No hernia      was identified. After 24 hours of unsatisfactory medical management, the      surgery department was consulted. The CT scans were reviewed once more with      the radiology department, and careful analysis identified a right obturator      hernia (Figure). After further detailed questioning, the patient relayed      symptoms consistent with a positive Howship-Romberg sign, although she      attributed the pain to hip arthritis.   

     The patient was taken to the operating room for an      exploratory laparotomy, which confirmed a right obturator hernia with strangulated small bowel. Re?duc?tion of the involved segment and re?section with primary      anastomosis (side-to-side functional end-to-end anastomosis) were      undertaken, followed by primary repair of the defect using a single      polypropylene figure-of-eight suture, avoiding the entrapment of the      obturator vessels and the obturator nerve. After the procedure, supportive      total parenteral nutrition was started, and the patient was transferred to      the intensive care unit, where she re?mained for 48 hours. As she      slowly im?proved, an enteral diet was tolerated and parenteral      nutrition was discontinued. After 12 days in the hospital and an      un?eventful recovery, she was discharged to the nursing home.  

     As this case exemplifies, correctly diagnosing an      obturator hernia preoperatively is exceptionally      difficult. Most cases are seen in debilitated      women, occurring after loss of the protective fat in the obturator canal.      Many obturator hernias present as mechanical small bowel obstruction which      fails to resolve, leading to exploratory laparotomy and subsequent      discovery of the hernia. CT scanning or other radiologic studies may be      helpful for establishing the diagnosis and planning surgical intervention.

 CT scans may      demonstrate a low-density mass that lies between the obturator externus and      pectineus muscles, contributing to a successful diagnosis in most cases.

 The combination      of acute small bowel ob?struction and a Howship-Romberg sign in a thin,      frail, elderly woman with no history of abdominal surgery is highly      suggestive of an obturator hernia.  

     It is recommended that the defect be identified and      closed, but which type of repair to use is solely the surgeons'      preference. The hernia can be successfully repaired with a range of methods      from single suture closure or synthetic mesh employed in a plug and patch      fashion to more elaborate techniques that use the urinary bladder, uterine      fundus, and round ligament or pectineus muscle.

 In our case, we thought it appropriate to close the      defect with a single polypropylene suture due to the ease of this technique      and the defect's small opening.   

     During the operation, it is critical to identify the      three structures (artery, vein, and nerve) that go through the foramen and      avoid them in the repair. When one encounters a loop of small bowel      incarcerated in the hernia, which is the most common intraoperative      finding, it is advised to employ gentle traction on the bowel segment and      attempt to stretch the defect.

 If that is not possible, the obturator membrane can be      safely incised in its lower margin, because in more than 50% of cases, the      sac lies just superior to this border and below the vessels and nerve.

     The jejunum and ileum should be in?spected thoroughly to assess the need for resection and      anastomosis, which is required in fewer than half of obturator hernia      patients.

 In our patient, a segment of ileum was incarcerated in the      defect and an area of ischemia was identified, which prompted the decision      to resect and anastomose. The defect was then inspected and closure was      performed as stated previously under direct visualization of the obturator      vessels and nerve.  

     The clinical course for patients with an obturator      hernia is usually favorable, even though many patients, like ours, require      small bowel resection. The reported mortality rate for the procedure is      between 8% and 13%, with a higher rate of mortality in Asians and Africans.

 Most of the      mortalities occur secondary to cardiovascular events, peritonitis, and      pulmonary embolism and are linked more to associated comorbidities and      underlying preoperative status than to the procedure itself.

     An obturator hernia is one of the rarest of the      abdominal wall hernias. It is difficult to diagnose preoperatively unless      there is a high index of suspicion. Clin?icians should include      obturator hernia in the differential diagnosis of any malnourished, elderly      woman presenting with a Howship-Romberg sign and no history of abdominal      surgery. CT scanning plays a key role in diagnosing this condition early.      In our case, careful review of ab?dominal and pelvic CT scans and      recognition of the patient's description of hip pain as a      Howship-Romberg sign were instrumental in making the diagnosis      preoperatively. Intra??operative assessment of the defect and      repair are necessary. Small bowel resection should be performed when the      segment of bowel in?volved is not viable.        

     1. Skandalakis LJ, Skandalakis PN, Gray SW, et al.      Obturator hernia. In: Nyhus LM, Condon RE, eds. 

 4th ed.      Phil?a?delphia, Pa: Lippincott Williams & Wilkins; 1995:     425-439.   

     2. Lobo DN, Clarke DJ, Barlow AP. Obturator hernia: a      new technique for repair. 

     3. Bjork KJ, Mucha P Jr, Cahill DR. Obturator hernia. 

     4. Abrahamson J. Hernias. In: Zinner MJ, Schwartz SI,      Ellis H, eds. 

 10th ed. Norwalk, Conn: Appleton      and Lang; 1997:540-546.  

     5. Archampong EQ. Preoperative diagnosis of      strangulated obturator hernia.

     6. Mercader VP, Fein DA, Gembala-Parsons RB, et al. CT      of an obturator hernia. 

     7. Veeckmans G, Hermans P, Wyffels G, et al. CT-scan      diagnosis of bilateral obturator hernias in a patient with chronic chylous      ascites. 

Sergio A. Carrillo, Surgery Resident, Department of Surgery; David Varnagy, Chief Resident, Department of Surgery; Donald Minervini, Attending, Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL

August 2006

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Perforated Jejunal Diverticulitis

Successful resection of a PNET tumor of the kidney with vena caval and cardiac invasion

Obturator hernia: Clinically elusive and radiologically effortless

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