	Two uncommon appendiceal pathologic entities are tumors of the appendix and appendicovesical fistulas. Fewer than 1% of all appendectomy specimens contain tumors, of which less than 10% are villous adenomas.

 Appendicovesical fistulas account for fewer than 5% of enterovesical fistulas.

 Surgical treatment ranges from appendectomy to right hemicolectomy and primary bladder repair. We report a rare case of an appendicovesical fistula caused by a villous adenoma of the appendix.

 A 46-year-old, morbidly obese woman was referred to a urologist for evaluation of recurrent urinary tract infections. Over the past year, she had five such infections and recently had developed cloudy urine, which was occasionally mixed with blood. She had reported an episode of suprapubic and right lower quadrant abdominal pain 1 year earlier, which had been evaluated with computed tomography (CT) scanning of her abdomen and pelvis. The scans showed a nonspecific density adhering to her bladder and uterus. She was treated with antibiotics, and her abdominal pain resolved.

	The patient reported no recent history of nausea, vomiting, or change in bowel movements. Her medical history was significant for asthma and hypertension; the latter was controlled with hydrochlorothiazide and amlodipine. Her surgical history included knee arthroscopy. The patient did not drink alcohol, never smoked cigarettes, and did not have a family history of colon cancer.

	Physical examination showed she was afebrile and hemodynamically stable. She had right lower quadrant tenderness without guarding or rebound on palpation. There was also mild tenderness over her right costovertebral angle. A rectal examination was normal, and her urinalysis was consistent with a urinary tract infection.

	The patient underwent urologic evaluation, including cystoscopy and a cystogram. Cystoscopy revealed a normal bladder with the exception of a small opening at the dome, which was surrounded by erythema. The contrast from the cystogram filled her cecum and the right side of her colon after having filled her bladder (Figure 1). This finding suggested a fistulous communication between the urinary bladder and the large bowel.

	The patient was referred to a general surgeon, who obtained a colonoscopy and a CT scan with oral contrast of her abdomen and pelvis. The colonoscopy revealed a normal cecum and colon. The CT scan was limited by the patient's large body habitus, and although a fistulous tract could not be visualized, it did show her cecum adhering to her bladder.

	Colovesical fistula was suspected, and the patient was brought to the operating room. A lower midline incision was made, and exploration found multiple adhesions in the right lower quadrant. The cecum adhered to the posterior wall of the bladder. The appendix was inflamed and appeared to have ruptured into the bladder wall causing an intense inflammatory reaction on the dome of the bladder. There was also a small palpable mass at the base of the appendix. Because of this mass, a right hemicolectomy was performed with en bloc resection of a portion of the bladder. A primary ileotransverse colon anastomosis was undertaken with primary closure of the bladder.

	The patient's Foley catheter was removed on postoperative day 6, and she was discharged to home on postoperative day 7 after a cystogram established that there was no leak. Final pathologic analysis revealed a 4-cm tubulovillous adenoma with multifocal severe dysplasia (Figure 2). There was no evidence of invasive disease arising from the base of the appendix.

 Tumors of the appendix are rare, with most primary appendiceal neoplasms found incidentally during surgery for acute appendicitis. Surgical treatment ranges from appendectomy to right hemicolectomy, depending on the histology, size, and degree of spread or invasion.

	In a retrospective study by Connor and colleagues, appendiceal tumors were identified in 74 of 7,970 (0.9%) appendectomy specimens.

 Of these tumors, 57% were carcinoids and only 7% were villous adenomas. Schmutzer and associates quoted the incidence of appendiceal tumors as 1.1%, and among the 8,699 appendectomies performed at their institution between 1949 and 1972, only two villous adenomas (0.02%) were identified.

	Although appendiceal tumors are generally benign and villous adenomas of the appendix are usually not invasive, out of 35 cases, Hameed identified 22 that transformed from noninvasive adenoma to carcinoma in situ.

 This finding suggests that villous adenomas of the appendix may be more likely to undergo malignant transformation than other appendiceal neoplasms. Jafari and colleagues reviewed 11 cases of villous adenoma of the appendix, and clinical and pathological evaluations found an associated malignancy in 4 of them.

	Appendicovesical fistula is an uncommon type of enterovesical fistula and a rare complication of appendicitis. Over 100 cases of appendicovesical fistula have been reported.

 The most common clinical features of these fistulas are recurrent cystitis complicating unrecognized appendicitis and a lack of gastrointestinal symptoms. Diagnosing the condition usually involves a combination of cystoscopy, cystography, and CT scanning. Treatment often includes appendectomy or right hemicolectomy with en bloc partial cystectomy and primary bladder repair.

	Only five cases of appendicovesical fistulas arising as complications of appendiceal tumors have been described in the literature; two resulted from mucinous adenocarcinoma of the appendix,

 and one was a villous adenoma of the appendix.

 Patients who present with recurrent cystitis and are found to have a vesicoenteric fistula should have their entire colon evaluated for a possible inflammatory or oncologic process.

 It is difficult to diagnose an appendicovesical fistula resulting from a tumor of the appendix because imaging studies and colonoscopy are unlikely to confirm the etiology of an appendiceal tumor. A history of right lower quadrant pain and recurrent cystitis in a patient over age 40 should raise suspicion of a colovesical fistula. Although the most common cause of an appendicovesical fistula is failure to recognize and treat acute appendicitis, surgeons should be prepared to treat this rare pathologic entity with the appropriate operation if the etiology is a primary benign or malignant appendiceal tumor.

 1. Connor SJ, Hanna GB, Frizelle FA. Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7,970 appendectomies. 

	2. Larsen A, Bjerklund Johansen TE, Solheim BM, et al. Diagnosis and treatment of enterovesical fistula. 

	3. Sarr MG, Fishman EK, Goldman SM, et al. Enterovesical fistula. 

	4. Schmutzer KJ, Bayar M, Zaki AE, et al. Tumors of the appendix. 

	5. Hameed K. Villous adenoma of the vermiform appendix. A review with report of a case. 

	6. Jafari N, Christ M, Menaker GJ, et al. Villous adenoma of appendix?report of a case and review of the literature.

 Am J Proctol Gastroenterol Colon Rectal Surg. 

	7. Ikeda I, Miura T, Kondo I. Case of vesico-appendiceal fistula secondary to mucinous adenocarcinoma of the appendix.

	8. Dalton DP, Dalkin BL, Sener SF, et al. Enterovesical fistula secondary to mucinous adenocarcinoma of appendix. 

	9. Lund PG, Krogh J. Appendicovesical fistula associated with neuroma of the appendix. 

	10. Di Paola M, Stockwell WS. Appendico-vesical fistula due to an appendix abscess with associated goblet cell carcinoid of the appendix.

	11. Timmermans LG, Casselman J, Defloor E. Association of an appendicovesical fistula and an appendiceal adenoma. Case report [in French].

Articles

Surgical Rounds

Mark C. Takata, Chief Resident, Department of Surgery, University of Connecticut, Farmington, CT; Ursula McMillian, Resident, Department of Surgery, St. Raphael's Hospital, New Haven, CT; Sabino Zani, Resident, Department of Surgery, University of Connecticut, Farmington, CT; Wayne Frederick, Assistant Professor of Surgery, Department of Surgery, University of Connecticut, Farmington, CT, Associate Director, Howard University Cancer Center, Washington, DC

Villous adenoma of the appendix presenting as an appendicovesical fistula

				University of California—San Francisco-East Bay

 is a Gram-positive rod with toxins similar to 

. This pathogen is rarely encountered, with only a few cases reported in the world literature. We present the case of a young girl who presented with symptoms of acute appendicitis. After proper resuscitation, an appendectomy was performed promptly. Despite these efforts, the patient’s condition progressed to septic shock and she died. An autopsy confirmed the death was secondary to sequelae of acute gangrenous appendicitis with positive peritoneal fluid cultures for 

 A 16-year-old girl came to the emergency department with symptoms of acute appendicitis. She had a 4-day history of worsening diffuse abdominal pain, nausea and emesis, subjective chills, fever, dysuria, and anorexia. Her only significant medical history was an elective abortion 6 months earlier. The patient was taking Depo-Provera

 for birth control and reported no allergies or use of other drugs. On initial physical examination, she was found to have tachycardia, a board-like abdomen, and cool but perfused extremities. Laboratory studies revealed a white blood cell (WBC) count of 39,000/µL, hemoglobin of 20 g/dL, hematocrit of 66% (normal, 35%—45%), and  urine that was positive for bacteria. A computed tomography (CT) scan of the abdomen and pelvis showed a large collection of free fluid in her peritoneum, a large bilateral pleural effusion, and cecal inflammation, which suggested a perforated appendix.

	An exploratory celiotomy was performed immediately and revealed 2 to 3 L of nonbloody, serous fluid. Her stomach and small and large bowel appeared dusky. The appendix was gangrenous, and there was no evidence of macroperforation. The other intra-abdominal organs were noted to be normal, albeit hypoperfused. Bilateral thoracostomy tubes were placed, and these drained more than 1 L of clear fluid. The patient was brought to the intensive care unit, but her condition did not improve.

	Postoperative laboratory studies showed a WBC count of 34,000/µL, hematocrit of 47%, potassium of 6 mEq/L (normal, 3.5—5 mEq/L), and corrected calcium of 4.8 mEq/L (normal, 8&mdash;10 mEq/L). The patient became acidotic and required increasing ventilator support for worsening respiration. On physical examination, her abdomen was rigid and distended. She was taken back to the operating room, and the bowel from the gastroesophageal junction down to the sigmoid colon appeared ischemic. The patient became hemodynamically unstable and died during the operation despite resuscitative measures.

	Her blood cultures were negative for bacteria, but peritoneal fluid cultures grew 

 Pathology of the appendix found an acute gangrenous appendix with microperforation. An autopsy confirmed septic shock secondary to sequelae of acute gangrenous appendicitis. It was concluded that the patient died from 

—induced toxic shock syndrome. Further investigation of the patient’s medical history revealed that her abortion was achieved with medical intervention using mifepristone or misoprostol via an unknown route 7 months before her presentation to the hospital. Given the large time gap between her abortion and clinical presentation, the patient’s elective medical abortion may not have caused her condition. Nevertheless, our literature review indicates this case may be one of the first reported incidences of acute appendicitis fatality associated with 

 is a Gram-positive obligate anaerobe that accounts for 1% of 

 Additionally, it is among the major bacterial groups detected as part of the intestinal flora of humans associated with various physiologic activities. 

 produces two toxins: lethal and hemorrhagic. These toxins appear similar to 

 is an edema-forming toxin that exerts apoptotic cell death by disrupting mitochondrial homeostasis.

 In vivo, the toxin may also act as a super-antigen, activating the cell-mediated immune system in a nonspecific manner, causing immunosuppression and a toxic-shock—like condition.

—induced fatalities. One case report concerned a healthy young woman who died 7 days after receiving mifepristone for an elective abortion. The Food and Drug Administration issued a health advisory in 2005 regarding the deaths of 4 women in the United States and Canada from 

—induced toxic shock syndrome following elective medical abortions using mifepristone and intravaginal misoprostol.

—associated fatalities are rare and generally occur after uneventful childbirth or an elective abortion. We found no other reports in the literature of 

 fatalities associated with acute appendicitis.

—induced toxic shock syndrome and mifepristone and intravaginal misoprostol is unknown, one hypothesis is that mifepristone contributes to septic shock by blocking progesterone and glucocorticoid receptors, interfering with the controlled release and functioning of cortisol and cytokines.

 Failure of physiologically controlled cortisol and cytokine responses results in an impaired innate immune system and subsequent disintegration of the body’s system of defense needed to prevent the endometrial spread of 

	The clinical presentations of the few reported cases of 

 include influenza-like prodrome in a previously healthy woman, progressive refractory hypotension, local and spreading tissue edema, marked leukocytosis, elevated hematocrit, and severe hypocalcemia.

 Although our patient’s blood cultures were sterile, the diffuse tissue edema and the laboratory and pathology findings along with a positive peritoneal fluid culture for 

 led us to conclude that she died from a rare complication of acute appendicitis. 

 should be suspected in any young, healthy, afebrile woman who presents with sepsis, an elevated hematocrit and WBC count, and profound hypocalcemia. Performing a laboratory test to identify 

 preoperatively would require delaying proper treatment. Prompt surgical and medical care are imperative.

	Administration of intravenous (IV) immunoglobulin is recommended. Although treating septic shock with IV immunoglobulin remains experimental, there is evidence to support its use. A 2002 review showed that overall mortality was reduced in patients with sepsis and septic shock who received polygonal IV immunoglobulin (n = 492; relative risk, 0.64; 95% confidence interval, 0.51—0.80).

 Furthermore, in animal experiments, lethal toxicity of the 

 filtrate was assayed on 6-week-old BALB/c mice.

 All mice inoculated with culture filtrate containing 1:100 toxin dilution died within 24 hours. Those mice inoculated with filtrate preincubated with 

 antitoxin IV immunoglobulin survived. For otherwise healthy young women who have a recent history of elective medical abortion and present with clinical signs of sepsis supported by laboratory test results, adjuvant IV immunoglobulin should be provided in addition to the medical and surgical treatment necessary to deal with septic shock.

 is an intestinal flora that naturally resides in most humans. This bacterium makes up 1% of all 

 Surgeons who encounter young healthy women with a history of influenza-like prodrome followed by acute abdomen should be suspicious of rare disorders like 

—induced sepsis. This especially holds true if the patient has a recent history of an elective medical abortion. Initial treatment should consist of administering immunoglobulin, followed by any necessary medical or surgical intervention.

 1. Popoff MR. Purification and characterization of 

	2. Petit P, Breard J, Montalescot V, et al. Lethal toxin from 

 induces apoptotic cell death by disruption of mitochondrial homeostasis in HL-60 cells. 

	3. Nakamura S, Ogura H, Tanaka J, et al. Difference in susceptibility of various cell cultures to cytotoxic culture filtrates of 

	4. Sinave C, Le Templier G, Blouin D, et al. Toxic shock syndrome due to 

: a dramatic postpartum and postabortion disease. 

	5. Centers for Disease Control and Prevention (CDC). 

 toxic shock syndrome after medical abortion with mifepristone and intravaginal misoprostol”--”United States and Canada, 2001-2005. MMWR Morb Mortal Wkly Rep. 2005; 54(29):724.

Daniel Shibru, PGY-5 Research Resident, Department of Surgery; Christopher Newton, Former Chief Resident, Department of Surgery; Jonathan Svahn, Clinical Assistant Professor, Department of Surgery, University of California?San Francisco-East Bay, Oakland, CA

Acute gangrenous appendicitis associated with Clostridium sordellii?induced toxic shock syndrome

 Many of today's financial books advise readers that investing depends on their personal situation or goals and fail to provide concrete investment options. Surgeon investors who don't have time to read every book or explore every investing option can read Robert Pagliarini's 

 (St. Martin's, 2006). This book is filled with advice on how to implement investment and savings changes. The book is broken into six chapters: one for each day of the ?makeover.' A short quiz appears at the beginning of each chapter that helps readers decide whether they need to read that chapter or which areas of the chapter deserve their focus.

	Each section offers step-by-step advice on finding the right insurance, investing for a goal, fiscal planning, retirement, and surviving a financial catastrophe; the advantages and disadvantages for each step or project outlined are detailed. Pagliarini also adds anecdotes, including a "Don't Let This Happen to You" feature. Supplemental blocks throughout the book define key words and concepts, making the book an easy-to-read reference book for financial direction.

 The mortgage game has changed a great deal over a short period of time. Bargains and arrangements made 2 years ago no longer carry the same weight in savings today. CNNMoney.com suggests you start thinking traditionally. The housing market continues to cool, which means houses sit on the market longer and sellers are forced to ?compromise the sale'?a phrase that was rarely uttered over the past several years.

	Be aware of the changes. Interest rates, while historically low, have increased and may increase more. Adjustable rate mortgages no longer offer enough savings to balance future risks. It's also important to consider annual percentage rates (APRs) along with the interest rates. The APR figure includes points and the upfront costs of the loan. CNNMoney.com suggests comparing rates at sites like Bankrate.com and hsh.com. Because the number of people applying for new loans has dropped by 20%, you can take advantage of increased competition between lenders.

Do-it-yourself home improvement can cost 

 Sometimes surgeons, who are very skilled with their hands on the job, opt for a hands-on approach for home improvement projects. But even handy surgeons can make mistakes on their do-it-yourself projects, and these can prove very costly. Bankrate.com details several missteps that can drive up the money and time spent on a project. One of the biggest issues is obtaining the proper permits. While it may seem inconvenient to get a permit for each project, you definitely want to cover yourself and get the job done right.

	Always be sure you have the necessary tools and materials before starting a home improvement project. Buying or renting professional tools may be more expensive, but this investment can save time in the long run and help you avoid costly errors. Be sure to select the proper thickness of drywall and subflooring and apply the correct paint to each surface (eg, flat paint for ceilings, egg shell or satin for most interior walls, and semigloss for bathrooms). Prep every project before you dive into it, and live by the old clich? "measure twice, cut once." Finally, never work beyond your limits. Sometimes it pays to hire a professional to do the job instead of committing a large chunk of time to doing frustrating work that siphons money out of your pocket.

Even money from the tooth fairy can be saved 

 When should you begin teaching your children good money habits? According to the 

, it is never too early. Statistics show that the savings rate in the United States is less than 1%, the lowest of all industrialized nations. Many parents aren't setting a good example for their children. The JumpStart Coalition for Personal Financial Literacy reports that the direct buying power of the nation's children is expected to exceed $51.8 billion this year, while the fastest growing group to declare bankruptcy is adults aged 20 to 24. For these and many other reasons, the Pennsylvania Institute of Certified Public Accountants (PICPA) has developed a new brochure, 

, to help parents help their children develop good financial habits. Targeting elementary school children, PICPA's brochure suggests easy ways to save money, for example, saving any money received on birthdays or other special occasions. It also teaches children to set weekly or monthly goals, such as putting aside a certain amount of money to save for a big item like a bike. Developing good money habits early on ensures better financial responsibility later in life. A bad habit is hard to break?but so is a good habit. You can download a copy of this free brochure at 

www.picpa.org/financialliteracy/index.asp

Choosing the best care option for your child 

 You want your young child to have the best care possible while you're working. While child care can be outrageously expensive, it's not something you can skimp on. Because there are several options to explore, Bankrate.com suggests that you perform thorough research to determine which method of child care is right for you. The best place to begin is by asking friends and family with children to refer you to a reputable child care provider. This can help narrow your options.

	A professional nanny is widely considered the ideal choice, but nannies can?be tremendously expensive, especially if you go through a referral service that conducts background checks and screening interviews. Similar to a nanny is an au pair, who is usually between ages 18 and 26 and comes from another country to live with you and care for your children, usually for a period of up to 2 years. The State Department sets some of the costs involved, including airfare, training, and screening.

	Outside of your home, a family daycare or child care center may be a good option. A licensed family daycare is relatively affordable, and your child can interact with other children while playing with age-appropriate toys and equipment.

	Child care centers can be much more expensive and generally take a more educational approach. They usually focus on social interaction and education through a set curriculum.

?Percentage of married couples who say that money causes tension in their marriage. (

?Amount the Senate?Appropriations Committee approved for the Defense Department's yearly budget, which began October 1, 2006. (Associated Press, 2006)

?Amount the Senate?Appropriations Committee approved to fund the departments of Labor, Health and Human Services, and Education for the budget year beginning October 1, 2006. (Associated Press, 2006)

?Estimated cost per shot from a $24,150 bottle of rare Johnnie Walker whisky. (

?Percentage of college graduates with existing college debt who paid their tuition with a credit card. (

?Percentage of college graduates who say that education-related debt has contributed to depression. (

?Percentage of American men aged 30 to 55 who are not working. (

?Number of e-mails that are sent per day in the world. (

?Increase in September 2006 job cuts over September 2005. (

?Number of job cuts made by the auto industry in September 2006. (Associated Press, 2006)

 First, there was the combined whammy of the tech wreck and the post-9/11 recession that battered our 401(k) accounts. Next, inflation in health care and education costs further diverted indebted consumers from concentrating on retirement. Now, headlines are surfacing that any company facing tough times or intense shareholder pressure can pull the rug out from under its retirees hoping for the traditional three-legged stool of retirement: savings, Social Security, and pension. Granted, many surgeons in private practice don't even have the possibility of a pension, but they may be relying on a spouse to reap the benefits of a pension plan. All three legs are in trouble?we aren't saving enough, Social Security is under attack, and traditional pensions are disappearing fast.

	For retirees facing a sudden loss of pensions and benefits, there are very few options, except going back to work or turning home equity into a personal bank. So the time to start taking on the lion's share of your retirement responsibility is now, whether you're 5, 10, or 20 years away from hanging up your white coat.

	If you're not certain where you stand, get some help. If you've never sat down with a financial advisor, it may be time to get a second opinion on your retirement readiness. The meeting may yield some ugly news, but it is better to know the options than simply cross your fingers. You may want to address the following topics in your retirement readiness meeting:

?It is arguable that traditional retirement is going to be dead for many of us when we get there. You may want to think about a second part-time career or new ways to earn income.

?Annuities are investments that provide fixed or variable payments to the investor over a set period of time. The collapse of traditional plans has put new focus on the annuity business, and it is worth discussing with an unbiased expert.

?In the last few years before retirement, see if you are able to live as though you are already retired. Give up the lattes and the pricey clothes and dinners. See if you can live with a smaller car or a used one. Retirement is easier if you can downshift into it, from a monetary standpoint.

?It may be strange to hear health advice tied to your financial well-being, but it should be one of the first things you consider. That's because the numbers on a bathroom scale, blood pressure monitor, or cholesterol report can dramatically affect the cost of your health care and insurance premiums going into retirement. You will find that preexisting conditions can boost your premiums or even deny you coverage. That is a very ugly surprise going into the years when you will need health care coverage the most.

?It may seem a bit extreme to switch jobs just because a particular employer has better benefits and savings options, but if the position (ie, a place in a group practice or as a member of hospital staff) appeals to you and you can make the move without endangering what you've already accrued, why not consider it?

?Various IRA and 401(k) options allow you to make additional contributions over standard savings limits if you are over age 50. Make sure you know what those additional amounts are and take full advantage of them.

?In a 30- to 40-year career, you may have gathered bits and pieces of pension benefits, personal savings, and investments along the way. Likewise, you may have insurance policies, savings bonds, and other small investments that may have slipped your attention. A reevaluation of retirement options should begin with a full accounting and reorganization of all investment and savings assets, preferably in an outline that's easy for you and your advisor to access.

Surgeon's Bulletin Board

				Clarence and Mary Dennis Professor and Chairman

Mucocele of the appendix is an uncommon but potentially dangerous pathological entity that presents in a variety of ways. The authors discuss the diagnostic workup of an appendiceal mucocele from computed tomography scanning to resection, emphasizing the influence of pathological diagnosis on the operative procedure. Right hemicolectomy is sufficient for most patients with appendiceal mucocele; however, the significant risk of postoperative complications and concomitant life-threatening conditions has led the authors to recommend careful resection and exploration of the peritoneum.

	Appendiceal mucocele is a rare but well-recognized entity that can mimic several common clinical syndromes or present as an incidental surgical or radiological finding. It has a 0.2% to 0.4% prevalence among appendectomies.

 The term mucocele is widely used in diagnosing both benign and malignant lesions, but specific criteria are being proposed for definitive diagnosis and surgical management of appendiceal mucocele.

 While some neoplasms with malignant potential may be treated definitively by resection, other seemingly benign lesions must be treated conservatively due to complications that ensue from peritoneal and cecal inoculation and the possibility of progression to malignancy.

	Mucocele can result from mucosal hyperplasia, mucinous cystadenoma, or mucinous cystadenocarcinoma. Signs and symptoms occur in fewer than 50% of cases and are generally associated with malignancy.

 These include pain in the right lower abdominal quadrant, an abdominal mass, weight loss, nausea, vomiting, change in bowel habits, anemia, and hematochezia. Depending on the location of the appendix, other signs may be observed, such as hematuria. The most dreaded complication of benign or malignant mucocele is pseudomyxoma peritonei, which is difficult to treat surgically or medically. It has an uncertain prognosis, with a 5-year survival rate between 53% and 75%.

	More than half of appendiceal mucoceles are mucinous cystadenomas, most of which can be treated by appendectomy alone, with careful exploratory laparotomy for mucinous peritoneal adhesions typical of pseudomyxoma.

 Wide resection of the ap-pendix, however, is currently the standard for conservative surgical management of unspecified appendiceal mucocele.

 A 54-year-old man of Caribbean descent presented with a constant, dull right lower quadrant pain of 2 years' duration. His pain did not radiate and was not affected by any activity. He reported no changes in his eating or bowel habits and no hematochezia or melena, although he noted several years of intermittent abdominal distention and vomiting, which was thought to be due to gastroparesis from uncontrolled diabetes. The patient had no history of surgery. On physical examination, he was afebrile and hemodynamically stable. The abdominal examination was normal except for focal tenderness over McBurney's point without rebound tenderness on palpation.

	Laboratory analysis was unremarkable. Axial computed tomography (CT) scanning revealed a 5 x 3 x 3-cm in diameter, blind-ending, tubular, fluid-filled structure that appeared to arise from the cecum, consistent with mucocele of the appendix (Figure 1). Colonoscopy showed evidence of an appendiceal mass covered by cecal mucosa and protruding into the cecum.

	The patient underwent elective laparoscopic-assisted right hemicolectomy. Several dilated loops of small bowel were noted proximal to the adhesions, which were most extensive over the liver and gallbladder. Exploration of the peritoneum did not show evidence of malignancy.

	Pathological examination of the surgical specimen revealed a fluid-filled, distended appendix measuring 8 cm at its greatest diameter and with a base 4 cm in diameter (Figure 2). The obstructed appendix was found to communicate with a mucus-filled evagination of the cecal wall, arising 1 cm proximal to the ileocecal valve. Six lymph nodes discovered in the mesentery of the specimen revealed no pathological morphology. There were no abnormal peritoneal findings. The tumor was diagnosed on histological section as mucinous cystadenoma (Figure 3).

	The patient's postoperative course was uneventful, and he was discharged home on postoperative day 5. Three months after the operation, all symptoms had completely resolved and the patient was doing well.

 Mucocele of the appendix was first described by Rokitansky in 1842 and was formally named by Feren in 1876. Since that time, there has been some debate as to the gross diagnosis of mucocele. Some consider the term to encompass a large group of conditions involving the appendix, pancreas, or ovaries, with diverse morphological features and pathogenesis. These conditions share the common feature of obstructive process or hyperplasia of mucinous epithelium, or both, leading to gross mucinous accumulation. Others consider mucocele to be a strictly neoplastic process that can spread to lymph nodes, extend into surrounding tissue, or seed the peritoneum.

 The latter description encompasses most mucocele-related diagnoses, and thus, right hemicolectomy is an appropriate first step in managing suspicious mucinous collections of the appendix. Histopathological findings can confirm whether further tests are needed for workup of malignancy. If a patient has a mucinous cystadenoma of the appendix, as was the case with our patient, then right hemicolectomy is curative (except in cases that are complicated by pseudomyxoma peritonei).

	In a retrospective study of 135 patients with appendiceal mucocele, 55% were women; other reports have shown a distinct male predominance (4:1).

 Indications for removal of appendiceal mucocele are evolving as diagnostic procedures that lead to surgery for a wide variety of concomitant conditions improve. Forty percent of patients in the 135-patient study went into the operating room specifically for treatment of symptoms or to confirm a diagnosis, while the remaining 60% had their appendiceal mucocele removed on incidental finding. Although CT scanning is usually accurate in imaging a fluid-filled appendix, the appendix was often missed on CT scans for workup of coexisting conditions. This may explain the high incidence of surgical diagnosis for other conditions (although CT scanning was not available for a number of patients in that study). Still, in the workup for a patient's symptoms of right lower quadrant abdominal pain or a palpable abdominal mass, CT scanning has high sensitivity and specificity for detecting an abnormal appendix.

	Ultrasonography and endoscopy are becoming the standards for confirming CT findings before taking the patient to the operating room. Endoscopic biopsy and pathological determination can further guide the operative procedure if hemicolectomy is contraindicated or otherwise undesirable. CT scanning has the advantage of allowing precise observation of the relationship between the lesion and adjacent organs (Figure 1B) and any other abnormalities associated with mucocele. This diagnostic modality should be used before a patient undergoes endoscopy, colonoscopy, or ultrasonography. In suspected cases of appendiceal mucocele, fine needle aspiration should be avoided to preserve integrity of the appendix and prevent tumor inoculation.

	Although complications from appendiceal mucocele are minimal, there is evidence that complications are associated with concomitant neoplasms. These occurred in about one third of patients in the retrospective study and undoubtedly contributed to the high number of incidental findings of mucocele. While the incidence of ovarian and uterine neoplasms might be explained in part by the high number of gynecologic procedures reported, the association between appendiceal mucocele and colonic neoplasms is well established.

 This additional evidence makes a strong case for the use of surveillance colonoscopy and removal of polyps in any patient with an appendiceal mucocele. Most investigators agree that the adenoma-adenocarcinoma sequence is similar to the colonic polyp-adenocarcinoma sequence.

	No cystadenomas smaller than 2 cm have been reported, which suggests that all mucoceles larger than 2 cm should be removed to eliminate the chance of progression to malignancy. Furthermore, all patients, whether they have benign or malignant appendiceal mucocele, should be evaluated for pseudomyxoma peritonei. Although the condition is more common in malignant appendiceal mucocele (95% occurrence rate as opposed to 13% in patients with nonmalignant appendiceal mucocele), the grave consequences of pseudomyxoma peritonei and the somewhat better prognosis for patients whose condition is diagnosed and treated early should challenge the view that simple surgical resection sans careful exploration for every diagnosed appendiceal mucocele is sufficient.

 Appendiceal mucocele presents a challenge to the surgeon who does not appreciate the effect of pathological diagnosis on the operative procedure. Appendectomy alone should be performed only on mucinous lesions that are determined to be non-neoplastic after biopsy. If appendectomy is performed, precautions should be taken to minimize the risk of seeding the peritoneal cavity with tumorous mucin during manipulation. In our patient's case, simple appendectomy could have allowed spillage of fluid from the small collection between the obstruction and the cecal mucosa, and because of the multiple suspicious adhesions, it would have been inappropriate. Although these adhesions were not suspicious for malignancy on imaging studies, they did raise suspicion of malignancy because our patient had never undergone surgery before. In other instances, it has been shown that induration of the appendix, a spontaneous appendiceal perforation, or mucus extravasation emanating from the appendiceal lumen strongly suggest malignancy.

 These features, however, also may be present with benign tumors, which makes the gross diagnosis of neoplastic process difficult, at best.

	Although laparoscopic techniques have been described that minimize the prohibitive risk of seeding mucinous tumor implants during laparoscopic manipulation, appendectomy alone?whether open or laparoscopic?does not guarantee the removal of all neoplastic tissue, including extensions into surrounding tissue and lymph nodes.

 We recommend right hemicolectomy for cases in which the pathological diagnosis has not been established and for any cases suspicious for adenocarcinoma or complicated by concomitant adenocarcinomatous disease or pseudomyxoma peritonei.

 1. Caspi B, Cassif E, Auslender R, et al. The onion skin sign: a specific sonographic marker of appendiceal mucocele.

	2. Gonzalez Moreno S, Shmookler BM, Sugarbaker PH. Appendiceal mucocele. Contraindication to laparoscopic appendectomy. 

	3. Stocchi L, Wolff BG, Larson DR, et al. Surgical treatment of appendiceal mucocele. 

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

	5. Lam CW, Kuo SJ, Chang HC, et al. Pseudomyxoma peritonei, origin from appendix: report of cases with images. 

	6. Hinson FL, Ambrose NS. Pseudomyxoma peritonei.

	7. Higa E, Rosai J, Pizzimbono CA, et al. Mucosal hyperplasia, mucinous cystadenoma, and mucinous cystadenocarcinoma of the appendix. A re-evaluation of appendiceal mucocele. 

	8. Sasaki K, Ishida H, Komatsuda T, et al. Appendiceal mucocele: sonographic findings. 

	9. Pickhardt PJ, Levy AD, Rohrmann CA, et al. Primary neoplasms of the appendix: radiologic spectrum of disease with pathologic correlation. 

	10. Zissin R, Gayer G, Kots E, et al. Imaging of mucocoele of the appendix with emphasis on the CT findings: a report of 10 cases.

	11. Raijman I, Leong S, Hassaram S, et al. Appendiceal mucocele: endoscopic appearance. 

	12. Carr NJ, McCarthy WF, Sobin LH. Epithelial noncarcinoid tumors and tumor-like lesions of the appendix. A clinicopathologic study of 184 patients with a multivariate analysis of prognostic factors. 

	13. Fujiwara T, Hizuta A, Iwagaki H, et al. Appendiceal mucocele with concomitant colonic cancer. Report of two cases. 

	14. Kabbani W, Houlihan PS, Luthra R, et al. Mucinous and nonmucinous appendiceal adenocarcinomas: different clinicopathological features but similar genetic alterations. 

	15. Chiu CC, Wei PL, Huang MT, et al. Laparoscopic resection of appendiceal mucinous cystadenoma. 

Jonathan P. Lopez, Medical Student, Department of Surgery; Emad Kandil, Chief Resident, Department of Surgery; Alexander Schwartzman, Chief, Division of General Surgery, Department of Surgery; Michael E. Zenilman, Clarence and Mary Dennis Professor and Chairman, Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY

Appendiceal Mucocele: Benign or Malignant?

	We live in a crazy world. In order to ensure the free will of the American people, everyone and everything has his, her, or its rights. The Army Corps of Engineers has the right to make atrocious levee design errors and foolish mistakes without repercussion (except to New Orleans). FEMA has the right to waste billions of dollars while not providing for the essential needs of flood victims with its director’s resignation as the only consequence. The African-American mayor of New Orleans is allowed to call for a “chocolate city” with no legal repercussion or unanimous political rebuke. Foreign-born terrorists have protection from eavesdropping, even if the information collected would save American lives and property. A large segment of our population believes on religious grounds that embryos also have undeniable rights. I thought I had heard it all until I read a fascinating article in 

 about the rights of American citizens to direct the use of removed blood samples and tissue specimens.*

	As surgeons, when we resect tissue and submit it for histologic examination, we don’t inquire as to its ultimate disposition. I have always assumed that operative specimens are destroyed, because on those occasions when I wanted further analysis of material from my hospital or from another institution, I was told that only paraffin-embedded blocks were available. Similarly, when blood samples are collected for electrolyte determination, hemogram, and particularly type and crossmatch, I have always assumed that the unused serum is discarded. It is probably the same at your hospital: if more blood is needed, the blood bank requires another specimen before it can crossmatch more units. Perhaps in naivety, I never imagined that such specimens were preserved and banked.

	On the other hand, oncologists and infectious disease specialists have long made a practice of freezing specimens for later identification of genetic markers, antigens, cellular reactants, etc, and use in developing antisera and immunizations. Among many other benefits, these banked specimens have resulted in the development of serologic tests for HIV, hepatitis, and prostate cancer; immunizations for such infectious diseases as polio, measles, and smallpox; and effective new therapeutic agents against a variety of malignancies.

	Despite the incredible successes and global benefits derived from specimens relinquished voluntarily, an increasing number of people have expressed serious concerns about the outcome and use of their biologic products. They have become the nucleus of a new 

	While lots of questions remain, courts have decided that patients do not own or have property claims for specimens once they have been removed. This was determined in a case involving John Moore, a patient cured of hairy-cell leukemia by splenectomy. Moore unsuccessfully sued Dr. David Golde, a UCLA cancer researcher, for ownership of Mr. Moore’s serum samples. Ultimately deciding in favor of Dr. Golde, the California Supreme Court declared that giving patients ownership of their removed specimens would “hinder research by restricting access to the necessary raw materials.”*

	While it has now been acknowledged that patients do not own the specimens, it is far from clear who does: the research scientist or the institution. Dr. William Catalona is a brilliant prostate cancer scientist (and former neighbor). While at Washington University in St. Louis, he did pioneering work on the use of PSA screening for prostate cancer and banked 4,000 tissue and 250,000 serum samples from patients. When he provided a commercial venture with samples free of charge in order to further his research, the university took possession of the material, fully recognizing its potential economic value. Washington University claimed that it owned the intellectual property of its faculty members and sued Dr. Catalona (by then at Northwestern University) for ownership of the biological material. The ongoing battle has been extremely contentious. Dr. Catalona wrote his patients and pointed out that the consent forms they had signed directed donation to him and not the university. He urged them to release their specimens to Northwestern for his use, and many thousands did so. Nonetheless, Washington University has refused to acquiesce, and this matter will have to be decided by the courts. The decision will have important long-lasting implications on the use of biological material in medical research.

	Although many patients do not seem to object that their specimens are banked for future use in medical research, an increasing number do. The two primary concerns expressed are privacy issues and financial gain.

	Americans are becoming progressively more suspicious that the government and large institutions are invading their privacy and, in essence, spying on them. That’s the topic of Tracy Letts’ marvelous play 

, in which two strangers meet and rapidly have an affair in a tawdry Oklahoma motel. Soon thereafter, the couple feel themselves to be besieged by bugs and, try as they may, they can’t exterminate the imaginary creatures. Of course, the word “bug” is used as a double entendre, and the couple so intensely imagines they are being spied upon by the government that they resort to self-immolation as their only option for escape. This theater piece effectively uses dramatic license to make its point, but more people are becoming truly concerned about protecting their privacy. Wiretapping and other forms of surveillance were major obstacles to overcome in the passage of the Patriot Act. Identity theft is a real and critical concern to all citizens; Social Security numbers, fingerprints, and DNA are all important private possessions worthy of protection. Since all donated specimens contain such markers as DNA and tissue antigens, patients are increasingly reluctant to have them stored in readily identifiable formats.

	Another concern is financial. Who should receive profits derived from harvested patient samples—the investigators? Their universities? Private companies that make investments? How about the patients? John Moore, whose plight I described, initiated his lawsuit when he heard that Dr. Golde made a lucrative financial arrangement with a biotech company using Mr. Moore’s stored biological samples. Ted Slavin, a hemophiliac with a high titer of antibody to hepatitis B, made a fortune selling his blood as a source of valuable antibody. An effective entrepreneur, he developed a company that sold blood from other hepatitis-immune patients as well. There is no question but that specific biological specimens have substantial economic value, and donors feel that they are entitled to at least share in the windfall. Some unfortunate individuals are so obsessed about this issue that it seriously clouds their judgment. Tom Pollock, an incredibly valuable Downstate faculty member, was murdered by a demented individual who imagined that Kings County Hospital earned a fortune from a discovery made during his successful bronchial sleeve resection for massive hemoptysis but did not cut him in on the take.

	Handled correctly, there are adequate biological resources for patients, research scientists, institutions, and biotech companies to share. It is important to reconcile this conflict because it is the general public that benefits the most from diagnostic and therapeutic advances.

 activism is really just beginning. As a result, we should all expect more aggressive and restrictive demands for sharing profits, as well as the institution of specific and restrictive consent forms for venopuncture and biopsy, registration and institutional coding of patient samples, heightened confidentiality requirements that go beyond even the current outrageous HIPAA guidelines, and an explosion of legal bickering. The title of 

 article “Taking the Least of You,” is misnamed. 

 advocacy certainly isn’t taking the least from us.

	*Skloot R. Taking the least of you. The New York Times Sunday Magazine. April 16, 2006:38.

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

Tissue rights

					This case report highlights the advantages of laparoscopic examination of the abdominal cavity in patients presenting with an acute abdomen who do not have any contraindications to laparoscopy. Localization was greatly aided by computed tomography scanning, which showed extraluminal air near the terminal ileum. When extracting a foreign body, a key decision is whether to use an intracorporeal or extracorporeal approach. Other case reports provide some guidelines, indicating that intracorporeal extraction is possible if the foreign body is smooth in contour. Asymmetrical objects such as fish bones are extracted more effectively using an extracorporeal approach, and resection is generally required. The authors used an extracorporeal approach; the fish bone was removed by resection of the segment, and a primary anastomosis was performed through a 6-cm infraumbilical incision.

								University of Texas Southwestern Medical Center

	Foreign body ingestion is a common clinical problem in adults and children, and a substantial proportion of patients (14%) will require emergency surgical intervention.

 Intestinal perforations from ingested foreign bodies often mimic other causes of an acute abdomen and are typically identified during surgery. We report the case of an ingested fish bone that caused perforation of the small intestine and mimicked acute appendicitis. The condition was successfully diagnosed and treated using a laparoscopic approach. Laparoscopic management allows for localization and treatment of such perforations, preventing the need for a formal laparotomy.

 A 73-year-old Hispanic woman with a medical history of diabetes mellitus, hypertension, and previous cataract surgery presented to the emergency department reporting periumbilical abdominal pain. The pain began 11 hours earlier and migrated to her right lower quadrant 3 hours before her arrival at the hospital. The patient stated that she had never experienced this kind of pain before. She reported no nausea, vomiting, fever, or chills, and noted normal passage of flatus and stool. She also reported no use of intravenous drugs, tobacco, or alcohol. The patient had no allergies and took no prescription medications. She was afebrile and had normal vital signs.

	Physical examination revealed focal tenderness in the right lower quadrant with rebound and positive Rovsing's, psoas, and obturator signs on palpation. A rectal examination was normal, and a stool sample was guaiac-negative. Her laboratory tests on admission revealed an elevated white blood cell count of 11,000 mm

 with normal electrolytes, international normalized ratio, and prothrombin and partial thromboplastin times. A computed tomography (CT) scan of her abdomen showed inflammatory changes in the right lower quadrant, a small amount of contained extraluminal air without evidence of diverticulitis, and a thickened distal ileum (Figure 1). The appendix was not visualized.

	The patient was taken to the operating room for diagnostic laparoscopy. A 5-mm umbilical optical trocar was placed, along with two 5-mm working ports: one in the suprapubic position and one in the left lower quadrant. The appendix was identified and found to be normal. The cecum, ascending colon, stomach, duodenum, gallbladder, and left colon were also normal without evidence of inflammation or purulent fluid. Next, the small bowel was examined from the terminal ileum to the ligament of Trietz. Inflammation and matted adhesions were identified in the midjejunum. After this area was carefully examined, a foreign body was found penetrating the small bowel (Figure 2). The area of penetration was on the antimesenteric side and was easily brought up to the anterior abdominal wall (Figure 3). A small 6-cm midline incision was made below the umbilicus, and the area of perforation was externalized (Figure 4). Because of the large amount of inflammation and edema to the bowel wall, resection with a side-to-side stapled anastomosis was performed extracorporeally. The bowel was returned to the abdominal cavity, and the abdomen was closed.

	The resected segment of bowel was examined on the back table and was found to contain a 2-cm fish bone that had penetrated the bowel wall (Figure 5). The patient tolerated a regular diet on postoperative day 2 and was discharged to home on postoperative day 4 without any complications.

 Ingestion of foreign bodies is common and causes a significant amount of morbidity and mortality. It is estimated that 1,000 to 2,000 people in the United States die annually from complications related to ingesting foreign bodies.

 Fewer than 1% of ingested foreign bodies will perforate the bowel, and the greatest risk is with large, sharp, or pointed objects.

Although most sharp objects pass without complications once beyond the esophagus, they carry an increased risk of complications, including bowel obstruction, perforation, and erosions into adjacent organs. Patients may develop abdominal pain and tenderness, nausea, vomiting, fever, hematochezia, or melena.

 According to Pinero Madrona and colleagues, intestinal perforations are caused most commonly by bone fragments, followed by toothpicks and fish bones.

 Perforated hollow viscera generally are identified during surgery; however, symptoms of an acute abdomen are thought to be caused by acute appendicitis, diverticulitis, or perforated peptic ulcer.

 The most common location for perforation of the gastrointestinal tract is in the ileocecal or rectosigmoid regions. This is due to the change in direction in intestinal transit between a mobile portion of the mesocolon (ileum and sigmoid) and a more-or-less fixed portion of the retroperitoneum (cecum and rectum).

	Foreign body perforations can be diagnosed on small bowel series or CT scanning.

 Our patient's CT scans showed extraluminal air in the right lower quadrant of the terminal ileum. In addition, the appendix was not visualized, making the diagnosis of appendicitis unlikely.

	Diagnostic laparoscopy for acute abdominal pain and peritonitis resulting from foreign-body intestinal perforation has decreased the need for laparotomy.

 There are several reported cases of laparoscopic management of hollow viscus perforations after foreign-body ingestion.

Billy J. Kim, Resident, Department of Surgery; Josh E. Roller, Chief Resident, Department of Surgery; Mark Watson, Assistant Professor, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX

November 2006

Villous adenoma of the appendix presenting as an appendicovesical fistula

Acute gangrenous appendicitis associated with Clostridium sordellii?induced toxic shock syndrome

Surgeon's Bulletin Board

Appendiceal Mucocele: Benign or Malignant?

Tissue rights

Laparoscopic management of intestinal perforation by a fish bone, mimicking acute appendicitis

Using Radiological Imaging to Differentiate Appendicitis From Fibroids in Gravid Patients