	In 1910, Demetrius Chilaiditi first described a rare condition in which the bowel is interposed between the liver and diaphragm.

 This finding is often seen incidentally on radiographic studies and misdiagnosed as pneumoperitoneum. We report a case of internal hernia with hepatodiaphragmatic interposition of the small bowel. The hernia contents were incarcerated through the hernia neck, which was formed by adhesions between the liver and the diaphragm, resulting in Chilaiditi's syndrome. This is the second reported case of Chilaiditi's syndrome involving the small bowel

?and the first report where the etiology was unknown.

 A 65-year-old woman with hypertension and no history of abdominal surgery presented to the emergency department reporting severe continuous abdominal pain of 2 days' duration and associated obstipation, nausea, and nonbilious vomiting. She had no recent history of fever but noted a 1-year history of intermittent right upper quadrant pain.

	The patient was hemodynamically stable and afebrile. Physical examination showed a soft, mildly distended, tympanitic abdomen, with tenderness to palpation in the right upper quadrant. Her bowel sounds were hypoactive on auscultation and a stool sample was guaiac-negative. A complete blood count showed a leukocyte count of 10,800/mm

?with 81% neutrophils. An abdominal computed tomography (CT) scan showed diffuse small bowel distention to the distal ileum and small bowel loops overlying the liver with punctate foci of gas, which was suspicious of pneumoperitoneum (Figure 1).

	A repeat white blood cell count 6 hours later was 18,000/mm

. A presumptive diagnosis of bowel ischemia was made, and the patient was taken to the operating room for diagnostic laparoscopy. Exploration revealed distended loops of small bowel and adhesions between the liver and abdominal wall, which created an internal hernia with small bowel going through the defect and lying above the liver (Figure 2). There was some free fluid above the liver, a sample of which was sent for culture. The bowel was reduced and enterolysis was performed (Figure 3).

	By postoperative day 1, the patient's symptoms had resolved, she was tolerating a regular diet, and had normal bowel function. The peritoneal cultures were negative for any bacterial growth, and the patient was discharged from the hospital.

 In 1910, Demetrius Chilaiditi first described a condition in which the colon or small intestine is interposed either temporarily or permanently between the liver and the diaphragm.

 This anomaly has an estimated prevalence between 0.025% and 0.28% in the general population

 but is more common in men. Only 27 cases have been published in the literature,

 most of which were caused by colonic interposition with hepatodiaphragmatic adhesions from previous abdominal surgeries or sexually transmitted diseases.

 On abdominal radiographs, interposition of the bowel between the liver and diaphragm can be seen as air between the diaphragm and the liver, which is known as Chilaiditi's sign.

?A CT scan can distinguish this condition from pneumoperitoneum by identifying the surrounding bowel wall. Interposition of the bowel between the liver and diaphragm can result in abdominal symptoms ranging from pain to obstructive symptoms, including emesis, distention, and constipation. When these symptoms occur, the condition is termed Chilaiditi's syndrome.

	On abdominal radiographs, a diagnosis of pneumoperitoneum is often mistakenly made. Surgical intervention can be avoided if surgeons are aware of the possibility of Chilaiditi's syndrome. Conservative management of this syndrome, including bowel rest, hydration, and nasogastric decompression as needed, is often successful in resolving symptoms. Suspected cases of bowel incarceration or ischemia, however, should be treated with emergent surgical intervention.

 Chilaiditi's syndrome is a rare condition that is usually asymptomatic and is often misdiagnosed as pneumoperitoneum. This clinical entity should be kept in mind by surgeons and radiologists so that unnecessary surgical intervention can be avoided. Although Chilaiditi's syndrome is generally associated with colonic interposition, our case involved interposition of the small bowel, which resulted in acute intestinal obstruction. Loops of jejunum were trapped above the liver due to adhesions, with no known cause. This is the second reported case of small bowel interposition causing Chilaiditi's syndrome and the first of unknown etiology, because our patient had no previous abdominal surgeries or sexually transmitted diseases.

 1. Chilaiditi D. Zur Frage der Hapatoptose und Ptose in allgemeinen im Auschluss an drei F?lle von tempor?rer partieller Leberverlagerung. 

Fortschritte auf dem Gebiete der Roentgenstrahlen.

	2. Risaliti A, De Anna D, Terrosu G, et al. Chilaiditi's syndrome as a surgical and nonsurgical problem.

	3. Orangio GR, Fazio VW, Winkelman E, et al. The Chilaiditi syndrome and associated volvulus of the transverse colon. An indication for surgical therapy. 

	4. Saber AA, Boros MJ. Chilaiditi's syndrome: what should every surgeon know? 

	5. Oh SN, Rha SE, Byun JY, et al. Chilaiditi syndrome caused by Fitz-Hugh-Curtis syndrome: multidetector CT findings.

	6. Plorde JJ, Raker EJ. Transverse colon volvulus and associated Chilaiditi's syndrome: case report and literature review. 

Articles

Surgical Rounds

Kashaf Sherafgan, Resident, Department of Surgery, Mount Sinai Hospital, New York, NY; Sergey Khaitov, Resident, Department of Surgery, Mount Sinai Hospital, New York, NY; Fred Silvestri, Assistant Clinical Professor, Department of Surgery, Englewood Hospital & Medical Center, Englewood, NJ

Chilaiditi's syndrome with incarcerated hepatodiaphragmatic small bowel hernia of unknown etiology

	Only 5% of intussusceptions occur in adults.

 Symptoms of adult intussusception mimic those of bowel obstruction and may be acute or chronic, as opposed to the acute onset typically observed in children.

Reports identify a discrete lesion in up to 95% of cases,

 with malignancy accounting for up to 48% of small bowel lesions

; thus, surgical exploration is mandatory.

?We report a case of adult intussusception that was found to be caused by a carcinoma of unknown primary origin.

 A 62-year-old white woman with a 50-pack-year history of smoking was admitted to the hospital for evaluation of intermittent gastrointestinal bleeding and periumbilical pain that worsened over 24 hours. Her medical history was significant for T1 N0 M0 adenocarcinoma of the left upper lobe of the lung, which was diagnosed 7 years earlier. She had undergone primary definitive radiation therapy and had complete resolution of the adenocarcinoma. Her medical history also included hyperlipidemia, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and a myocardial infarction (MI). The patient's daily medications included digoxin, enalapril, furosemide, atorvastatin, lorazepam, pantoprazole, diltiazem, nebulizer treatments, and a multivitamin. She was intolerant to beta-blocking agents and allergic to penicillin and metoprolol. Her surgical history included repair of an abdominal stab wound when she was an adolescent, appendectomy, cholecystectomy, umbilical hernia repair, and coronary artery stent placement after her MI. She had no family history of colon cancer or colonic polyps. ?

	The patient's initial symptoms began 4 months earlier and manifested as right-sided flank pain. Evaluation at that time included a computed tomography (CT) scan, which revealed a 7-cm, right adrenal mass that appeared to be metastatic. Needle biopsy confirmed a hemorrhagic lesion but showed no evidence of a neoplasm. The patient's pain resolved but recurred 3 months later as left-sided flank pain. CT scans at that time showed the right adrenal mass, which did not change in size, and a new 5.6-cm left adrenal mass with hemorrhage. A positron emission tomography (PET) scan was subsequently obtained and showed significant uptake in the bilateral adrenal glands, the right pelvis anterior to the sacrum, and the left lower quadrant, raising concern of malignancy. There was no uptake within the lungs.

	Shortly after the PET scan, the patient began having episodes of profound anemia and required several blood transfusions. She noticed ongoing dark-colored stools, which were found to be heme-positive. The patient underwent gastrointestinal evaluation at this time since she was also experiencing nausea, dry heaves, diminished appetite, and fatigue, and reported losing 10 pounds over the previous 5 months. Gastroscopy was unremarkable, and colonoscopy revealed only a rectal hyperplastic polyp, which did not explain the bloody stools. She was scheduled for capsule endoscopy to further evaluate the small bowel. Upon presenting for the study, she reported worsening abdominal pain and was subsequently admitted to the hospital.

	During this hospitalization, the patient was found to have normocytic, normochromic anemia with a hematocrit of 25%. Coagulation parameters were within normal limits. Mild elevations were seen in alkaline phosphatase and liver enzymes, and urinalysis showed a trace of blood. Physical examination revealed a soft, nondistended abdomen with tenderness across the lower abdomen on palpation. No peritoneal signs, masses, or hernias were noted. A contrast-enhanced CT scan of the abdomen and pelvis showed bilateral adrenal gland masses (Figure 1). There were multiple dilated small bowel loops exhibiting high-grade obstruction, and the target appearance of intussusception was observed within the right hemipelvis (Figure 2). A soft tissue nodule measuring 1.5-cm was also associated with the intussuception (Figure 3). No free air was visible.

	Preoperative reduction of the intussusception was not attempted. The patient was advised to undergo an exploratory laparotomy, and cardiac clearance was obtained. With the patient under general anesthesia, a mass was palpated in the right lower quadrant. A midline incision was made, and, upon entering the peritoneum, a large amount of ascitic fluid was encountered. Once adequate retraction was obtained, the intra-abdominal contents were examined. No abnormalities were palpable in the liver or colon. The adrenal glands were enlarged, which was consistent with the CT findings, but no attempts at resection were made. At this point, the terminal ileum was identified and the small bowel was run proximally. Intussusception was observed in the distal small bowel and was reduced to reveal serosal dimpling with an intraluminal mass. The small bowel was resected using side-to-side stapled anastomosis, and the specimen was sent to pathology. Gross examination revealed that the specimen measured 8.4 cm in length, with margins measuring 3.7 cm and 2.9 cm in diameter. The lumen contained a 3.2 x 2.7 x 0.8-cm, hemorrhagic, polypoid mass, which was located 2.8 cm from the dilated margin. Frozen-section evaluation indicated the lesion was probably metastatic, most likely adenocarcinoma or melanoma. Two additional masses were encountered within the small bowel, which were also resected and sent for permanent-section pathology. Hand-sewn anastomoses were performed at these sites. Inspection at the ligament of Treitz revealed a large fixed mass within the proximal jejunum in immediate proximity to the superior mesenteric artery, aorta, and inferior vena cava. The mass could not be resected because of its difficult location; thus, an enterotomy was made to remove the bulk of this hemorrhagic lesion and the base was carefully fulgurated. Three units of blood were given intraoperatively. The abdomen was then closed, and the patient was transferred to the surgical intensive care unit (ICU).

	She was extubated that evening and transferred out of the ICU on postoperative day 1, at which time parenteral nutrition was initiated. Her postoperative recovery was complicated by a pelvic abscess, which was successfully drained.

	Final pathology evaluations of all specimens returned a diagnosis of Grade 3 of 4 metastatic undifferentiated carcinoma, solid type, of large round cell tumor origin. High-grade cellular atypia and frequent mitoses were noted. The associated lymph nodes were negative for tumor, and all resected specimens had clear margins. Metastatic origin of the tumor is supported by Figure 4. Tumor cells are visible throughout the submucosa while normal architecture of small bowel mucosa is maintained. Figure 5 supports a diagnosis of carcinoma because the tumor exhibits cytoplasmic staining for epithelial membrane antigen (EMA), cytokeratin and CAM 5.2. Positive cytokeratin staining helps to exclude the possibility of lymphoma or melanoma. The staining patterns of additional immunohistochemical stains helped exclude malignant melanoma and lymphoma and adrenal gland origin. Upon subsequent review, the histology was not consistent with the patient's previous lung adenocarcinoma; thus, the primary source of the carcinoma was unknown.

	In the months following surgery, medical oncology played a large role in managing the patient's care. She continued to have gastrointestinal blood loss, requiring weekly blood transfusions. She was again evaluated with upper and lower endoscopy but no specific source of bleeding was identified. The patient was not a candidate for radiation therapy and repeatedly refused to undergo palliative chemotherapy. She received home hospice care until approximately 3.5 months postoperatively, when she finally decided to pursue a trial of palliative chemotherapy. ACT scan at that time showed slight enlargement of the adrenal masses, interim development of pulmonary metastases, and a mass within the proximal jejunum. Attenuated doses of carboplatin and paclitaxel were administered, but she did not tolerate this well and was readmitted to the hospital with a hematocrit of 15.3%. Once medically stable with a hematocrit of 33.8% and no active bleeding, she was discharged to home hospice care. ?

 This case brings up several clinical points when assessing a patient for bowel obstruction. There are many causes of bowel obstruction in adults, with intussusception accounting for approximately 1%.

?Our patient experienced intermittent obstructive symptoms over a 4-month period that ultimately resulted in high-grade obstruction. Because of her history of lung cancer and the interim development of bilateral hemorrhagic adrenal masses, a malignant etiology for this obstruction was suspected. The subsequent finding on CT scan of intussusception with high-grade small bowel obstruction further obviated surgical intervention.

	When adult intussusception is diagnosed, a pathologic lesion is identified in 86% to 95% of cases.

 The lead point for the intussusception can include benign causes such as adhesions, Meckel's diverticulum, and lipoma

however, the incidence of malignancy can be high, especially in patients with a history of cancer. Begos and colleagues evaluated enteric lesions causing intussusception in their patients and found malignancies in only 14%.

 In comparison, Barussaud and associates found 37% of such lesions to be malignant,

 Nagorney and colleagues reported 46% to be malignant,

 and Azar and Berger reported 48% to be malignant.

Metastases were responsible for a significant number of such masses.

	A 1999 study by Eisen and associates evaluated 27 intussusception cases, of which 7 patients had a previous malignancy.

 Intussusception of the small bowel occurred in 81% of these patients, and all cases were metastatic. The most common primary source was melanoma, followed by lymphoma, lung carcinoma, and sarcoma. Azar and Berger found a similar pattern with regard to the primary source.

?Of the 58 patients they evaluated, 44 had enteric lesions causing intussusception. Forty-eight percent of these were malignant, 96% of which were metastases. The most common primary cancer in their study was melanoma. Other primary sources included lymphoma, sarcoma, and squamous cell carcinoma.

	The unknown source of gastrointestinal bleeding in our patient appeared intraoperatively to be secondary to the friable, hemorrhagic tumor we found in the proximal jejunum. Studies show that many adults with intussusception have guaiac-positive stool or hematochezia.

 This finding corresponds with the 29% incidence reported by Azar and Berger

; however, it is impossible to determine whether the guaiac-positive stools in our patient were exclusively due to the jejunal mass or if the intussusception also contributed.

	We did not attempt to reduce the intussusception before surgery because we knew from the CT scan that it had an enteric location, and, due to the patient's history of lung cancer, we suspected malignancy. Opinions regarding the reduction of intussusception vary in the literature. Data in the 1981 article by Nagorney and associates revealed only 33% of enteric intussusceptions are malignant and they are more commonly metastases, rather than primary small bowel malignancies. The authors suggested that reduction of an intussusception already metastatic to the small bowel would do little to affect the disease course in terms of tumor spread.

 Reduction is preferable if the lesion is metastatic because it allows bowel length to be preserved; however, if a patient's history supports the potential for a primary malignancy, reduction is contraindicated.

	In 1997, Azar and Berger published a review article that recommends avoiding reduction for all intussusceptions, except those which occur postoperatively and cause bowel obstruction.

 The latter presentation often has its etiology at the site of a suture line or an adhesion and may be reduced intraoperatively, whereas the potential for malignancy with other presentations makes primary resection the most appropriate option.

	Similarly, Weilbaecher and associates and Barussaud and colleagues recommend resection without reduction due to the potential for tumor seeding

; however, Barussaud and colleagues do provide an exception for cases where the disease process may require further bowel resections. Peutz-Jeghers disease was ?cited as a situation where reduction of the intussusception followed by limited resection would be appropriate.

 Adult intussusception is an unusual finding with several distinct features that differentiate it from childhood intussusception. The presenting symptoms, potential comorbidities of the patient, etiology of the intussusception, and proper management are quite different from what is generally experienced in pediatric cases. Whether it is caused by a primary or metastatic malignancy or a benign lesion, the surgeon will need to decide whether reduction is warranted or if primary resection is the best option for the patient. As a general rule, surgeons should have a high index of suspicion for malignancy in cases of adult intussusception and surgical exploration is required.

 1. Laws HL, Aldrete JS. Small bowel obstruction: a review of 465 cases. 

	2. Stewardson RH, Bombeck CT, Nyhus LM. Critical operative management of small bowel obstruction. 

	3. Donhauser JL, Kelly EC. Intussusception in the adult. 

	4. Dean DL, Ellis FH Jr, Sauer WG. Intussusception in adults. 

	6. Brayton D, Norris WJ. Intussusception in adults. 

	7. Reijnen HA, Joosten HJ, de Boer HH. Diagnosis and treatment of adult intussusception. 

	8. Nagorney DM, Sarr MG, McIlrath DC. Surgical management of intussusception in the adult. 

	9. Stubenbord WT, Thorbjarnarson B. Intussusception in adults. 

	10. Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. 

	11. Azar T, Berger DL. Adult intussusception. 

	12. Weilbaecher D, Bolin JA, Hearn D, et al. Intussusception in adults. Review of 160 cases. 

	13. Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: institutional review. 

	14. Agha FP. Intussusception in adults. 

	15. Coleman MJ, Hugh TB, May RE, et al. Intussusception in the adult. 

	16. Sanders GB, Hagan WH, Kinnaird DW. Adult intussusception and carcinoma of the colon. 

	17. Felix EL, Cohen MH, Bernstein AD, et al. Adult intussusception; case report of recurrent intussusception and review of the literature. 

	18. Barussaud M, Regenet N, Briennon X, et al. Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study. 

	19. Haas EM, Etter EL, Ellis S, et al. Adult intussusception. 

Nicole Schimke, Resident in General Surgery, Department of Surgery, Mercy Medical Center? Des Moines, Des Moines, IA; Dennis Whitmer, Attending Surgeon, Department of Surgery, Mercy Medical Center?Des Moines, Des Moines, IA

Carcinoma of unknown primary origin presenting as adult intussusception

	Intussusception rarely presents in adults and, when found, is most commonly the result of a definable pathologic lead point. Unlike its pediatric counterpart, which is generally managed with nonsurgical reduction, operative intervention is the primary treatment for adult intussusception. We report the case of appendiceal intussusception in an 81-year-old woman. Pathologic evaluation identified the lead point to be a villous adenoma. This case is interesting because it demonstrates a relatively uncommon type of adult intussusception, one that is secondary to a rare neoplastic lesion.

 An 81-year-old woman presented to the emergency department with the chief symptom of nonresolving, cramping abdominal pain of 3 days’ duration. The pain was initially periumbilical but had migrated to the patient’s right lower quadrant. She reported having felt similar pains in the past, although not as severe. The patient had no obstructive gastrointestinal symptoms and had never had a screening colonoscopy. Her medical history included arthritis, hypertension, and osteoporosis, for which she took prednisone, hydrochlorothiazide, and alendronate, respectively. Her surgical history was significant for a hysterectomy, which had been performed many years earlier.

	The patient was afebrile with normal vital signs. Physical examination was significant for diffuse abdominal tenderness with localized peritoneal signs in the right lower quadrant. A distinct, mobile mass was palpable in the area where maximum tenderness was elicited. Laboratory studies showed leukocytosis (21,000/

L) associated with bandemia. Computed tomography (CT) scans of the abdomen showed a “target sign” in the right lower quadrant (Figure 1). A diagnosis of intussusception was made, and after discussing treatment options with the patient, an exploratory laparotomy was decided upon.

	During laparotomy, a diffusely enlarged, erythematous, nonperforated appendix measuring approximately 15 cm in length and 2 cm in width was found (Figure 2). The appendix was partially intussuscepted at its base and associated with a small cecocolic intussusception. The ileocolic valve was intact. The liver was palpated and the remainder of the exploration did not identify any additional disease. A partial cecectomy was performed. Pathology examination revealed diffuse villous adenoma of the appendix (Figure 3). The specimen showed no invasive disease and negative margins were obtained. The patient recovered uneventfully and was discharged to home without complications. She was referred for outpatient colonoscopy.

 Intussusception has long been described in the medical literature. The first report  was by Barbette of Amsterdam in 1674.

 In the mid-1700s, Cornelius Henrik Velse was the first to describe a successful operation on adult intussusception.

 In 1837, John Hunter reported three cases of adult intussusception, one of which involved ileoileal intussusception in a ship’s cabin boy.

 The etiology in this case was parasitic, and Hunter’s proposed initial therapy was nonoperative. He recommended inducing emesis to “invert the peristaltic motion of the containing gut, which will have a tendency to bring the intestines into their natural situation.”

	Most patients presenting with adult intussusception will report vague abdominal pain that has been intermittent or chronic. Acute symptomatology would suggest ischemia or impending perforation. Azar and Berger reported abdominal pain as the most common symptom.

 Nausea, bleeding, diarrhea, constipation, a mass, and weight loss were reported less often. Physical examination may reveal an abdominal mass, with previous series indicating that masses can be palpated between 24% and 42% of the time.

 Masses that shift and are only palpable during symptomatic periods should raise suspicion of intussusception.

	In previous decades, diagnosing adult intussusception preoperatively was difficult. Most patients would proceed to the operating room with a diagnosis of obstruction. The increased use of new technology is making the preoperative diagnosis of adult intussusception more common. Azar and Berger found 40% of their institution’s patients were diagnosed preoperatively.

 In their review, CT scanning was the most accurate imaging modality for identifying adult intussusception.

	Unlike pediatric cases, intussusception in adults is rare, accounting for fewer than 5% of total intussusceptions and causing fewer than 1% of intestinal obstructions. Another key difference between adult and pediatric intussusception is the etiology. Adult intussusception is most often caused by a definable pathologic lead point. Peristalsis pushes this lead point downstream, causing the intussusceptum to telescope into the receiving intussuscipiens. As the bowel intussuscepts, it pulls its mesentery with it. This can trap the vascular supply between the intussusceptum and the intussuscipiens, providing a mechanism for ischemia of the bowel wall and perforation. Although intussusception tends to occur more frequently at junctions between freely moving and fixed portions of the bowel, it may occur almost anywhere throughout the gastrointestinal tract.

	Begos and colleagues performed a meta-analysis on the location and etiology of adult intussusception.

 They evaluated 1,048 cases and found that 64% occurred in the small intestines. Most of these (63%) were secondary to benign lead points. Idiopathic (23%) and malignant (14%) disease accounted for the remaining small bowel cases. Colonic intussusception only accounted for 36% of cases. In contrast to intussusception of the small bowel, most colonic intussusceptions (58%) were from malignant lead points. Benign (29%) and idiopathic (13%) processes accounted for the other colonic cases.

	Because adult intussusception is most often secondary to a pathologic lead point, the involved bowel generally should be resected without reduction, helping to avoid the risk of spillage. This method also optimizes the potential oncologic value of the operation; however, reduction before resection may be considered when benign disease is suspected or in cases where preserving bowel length is important.

—Appendiceal intussusception is rare. Collins and associates identified seven such cases among the 71,000 pathologic specimens reviewed.

 In 1941, McSwain reported a case of appendiceal intussusception and provided a review of the literature.

 In his discussion, he identified five types of appendiceal intussusception, which are still referenced today (Figure 4). A sixth type, however, has been added recently to include compound intussusceptions or those associated with significant cecocolic intussusception. Our patient had a type 3 intussusception, which Fink and associates note as the most common type.

 To date, approximately 200 cases of appendiceal intussusception have been described. In 1964, Fink and associates identified and discussed 118 cases.

 They reported the average age of diagnosis at 20 years, with ages ranging from 1 year to 85 years. They also found a greater incidence among men, with a 4:1 male-to-female ratio. Recent case reports, however, show a nearly equal distribution between the sexes.

	Fink and associates concluded that appendiceal intussusception is typically the result of either anatomic susceptibility or a pathologic lead point. Anatomic susceptibility is related to the width of the appendiceal base and the mobility of the appendix. They also discussed the various etiologies of the pathologic lead points but not their relative incidence. The authors recommended operative management, designating simple appendectomy as the procedure of choice with larger resection necessary for bulky disease or in cases of associated cecocolic intussusceptions.

	Appendiceal intussusceptions are thought to be either idiopathic or secondary to an identifiable pathologic lead point; however, due to their rarity, no large series or meta-analyses are available and the incidence of idiopathic versus secondary intussusception is unknown. Reported pathologic lead points include fecaliths, foreign bodies, parasites, endometrial implants, lymphoid tissue, polyps, mucoceles, carcinoids, and adenocarcinoma. Adenocarcinoma of the appendix has obvious treatment implications, but recent case reports suggest most appendiceal intussusceptions are not secondary to adenocarcinoma. A July 2005 PubMed search for case reports of appendiceal intussusception yielded 53 abstracts that described the etiology of the intussusception (Table). The earliest reported case was from 1976 and the most recent was from 2005. Only seven of these intussusceptions resulted from malignant disease; thus, it can be inferred that a routine recommendation of right hemicolectomy for appendiceal intussusception may lead to significant overtreatment.

	As recommended by Fink and associates, appendectomy appears to be the operation of choice for appendiceal intussusception. The operative decision making, however, must be selective and based upon the specific pathology encountered. Ileocolic resection may be required for a bulky appendiceal mass or for associated cecocolic intussusception; right hemicolectomy is required if adenocarcinoma is suspected or identified.

 Appendiceal intussusception is rare in adults. While the potential causes for appendiceal intussusception are understood, the true incidence of the various etiologies is unknown. Appendectomy is the treatment of choice, but a larger resection may be required for a bulky mass, associated cecocolic intussusception, or for malignant disease.

. Geneva, Switzerland: Francois Miege; 1674.

	2. Velse CH. Lugduni Batavorum. J Luzac; 1742.

	3. Hunter J. On Introsusception (read August 18, 1789). In: Palmer JF, eds. The Works of John Hunter, F.R.S. London, England: Longman, Rees, Orme, Brown, Green, & Longman; 1837: 587-593.

	4. Azar T, Berger DL. Adult intussusception. 

	5. Dean DL, Ellis FH, Sauer WG. Intussusception in adults. 

	6. Stubenbord WT, Thorbjarnarson B. Intussusception in adults. 

	7. Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. 

	8. Collins DC. 71,000 human appendix specimens. A final report, summarizing 40 years’ study. Am J Proctol. 1963; 14(12):265-281.

	9. McSwain B. Intussusception of the appendix. 

	10. Fink VH, Santos AL, Goldberg SL. Intussusception of the appendix. 

	11. Flint R, Wright T. Intussusception of a normal appendix: how to avoid a right hemicolectomy. 

	12. Nitecki SS, Wolff BG, Schlinkert MD, et al. The natural history of surgically treated primary adenocarcinoma of the appendix. 

Matthew S. Pugliese, Resident, Department of General Surgery, Swedish Medical Center, Seattle, WA; Steven F. Counter, Attending Surgeon, The Polyclinic, Department of Surgery, Swedish Medical Center, Seattle, WA                      

Appendiceal intussusception caused by villous adenoma

Find your ideal asset protection strategy

 The risk of losing personal assets is greater for surgeons than for nearly any other profession. Some common threats faced by surgeons include taxes, lawsuits, squabbling with a business partner, divorce, and malpractice. These risks must be taken seriously because they can jeopardize a surgeon's practice, assets, family finances, and retirement. Many surgeons believe they are protected when they are, in fact, vulnerable.

?The often-used professional corporation does not offer a surgeon protection against malpractice. Malpractice suits may have more to do with a surgeon's deep pockets than his or her culpability. Malpractice insurance offers no guarantees that your income is protected, since policies come with exclusions. Trust structures, commonly used by surgeons, also can be ineffective. When a grantor places assets in a living revocable trust, those assets are not protected. In most states, even an irrevocable trust may not provide complete protection.

	For surgeons, wealth preservation and asset protection techniques should reach beyond malpractice insurance. Successful planning to protect your assets can decrease the threat of most lawsuits by removing a predator's economic incentive: the assets. Some plans call for multiple entities so that all the eggs are not placed in one basket. Dangerous assets, for example, can be segregated from safe assets. Or entities can be set up in multiple states to cause creditors additional headaches.

?It is important to consider organizational structures that offer significant asset protection. Family limited partnerships (FLPs) and limited liability companies (LLCs) are effective because they have two levels of ownership: the active level (ie, general partners and managing members) and the passive level (ie, limited partners and members). A general partner or managing member with 1% ownership controls his or her respective entity. Thus, a surgeon is able to give away 99% of the entity and still maintain total control.

	Several key provisions incorporated in an FLP or LLC are what make them effective "family" protection vehicles. These provisions protect the FLP or LLC by keeping creditors from getting their hands on its assets, nor can creditors assume management control. FLP and LLC interests can also be discounted by about 35% for lack of marketability and control or if they are under minority ownership. This can save large amounts of estate tax. An LLC can also own and protect personal property such as your home. This strategy is especially protective when the home has been stripped of equity.

	After a clear organizational structure is in place, it is important to implement a combination of trusts to protect surgeons and their families. The Heritage Trust is unequaled as a legal strategy because of its limitless possibilities. This trust is a mix of strategies and trusts designed to achieve maximum protection and minimum taxation for surgeons, relatives, and future generations. Common trust instruments used by surgeons as part of this strategy include living trusts, irrevocable trusts, irrevocable life insurance trusts, privacy trusts, and nonself settled trusts.

	The ultimate asset protection approach for each surgeon uses many of the above strategies as applied to his or her unique practice, financial situation, and objectives. Consult an asset protection specialist to review and structure your own protection.

is a pioneer in the asset protection field. He practices law in the fields of asset protection and estate planning, trusts, and business structuring. To request the new booklet 

For Doctors' Eyes Only: How to Protect Your Hard Earned Assets,

www.assetprotectionlaw.com/physicians.htm

	For surgeons, wealth preservation and asset protection techniques should reach beyond malpractice insurance.

Protect your most valuable asset: Your identity

 We all go to tremendous lengths to protect what is ours. We install sirens in our homes to frighten intruders. We set up alarm systems in our cars to scare off robbers. But all too often, we neglect to take steps to protect our identities?our most valuable asset.

	Identity theft is becoming more common today as we exchange personal information in the mail, over the phone, and via the Internet. Surgeons, while not at greater risk than the general public, may seem like more appealing targets because of their higher incomes and good credit status. If you own a practice, you may be especially vulnerable to this white-collar fraud when dealing with health care billing and payment systems. Working at a hospital doesn't protect you either; you need to know how your personal information is handled in hospital and insurer records.

	Surgeons often designate financial matters to outside people like accountants or bookkeepers, who may or may not be able to distinguish between valid and fraudulent charges. This provides more opportunities for a potential identity thief.

	Maintaining control and ownership over your identity is as much a part of your financial well-being as staying debt free and purchasing appropriate life and disability insurance policies. Just like positioning those motion detectors and panic buttons in your home and car, there are simple, strategic ways to minimize the risk of someone stealing your identity. Here are some steps you can and should take:

	??Order a credit report from each of the three major credit bureaus: Equifax [(800) 685-1111 or equifax.com], Experian [(888) 397-3742 or experian.com], and Trans Union [(800) 916-8800 or trans union.com].

	??Shred materials that contain your personal information (eg, account numbers, passwords, birth dates, and Social Security numbers).

	? When sharing sensitive information over the Internet, check for "https" at the beginning of the URL; the "s" indicates a secure site.

	??Do not provide your Social Security number to companies that do not need it. When supplying personal information, first find out how it will be used.

	??Avoid using easily guessed passwords such as your mother's maiden name or your birth date. Change passwords often.

	? Stay alert of billing cycles and inquire about bills that do not arrive on time.

	??Retrieve your mail when it arrives to prevent theft of correspondence containing private records. Use public mailboxes to send mail with personal data.

	Adhering to these guidelines will certainly minimize your risks, but there is no sure-fire way to prevent identity theft. If you do have an identity theft crisis, report the crime to one of the three major credit bureaus immediately, which will notify the other two agencies. Ask the bureau to place a ?fraud alert' on your file and request to be notified if new accounts are opened in your name.

	Identity theft may not be as obvious as a home invasion, but it can be even more tumultuous to rectify. Protect your name, and guard your credit. Put an alarm on your identity.

?at Heritage Financial Consultants in Lutherville, MD, and is an investment advisor representative, registered representative, and licensed insurance broker with Lincoln Financial Advisors Corporation, a registered investment advisor and broker-dealer. You may e-mail Kathy at 

This information should not be construed as legal or tax advice. You may want to consult a tax advisor regarding this material as it relates to your personal circumstances.

?Estimated number of homeowners who will see their house payments double over the next 2 years. (Economy.com, 2006)

?Percentage of Americans who say parents should charge their college-graduated children rent. (Money, 2006)

?Percentage of college students who receive financial help from their parents for costs other than housing and tuition. (Newsweek, 2006)

?Cost for the US Mint to produce a penny, up 27% from 2005. (

?Cost for the US Mint to produce a nickel, up 19% from 2005. (

?Number of gallons of wine France and Italy plan to distill into fuel or disinfectant to prevent a wine glut and maintain prices. (

?Amount the US Postal Service is expected to lose in fiscal 2006. (

?Estimated price of a first- class stamp if a proposed rate hike takes effect in 2007. (

?Percentage of baby boomers who begin second careers as a teacher or professor. (

Entries & Exits: Visits to Sixteen Trading Rooms

 Many investment books focus on one particular investment strategy, and ?most surgeon investors don't have time to read a dozen different books to learn the various lines of attack. Fortunately, Alexander Elder's new book Entries & 

 (Wiley; 2006) tackles several of them in one volume. Elder takes his readers into the trading rooms of 16 highly experienced traders to look over their shoulders and soak up their expertise. Each chapter describes one trader's particular investment methods and begins with a biography of that trader. Following the biography is a fully annotated set of color charts that illustrate two real trades from beginning to end?one winning, the other losing. Elder presents the entry of each trade on the right-hand side of the page and challenges you to step into the trader's shoes and speculate whether the trade will make or lose money. After you make your prediction, turn the page and see how the trade worked out. Going behind the scenes, Entries & Exits addresses a host of issues from choosing the right trading method, selecting markets, and keeping records to deciding whether you should have other people manage your money. The book accelerates investment novices on the learning curve and helps experienced traders refine their game.

Many Americans headed?for an uncomfortable retirement

, it is hopeful that you have a good grasp on how to prepare for retirement so that you can live comfortably with few to no financial worries. Yet according to Standard & Poor's 

, a Federal Reserve survey shows that the majority of Americans aren't taking the proper steps to save as much as they should to be secure in retirement. This consumer finance survey indicates that the percentage of American families who owned pooled investment funds (ie, mutual funds, hedge funds, and real estate investment trusts) decreased from 2001 to 2004, and families invested in more direct stock ownership instead. Standard & Poor's strongly suggests greater reliance on employee retirement plans and Roth IRAs for retirement savings. They recommend an asset allocation of 45% US stocks, 20% foreign stocks, 20% bonds, and 15% cash.

Look to India for the next booming foreign market

 Move over, China. Surgeon investors looking for the next big thing in overseas investing should look no further than India, where an exploding mutual fund market is making foreign money managers giddy. According to the 

, managed money in India's mutual fund industry has nearly doubled over the past 3 years, to around $48 billion. The majority of this is being managed by firms with foreign ties. The sudden boom comes as a result of India's deregulation of its protectionist economy. This has had a profound impact on Unit Trust of India, a monopoly fund that used to control 80% of all mutual fund assets but now has command over only 12%, freeing up other funds to take a bigger chunk of the market. Economic changes by the Securities and Exchange Board of India have given foreigners the ability to invest directly in local business, resulting in soaring stocks. Subsequently, interest rates have plummeted, drawing increased interest to mutual funds, which show significant room for growth in the future.

Heat up your portfolio with growth stocks

 As the weather has grown warmer, growth stocks have left value stocks in the cold. Standard & Poor's 

 states that growth stocks have outpaced value stocks over the past several months, a trend that seems likely to continue. Analysts say that growth stocks have shown strong 5-year profit, sales, and internal growth rates. They predict a strong earnings gain for growth stocks in 2006, while value stocks are expected to dip slightly. Standard & Poor's gives their ?strong buy' recommendation to the following growth stocks: Capital One (COF), Coach (COH), Colgate-Palmolive (CL), Danaher (DHR), Electronic Arts (ERTS), Eli Lilly (LLY), Home Depot (HD), Johnson & Johnson (JNJ), Kohl's (KSS), Microsoft (MSFT), Mylan Labs (MYL), Nabors Industries (NBR), PepsiCo (PEP), Procter & Gamble (PG), UnitedHealth Group (UNH), Valero Energy (VLO), Wal-Mart (WMT), and Wrigley (WWY).

Surgeon's Bulletin Board

	Nine months after Hurricane Katrina, the bridge over Tulane Avenue, between the Tulane University School of Medicine and the Tulane University Hospital, reopened. Once you have lived through a disaster, as we in New Orleans have, you realize how important tiny changes?even amoebic motions toward normalcy?become. The reopening of the bridge wasn't a major step on the road to convenience. The second floor entrance to the hospital was still under repair, which meant that from the bridge, we had to cross over to the parking lot, go down to the ground floor near the elevator, walk across LaSalle Street, and enter the hospital via the emergency department. Yet it was progress. I smiled as I first crossed the bridge and soon realized I was unconsciously whistling the great Simon and Garfunkel song "Bridge Over Troubled Waters."

	Or perhaps it wasn't really that unconsciously. The title of the song is quite pertinent. The passageway across Tulane Avenue certainly is a bridge. Built to withstand 90-mph winds, it was remarkable that the covered structure had remained intact despite being buffeted by winds as strong as 137 mph. In addition, there was plenty of water. At one point, the flooding was 3 feet deep, drowning the newspaper stands and submerging the large trash receptacles. The lobbies of both the medical school and the hospital experienced serious flooding, and, despite having concrete floors, both have had to be totally redone.

	As you might imagine, the critical word in Simon and Garfunkel's lyrics is "troubled." Historically, even under the best circumstances, the relationship between medical schools and teaching hospitals has been difficult. In many cases, each side stakes a claim of primacy and, in turn, each feels slighted. Since the boards on both sides of the street are comprised of financial wizards and important (or, in some cases, self-important) individuals, egos run large and competition rather than cooperation prevails. While there are many productive marriages, there are a lot of divorces; because the financial stakes are so high, the latter are often vitriolic, public, and just plain ugly.

	I might be criticized for saying so, but until recently, the relationship between Tulane University School of Medicine and Tulane University Hospital was less than ideal. When I was recruited, the university owned the hospital and had academic as well as financial interest in its success. The CEO at that time was a genius, and I don't use that description lightly. As a result, despite some problems, the hospital functioned marvelously. Beds were full, nursing care was excellent, and the staff had a real esprit de corps.

	The Tulane faculty was quite surprised when Columbia HCA, the for-profit health care giant, expressed interest in purchasing Tulane University Hospital and alarmed that the university was so interested in seeing it acquired. We were told that the hospital couldn't continue to exist long-term with such a small market share and that the Columbia regional network would markedly increase tertiary referrals. The medical school faculty were also told that Columbia would buy the practices of a large number of primary care physicians who would support the hospital. We were correct to be skeptical of these forecasts. What we weren't told was that the university was anxious to offload the financial responsibility for the hospital; in the wake of Katrina, they were absolutely right.

	The contract between Tulane and Columbia HCA transitioning an 80% interest in the hospital to the for-profit chain is very complex. It provides funding for resident education and the establishment of several clinical centers of excellence. As far as we know, Columbia has met these obligations, and then some. The hospital was also provided with options to recruit critical new faculty members, whom the university could not have hired without the additional support. In many ways, Columbia has been an excellent partner.

	On the other hand, there have been several problems. As could have been projected, education has taken a backseat. Columbia is interested in making money, not providing service. Nursing care has been far from ideal, and nurse-to-patient ratios have fallen as has the quality of ancillary caregivers. New programs are initiated only if they are likely to be financially successful. Tulane has clearly lost control of its hospital, a fact we all grapple with on a daily basis.

	Several other medical schools have sold their hospitals to for-profit chains, and the results have been much the same. A marriage of two unequals is intrinsically problematic.

	Before Katrina, the Tulane University Hospital environment was very busy yet not totally happy. Many practitioners felt like grown children watching their parents try to work through a troubled relationship, which included two other dependents: Charity Hospital and the New Orleans Veterans Administration Medical Center.

	All that changed with Katrina. Columbia HCA, with its deep pockets and apparent commitment, has been the savior of the medical school. The hospital has filled critical faculty positions terminated by Tulane for fiscal exigency. Columbia HCA pushed very hard and spent millions to reopen Tulane University Hospital, the critical source of faculty private practice funds. As you must realize, practice income is as much the lifeblood of all clinical medical school departments as it is for the community.

	The world of academic medicine has changed. It is no longer sustained by research, as important as such investigation is. The new technologies and faculty with super-specialized skills are incredibly expensive. Even wealthy universities have to dig deep to locate the necessary funding to run first-class medical schools and teaching hospitals. My initial assessment of the appropriateness of selling 80% of Tulane University Hospital was totally wrong. The relationship between Tulane and Columbia HCA isn't perfect, but few relationships are. It can, however, serve as a role model, particularly for other medical schools that are feuding with their for-profit partners. It has become fashionable to establish public-private partnerships. It is important for institutions not to overlook the possibilities of private-private partnerships as well. Tulane has been blessed to have Columbia as its 

Bernard M. Jaffe, Professor of Surgery, Tulane University School of Medicine, New Orleans, LA

Bridge over troubled waters

					This case report highlights the unusual complication of lung carcinoma metastasizing to the small bowel and causing intestinal obstruction and intussusception. Although the initial laparoscopic diagnosis and treatment were successful, the patient experienced additional complications and died. The occurrence of lung cancer metastasizing to the intestine is rare, and the prognosis is extremely poor. Intussusception in adults is usually treated differently than in infants, with resection of the intussuscepted segment being the mainstay of treatment. Reduction is generally not recommended because of concern of malignancy and the risk of contamination if a lesion is perforated. Using a minimally invasive approach in these patients can be beneficial since they are so frail.

	Intussusception occurs when one part of the intestine telescopes into another, causing obstruction. The condition is seen primarily in the pediatric population, generally in children between 3 months and 3 years of age. Only 5% of reported cases involve adults.

 Intussusception presents differently in adults than in children, with adults typically reporting chronic colicky abdominal pain, distention, nausea, and vomiting of more than 1 month's duration. Children usually present with acute changes in bowel habits and a palpable mass. Bowel obstruction may also occur and lead to edema and vascular compromise, causing ischemia, necrosis, gastrointestinal bleeding, and perforation of the bowel in both children and adults.

	Likely causes of adult intussusception include benign and malignant neoplasms, Meckel's diverticulum, postoperative factors, and inflammatory diseases. Most cases are caused by neoplasms such as primary and metastatic bowel cancer, lymphoma, polyps, or lipomas. Colonic intussusception is normally caused by a primary colonic adenocarcinoma, whereas small bowel intussusception is usually the result of a benign tumor, although malignant lesions have also been noted. The most common primary small bowel tumor to cause intussusception is leiomyosarcoma, followed by metastatic tumors such as malignant melanoma and Kaposi's sarcoma. Lung cancer rarely metastasizes to the small bowel but can cause various symptoms, including obstruction, hemorrhage, peritonitis, perforation, and intussusception. We report a case of small bowel obstruction caused by intussusception in a woman with a history of lung carcinoma and review the literature regarding this rare condition.

 A 56-year-old white woman with a history of T2 N0 M0 lung cancer presented to our institution reporting a 1-week history of nausea and bilious vomiting. She also noted diffuse abdominal pain, upper abdominal bloating, and severe constipation with no bowel movements for over 1 week. The patient had undergone curative resection of her giant cell variant of large cell lung cancer approximately 1 year earlier and had done well. In consultation with the oncology service, the patient underwent cisplatin-based therapy and received her last dose about 1 week before her current admission to the hospital.

	Physical examination revealed a soft but diffusely tender and tympanic abdomen with no peritoneal signs on palpation and normal bowel sounds on auscultation. The remainder of the patient's physical examination, including vital signs and laboratory evaluations, was unremarkable. A diagnosis of small bowel obstruction was made, and she was admitted to the medical service. Intravenous fluid hydration was initiated, and a nasogastric tube was placed, which drained 1.5 to 2.5 L of dark, bilious fluid daily. An abdominal radiograph showed multiple dilated loops of bowel with air-fluid levels. An upper gastrointestinal barium swallow study revealed mild small bowel dilation but no discrete strictures, masses, or other abnormalities (Figure 1). Computed tomography (CT) scans of the abdomen and pelvis were taken but were of poor quality because of residual contrast from the upper gastrointestinal barium swallow study. Colonoscopy and upper endoscopy were normal.

	Since the etiology of the small bowel obstruction could not be determined, the patient was taken to the operating room for diagnostic laparoscopic exploration. A distended proximal small bowel and a nondistended large bowel were observed (Figure 2). Further exploration revealed an enteroenteric intussusception of the distal small bowel (Figure 3). This portion of the bowel was reduced laparoscopically, and an approximately 20-cm segment of small bowel was resected and primarily anastomosed. The segment was first isolated by stapling both ends with an endoscopic linear cutting stapler, and intestinal continuity was established with an extracorporeal, hand-sewn, two-layer anastomosis.

	The patient recovered well from the procedure and was discharged from the hospital on postoperative day 5. Pathology evaluation of the small bowel revealed a 6.0 x 3.0 x 2.5-cm, metastatic, poorly differentiated, non?small cell carcinoma, which was a giant cell variant of large cell cancer consistent with lung origin (Figure 4). The tumor was seen invading the bowel wall and beginning to encroach into the mucosa. Low-power magnification revealed multiple inflammatory cells. The high-power magnification showed giant tumor cells surrounded by multiple types of inflammatory cells (Figure 5). The margins were free of tumor.

	The patient was readmitted to the hospital approximately 3 months later for small bowel obstruction due to metastatic lung disease. Open exploration with small bowel resection and primary anastomosis was performed. Although the procedure was successful in relieving the obstruction, the patient developed anemia, hypotension, tachycardia, atrial fibrillation, and abdominal distention. The abdomen was re-explored, which revealed diffuse bleeding despite normal coagulation parameters. The bleeding was attributed to diffuse metastasis of the patient's primary lung cancer. The patient's family was informed of her poor prognosis and decided on minimal supportive care. The patient died 7 days later, approximately 98 days after her initial procedure.

 Lung cancer may aggressively metastasize by directly invading surrounding tissues or by hematogenous or lymphatic spread. Lung cancer has been commonly found to invade the chest wall, diaphragm, pulmonary vessels, and pericardium, but it can also involve other structures of the thorax, such as the esophagus. In cases of lymphatic metastasis, the most likely location of disease spread is the pulmonary and mediastinal lymph nodes. The pattern of spread first involves the ipsilateral hilar lymph nodes and then the mediastinal lymph nodes. Hematogenous spread often involves the brain but can also include the liver, bones, adrenal glands, and kidneys. When lung cancers spread hematogenously, they are generally found within 2 years of lobectomy or pneumonectomy.

	Our patient's lung cancer metastasized to the small bowel and caused intussusception. A review of the literature from 1981 to the present revealed only 7 similar cases. Reports of lung cancer metastasizing to the small bowel have noted obstruction, peritonitis, small bowel perforation, and hemorrhage in addition to intussusception.

 Autopsy studies of lung cancer patients have shown that even asymptomatic patients had metastasis to the small bowel, which indicates that lung cancer may metastasize to the gastrointestinal tract more often than anticipated.

	Of the subtypes of lung cancer, the large cell variety is the one that most frequently invades the small bowel. Our patient's case was unique because she had a giant cell variety of large cell cancer invade the mucosa of the small bowel. This is a rare occurrence because the giant cell variety of large cell cancers accounts for only 0.8% of all lung cancers.

Weesam Alkhatib, Surgical Resident, Department of Surgery; Michael Moncure, Associate Professor of Surgery, Department of Surgery; Rosane Achcar, Pathology Resident, Department of Pathology, University of Kansas Medical Center, Kansas City, KS

September 2006

Chilaiditi's syndrome with incarcerated hepatodiaphragmatic small bowel hernia of unknown etiology

Carcinoma of unknown primary origin presenting as adult intussusception

Appendiceal intussusception caused by villous adenoma

Surgeon's Bulletin Board

Bridge over troubled waters

Diagnostic laparoscopy for intussusception secondary to metastatic lung cancer

Intussusception of the small intestine through an ileostomy: A rare cause of intestinal necrosis

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