								Cardinal Glennon Children?s Hospital

Genital avulsion injuries are frightening for the patient and formidable to the surgeon.

A rational approach to the situation helps produce a good outcome. Careful selection of which tissue to debride, along with proper selection of grafts and flaps for reconstruction, allows satisfactory results to be obtained and minimizes further morbidity. The authors report the case of a patient involved in a farming accident that resulted in penoscrotal degloving and discuss the principles that should be applied when repairing this type of injury.

	Avulsion of the skin from the external genitalia is a rare surgical emergency. These injuries usually result from machinery accidents involving loose clothing that is rapidly and forcefully torn from the victim.

Genital avulsion injuries are terrifying for patients and challenging for first responders and physicians because of the skin loss involved. Fortunately, there is usually a negligible amount of blood loss, minimal pain at the time of injury, and little damage to the erectile tissue or the spermatic cord.

 A 28-year-old man was working on a farm and suffered injury when he stepped over a power take-off (PTO) shaft from which the safety guard had been removed. He caught his coat in the PTO shaft and was pulled into the machinery, resulting in the degloving of his genital and perineal regions. At the scene of the accident, the patient was awake, alert, and oriented to person, place, and time. He was transported by helicopter to Saint Louis University Hospital. Physical examination revealed complete degloving of an area that measured 9 x 20 cm and encompassed the penile shaft, scrotum, and perineal region to the anal sphincter. The transporters had established hemostasis of the region with gauze, and the patient?s red blood cell count was within normal limits upon arrival to the hospital. His urethra appeared undamaged on retrograde urethrography, and an 18-French Foley catheter was placed for urinary diversion (Figure 1).

	The patient was taken to the operating room, where a diverting colostomy was performed by the trauma surgery team to give the perineal region time to heal. Further evaluation by flexible sigmoidoscopy found no rectal injury. The penile and scrotal regions were irrigated and debrided of devitalized tissue, and the testes were placed in thigh pockets (Figure 2).

	Postoperatively, the patient underwent daily whirlpool treatments to the genital area. He returned to the operating room 5 days later, where he received a 0.016-inch, unmeshed, split-thickness skin graft along the penile shaft. The graft was retrieved from his right thigh, attached to the corona and the base, and closed ventrally in a zigzag fashion (Figure 3). The testicles were sutured together in the midline, and a bipedicle flap was performed to cover his testicles and close the scrotal defect all the way up to the base of the penile shaft. The donor sites along the medial thigh were covered with a 0.012-inch, split-thickness, meshed skin graft.

	Five months after his initial repair, the patient developed a scar contracture along the base of his penis and was having tethering of his erections. The scar contracture was released with good results, and the colostomy was reversed at that time.

 The PTO shaft was introduced during the 1930s and revolutionized North American agriculture by facilitating the efficient transfer of mechanical power between farm tractors and implements.

 The PTO shaft is one of the most persistent hazards associated with farm machinery, despite new industry standards requiring guard shields for these devices. Many farmers tamper with or remove these guards, claiming that they are an inconvenience. This permits injuries to occur, especially to the tractor or machinery operators, who are the victims of 78% of PTO shaft entanglements.

 In 70% of these cases, the guard shield was absent or damaged. In 63% of cases, a bare shaft, spring-loaded pushpin, or through bolt was the type of driveline component at the point of contact, and in 50% of cases, stationary equipment such as augers, elevators, posthole diggers, and grain mixers were involved.

	When penile skin avulsion injuries occur, repair should be undertaken as early as possible, because delays result in prolonged disability and contribute to bacterial colonization.

Although several penile coverage techniques have been used in the past, such as burial of the denuded shaft within the scrotum or use of a local flap, these injuries are best treated with a split-thickness skin graft. This graft provides good elasticity, flexibility, and looseness, and allows patients to have full, functional erections.

	Before grafting the avulsed penis, it is necessary to catheterize the urethra. The penis is elongated to its full extent on the catheter, allowing for the appropriate graft length.

 Once the catheter is in place, all irregular edges of skin are trimmed away. Distal skin, even if it is in good condition, must be debrided to the coronal level, because prolonged distal edema commonly results secondary to disruption of the lymphatics that drain this tissue. Stretching residual skin to cover the penile shaft is not advised. Once the recipient bed has been prepared, a split-thickness skin graft should be harvested from a relatively hairless area, such as the thigh or abdominal wall. The graft must then be applied as a single sheet of medium thickness in an interdigitating, zigzag fashion to minimize longitudinal scar contracture, which can result from a straight closure along the full length of the penile shaft. The skin is placed directly on the fascia to prevent scarring beneath the graft. After the skin has healed, initially it is tight around the penile shaft and constricts erections in length and circumference, but it attains almost normal elasticity once the scar tissue beneath the skin graft softens. If further grafts or loosening are needed, additional skin can be added later. Some patients have been documented as experiencing pain with erections in the early postoperative period but, in our experience, these painful episodes rarely continue.

	Scrotal skin avulsion can be more difficult to repair. The integument of the scrotum has many glands, scattered hairs, and ridges. It is also extremely loose, and the deeper layers contain the dartos, which is a thin layer of smooth muscle fibers. Beneath the dartos lie the intercolumnar fascia and the cremasteric fascia and muscle, which are important for thermoregulation of the testicles to maintain adequate spermatogenesis.

 It is therefore important that the testicles be replaced as close to their original location as possible. Criteria for reconstructing an encasement for the testicles include (1) providing adequate cover to the spermatic cords and testicles without undue tension or constriction; (2) proper protection of the scrotal contents against trauma; and (3) ensuring the patient?s comfort in any position or activity. Accordingly, when a sufficient quantity of scrotal skin remains after the trauma, it should be used to reconstruct the scrotum without delay. If very little scrotal skin is available, the surgeon may remedy this by using thigh pockets, thigh flaps, or a meshed split-thickness skin graft.

	Immediate repair is often accomplished by creating thigh pockets; these can be temporary or permanent. Thigh pockets are created by embedding the testicles and spermatic cords in the most adjacent regions of the upper thighs.

The optimum position for these pockets is the medial upper thigh region, as far posterior as the length of the spermatic cords permit. It has been shown that if the testicles are placed in an anterior position, the spermatic cords may be placed under undue tension when the thighs are spread apart, depending on the length of the vasculature. Furthermore, patients report feeling more comfortable when the testicles are embedded at staggered levels in the medial thighs, because the testicles will not oppose each other when the thighs are brought together.

	The scrotum is usually reconstructed with either flaps or a meshed split-thickness skin graft. Proponents of flap reconstruction cite a functional outcome, a sensate and hair-bearing scrotum, and more reliable coverage without the problems of graft take. Rotational thigh flaps are most appropriate when reconstruction was delayed for men with testes in thigh pockets. These flaps require redundant skin and yield the best results when there is only a thin layer of subcutaneous fat.

 The gentle envelopment of the testicles and spermatic cords in relatively thin thigh flaps suspended below and posterior to the phallus still promises good functional and cosmetic cover and position. The base of these thigh flaps should be set superiorly and slanted well medially. The shape should be paddle-like, with the spermatic cords running under the handle and the testicles resting like balls in the center of the paddles. When brought together, the pedicles must be long enough to reach each other below and behind the phallus without restrictive webbing. The size of the flaps must be generous enough to avoid undue pressure on the testicles.

	Surgeons who favor meshed graft repair state that this method gives a final appearance of rugation, is readily available, and allows free drainage of fluid between meshes.

The repair usually begins by burying the testicles in the thigh pockets, which allows pseudocapsules to develop around them during the first stage of repair. The fibrous areas that overlie the testicles are then used as a bed for the split-thickness grafts during the second and final stages of repair. An alternative staged procedure begins with burying the testicles in thigh pockets during the first stage, expansion of perineal skin to provide a two-compartment scrotum during the second stage, and ultimately performing bilateral orchidopexy.

	Which procedure to use must be decided on a case-by-case basis but should include split-thickness skin grafting in situations that do not allow enough tissue for immediate reapproximation.

 Genital avulsion injuries are rare surgical emergencies, which pose difficulties for the surgeon and can be devastating for the patient. Surgeons who are confronted with these injuries must take a rational approach to provide the patient with safe and timely care and produce a favorable outcome. As with most contaminated injuries, thorough debridement and infection control are essential for maintaining healthy tissue for reconstruction. The actual reconstruction procedure should be determined on an individual basis, but the combined use of thigh flaps and split-thickness skin grafts will provide a cosmetic and functional repair, in most cases.

 1. Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: external genitalia. 

	2. Murphy DJ. Power take-off (PTO) safety. Centers for Disease Control and Prevention: National Agricultural Safety Database. Available at: 

www.cdc.gov/nasd/docs/d000701-d000800/d000745/d000745.html

	3. McAninch JW. Management of genital skin loss. 

	4. Millard DR Jr. Scrotal construction and reconstruction. 

	5. Culp DA, Huffman WC. Temperature determination in the thigh with regard to burying the traumatically exposed testis.

Articles

Surgical Rounds

James F. Tycast, Resident in Urology, Saint Louis University Hospital, St. Louis, MO; Anand V. Palagiri, Pediatric Urology Fellow, Cardinal Glennon Children's Hospital, St. Louis, MO; James M. Cummings, Professor of Surgery, Division of Urology, Saint Louis 	University Hospital, St. Louis, MO

Farm Accident Causes Penoscrotal Degloving

	Each month, Dr. Maria Flynn issues a Radiology Challenge, presenting images from one of a variety of imaging modalities and a case report. Can you diagnose the condition? Follow the link to find out whether your answer was correct, what was really wrong with the patient, and how the patient was treated. Then, come back next month to test your radiographic reading skills on a new case!

Dr. Maria Flynn is Chief of Genitourinary Imaging and Radiology Intern Program Director at the Naval Medical Center Portsmouth, as well as a Lieutenant Commander in the US Navy Medical Corps. She received her medical degree from Tulane Medical School in 1994 and completed her radiology residency at the National Capital Consortium in 2003. She is certified by the American Board of Radiology and has been appointed Adjunct Assistant Professor of Radiology and Radiological Sciences at the F. Edward Hébert School of Medicine.

	A 60-year-old man presented to his primary care physician due to a mass in his abdomen. He stated that the mass had been there for years, but it started bothering him after his recent weight loss. Laboratory analysis was unremarkable. A contrast-enhanced computed tomography scan of the abdomen and pelvis was performed (Figure).

Can you diagnose this lesion?

								The Bariatric Institute and Section of Minimally Invasive Surgery

	Ectopic livers are extremely rare and usually found incidentally during autopsy or laparoscopic surgery.

 They may be located in the ligaments or mesentery and on the surface of the gallbladder, spleen, or adrenal glands.

 Hepatic tissue in the gallbladder is typically asymptomatic and is found either incidentally or because of concordant complications. In 1940, Eiserth noted several cases of ectopic liver among 5,500 autopsy patients in Hungary.

 In 1982, Asada and colleagues reported on 1,060 cases in which laparoscopy revealed a 0.47% incidence of ectopic liver and a 0.09% incidence of accessory lobe.

We report the case of ectopic liver tissue discovered incidentally in the gallbladder of a patient who underwent elective laparoscopic cholecystectomy, and we provide a review of the literature.

 A 32-year-old woman presented to our institution after experiencing several months of right upper quadrant pain, accompanied by nausea and flank pain. Her symptoms worsened after meals, and episodes were increasing in frequency. The patient's physical examination was unremarkable, except for mild tenderness elicited during deep palpation of the right upper quadrant. There was no evidence of hepatosplenomegaly or jaundice, and tests for liver function and amylase levels were normal. Ultrasonography revealed multiple gallstones, without common bile duct dilatation.

	The patient was taken to the operating room, and laparoscopic cholecystectomy with a cholangiogram was performed with no complications. The only significant finding was a well-defined, 1 x 1-cm mass attached to the posterior wall of the gallbladder serosa and isolated from the liver (Figure 1). The patient tolerated the procedurewell, her postoperative recovery was unremarkable, and she was discharged to home on postoperative day 2.

	The excised gallbladder measured 8 x 2 x 2 cm, contained numerous green-to-yellow stones, and had an edematous serosal surface. A small, well-defined, gray nodule, measuring approximately 0.8 cm at its greatest dimension, was attached to the serosal surface midway between the fundus and the neck.Microscopic examination showed the nodule was composed of portal triads and lobules, which are characteristic of hepatic tissue (Figure 2). High-power observation revealed detailed components of the portal tract, including the vein, artery, and bile ducts (Figure 3).

 Embryological development of the liver and bile ducts begins between days 21 and 30 of gestation, with the appearance of an endodermal bud and the formation of the duodenum in the ventral angle between the foregut and the yolk sac.

This hepatic bud divides into a larger cranial portion, known as pars hepatica, and a smaller caudal portion, known as pars cystica. The pars hepatica extends into the mesenchymal tissue of the septum transversum and divides into the right and left lobes of the liver, which eventually give rise to the liver cells and intralobular bile ducts. The septal mesodermal cells form the hepatic capsule and the connective tissue of the liver.

	The pars cystica gives origin to the gallbladder and cystic duct around week 5 of gestation. Recanalization commences dur?ing week 6, starting with the common bile duct. The gallbladder gains its lumen during week 12. The close relationship between the development of the cystic portions and the trabecular parenchymal cell cords explains why ectopic livers may be found in the gallbladder.

	The term choristoma, from the Greek word meaning "to separate," describes displacement and was introduced by Albrecht in 1904. In pathological terms, choristo?mas are microscopically normal cells or tissues in abnormal locations.

	Liver tissue that forms outside the liver varies considerably and is usually found near or communicating with the liver or extrahepatic biliary system. Abnormally positioned liver tissue occasionally causes clinical symptoms.

 Several possible mech?anisms may explain ectopic livers at various sites. Two probable explanations are the development of an accessory liver lobe with atrophy or regression of the original connection to the main liver and the displacement or migration of a portion of the pars hepatica to the rudiment of various organs including hepatic ligaments, adrenal glands, pancreas, and umbilical cord.

 The most common location of ectopic liver is on the gallbladder.

	Liver choristomas or ectopic nodules of liver tissue that are attached to the gallbladder by their own mesentery and are completely detached from the liver are uncommon.

Their typical location is in the gallbladder wall but, in some cases, they are found within the submucosa of the gallbladder.

	Anomalous liver tissue in the wall of the gallbladder has been described by various categories and names. Simple classifications based on previous definitions are (1) accessory liver lobe, when there is attachment to the main liver organ; (2) ectopic or heterotopic liver nodule, when the choristoma is completely detached from the liver and is found in an abnormal location, usually attached to the gallbladder (choristoma); and (3) aberrant microscopic tissue, in cases of ductal origin, when the tissue is present within the lumen of a true Luschka duct in the wall of the gallbladder.

	The histologic appearance of ectopic liver tissue is similar to that of the liver, with lobules, central veins, and normal portal areas.

 Therefore, these anomalies may be underdiagnosed and, because of incomplete development, may quickly undergo atrophy or fibrosis, resolving prior to diagnosis.

	Liver choristomas are usually incidental asymptomatic findings, as in our case

; however, a pedunculated and aberrant liver may become strangulated and cause acute abdominal symptoms.

 and hepatocarcinoma have also been report?ed.

 These conditions occur because small ectopic liver tissue lacks a complete, functional architecture and may be metabolically handicapped, thereby facilitating the carcinogenetic process.

In our case, the hepatic nodule was situated in the serosa without any connection to the liver and was histologically normal tissue.

 Liver choristomas are exceedingly rare. While they are generally asymptomatic and an incidental finding during laparoscopy for unrelated issues, they should be considered in the differential diagnosis of any patient presenting with abdominal symptoms.

 1. Leone N, De Paolis P, Carrera M, et al. Ectopic liver and hepatocarcinogenesis: report of three cases with four years' follow-up. 

	2. Feldman M, Friedman LS, Sleisenger MH. Inherited metabolic disorders involving the liver. In: 

. 7th ed. St. Louis, Mo: Saunders; 2002:1240-1259.

	3. Eiserth P. Beitrage zur Kenntnis der Neebenlebern. 

	4. Asada J, Onji S, Yamashita Y. Ectopic liver observed by peritoneoscopy: report of a case. Gastroenterol Endosc. 1982;24:309-312.

	5. Tejada E, Danielson C. Ectopic or heterotopic liver (choristoma) associated with the gallbladder. 

	6. Angquist KA, Boquist L, Domellof L. Ectopic liver lobule with portal cirrhosis. 

	7. Costero C, Quilantan R, Melendez J. Higado ectopico de la vesicular. 

Chorus: Collaborative Hypertext of Radiology. 

	9. Acar T, Tacyildiz R, Karakayali S. Ectopic liver tissue attached to the gallbladder. 

	10. Clearfield HR. Embryology, malformation and malposition of the liver. In: Berk JE, Haubrich WS, Kaiser MH, et al, eds. 

. 4th ed. Philadelphia, Pa: Saunders; 1985:2659-2665.

	11. Thorsness ET. The relationship of true Luschke ducts, adenoma, and aberrant liver tissue in the wall of the human gallbladder. 

	12. Bassis ML, Izenstark JL. Ectopic liver; its occurrence in the gallbladder. 

	13. Cullen T. Accessory lobes of the liver. 

	14. Hamdani S, Baron R. Ectopic liver simulating a mass in the gallbladder wall: imaging findings. 

	15. Arakawa M, Kimura Y, Sakata K, et al. Propensity of ectopic liver to hepatocarcinogenesis: case reports and a review of the literature. 

Flavia C. Soto, Research Fellow; Samuel Szomstein,  Co-Director; Raul J. Rosenthal, Director, The Bariatric Institute and Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL

Ectopic liver attached to the gallbladder: An unusual incidentaloma

	These questions are similar to those asked on the American Board of Surgery Recertification Examination. You can use them to prepare for the examination, fulfill learning requirements for various maintenance of competence programs, or simply improve your surgical knowledge.

? Is caused by thrombosis of mucosal vessels

? Occurs after 3,000 cGy of abdominal radiation

? Is likely in patients who have undergone laparotomy

 Best treated with Roux-en-Y cystojejunostomy

? Invariably associated with an abdominal mass

? Associated with simultaneous duodenal ulcers

4. Adenoid cystic carcinoma of the salivary gland 

? Is most common in the submaxillary gland

5. The most common complication of open Roux-Y gastric bypass is 

? Can be routinely diagnosed on plain radiographs of the hand

 Cause avascular necrosis in 10% of patients

? Require thumb inclusion in a long-arm cast

? Present with pain over the ulnar side of the wrist

? Is associated with vitamin C deficiency

? Is caused by inadequate ability to clear protons in renal failure

? Can be reversed by bicarbonate administration ?

 Suppresses conversion of glucose to pyruvate molecules

8. The most common cause of intrahepatic presinusoidal portal hypertension is 

? Can reliably be eliminated by aggressive resuscitation

? Is due to diminished circulating blood volume

? Is generally of the high output variety

 Are more common than femoral hernias in women

 Occur more on the right side than on the left

 Cause strangulation more frequently than indirect inguinal hernias

 Can reliably be distinguished from indirect hernias on physical examination

 Occur lateral to the superficial epigastric vessels

 Can generally be treated with a one-stage operation

12. Risk factors for development of carcinoma of the head of the pancreas include 

 Upregulation of the APC (adenomatous polyposis coli) gene

American Board of Surgery Recertification Examination

Nowadays an empty nest is hard to come by

 When you were your adult child's age, you probably lived on your own; you may have even been engaged or married. Many of today's parents are still cooking meals and doing laundry for their 20-something-year-old child, who graduated from college years ago yet still lives at home. An article in 

 refers to this 21- to 35-year-old college graduate group as ?Generation Broke.' They conducted a recent survey and determined that this set owes an average of $30,000 in student loans. The 3 million graduates from the Class of 2006 in particular carry more than a cumulative $40 billion in student loans?and interest rates just jumped two percentage points. While it may be the graduates who are in debt, many feel that parents should take some of the blame. As much as 44% of the graduates surveyed gave their parents or guardians a "D" or an "F" in making financial preparations for their college. Advisors say planning ahead for college is key for parents, and if they ever want to turn their adult son or daughter's bedroom into that longed-for home office, they should consider helping their children dig out of debt.

Firms rebuild struggling?IPOs for profit 

 Surgeon investors have read about house flipping and even Web site flipping, but you may not have heard about a recent trend in the financial world known as Initial Public Offering (IPO) flipping. According to 

, this involves a buyout firm taking on a derelict company, turning it around over several years, and then selling it to public investors for a big profit. Private ownership allows the firms to slash costs and shed assets away from the public eye, allowing for the big turnaround. When time is taken to slowly and properly turn a company around, this method works very well. Since 2001, IPO flips have earned annualized returns of more than 20%. But when companies perform a buyout and flip it as soon as possible for a quick buck (ie, a strip and flip), the outcome is usually negative. For example, Burger King Holdings Inc. went through a public strip and flip on May 17, 2006 and has dropped 12.6% since. While an IPO flip seems like an attractive investment, you'll need to be assured that it is done properly and not just as a quick turnaround.

 That adjustable-rate mortgage (ARM) provided you with extra wiggle room when you first made your big purchase, but now that the initial term is running out and the interest on your ARM is about to rise, you may be contemplating your next move: Do you keep the loan or switch to a fixed-rate mortgage? According to a recent article in 

, that answer depends on how long you expect to own that real estate. If it is a house that you see yourself leaving in a few years, it may be worth paying the higher rate during those years to avoid refinancing costs and a prepayment penalty for getting out of your ARM. If it is an office from where you run your practice and you hope to own and maintain it for a while, 

 suggests comparing your current rate and possible future increases to a fixed-rate mortgage or hybrid ARM with a period of at least 7 to 10 years. Current rates on loans, while not as low as a few years ago, are still reasonable and at historic lows. If rates go up, you are locked in at a lower number; if rates go down, you always have the option to refinance. ?

 What if surgeons earned tips? Would your services warrant a 20% average? While you're not likely to put a tip jar on the counter next to the tongue depressors any time soon, the working stiffs who rely on tips for their income are finding that the average gratuity has risen above the regular 15% over the past few years. According to the 

, it's now generally acknowledged that a 20% gratuity should be given for great service at a restaurant. A recent Zagat survey found that the average American diner leaves an aftertax tip of 18.8%, which is up from 16.5% in 2001. It's still acceptable to give a mere

	10% tip for shoddy service, but make sure it is definitely the server's fault, because slow service could be the result of a kitchen error. Also remember that servers often split tips with busboys and hosts. Outside of a dining establishment, 20% is a good rule of thumb for bigger bills. For example, while a dollar per drink is a decent gratuity for a bartender, if you're ordering multiple expensive cocktails, 20% is more appropriate.

 While many surgeon investors have achieved financial success with exchange-traded funds (ETFs), some experts have speculated that the flood of new ETFs in recent years?a myriad of specialized ETFs in a multitude of market sectors?is confusing the public. According to the 

, around 280 ETFs are listed on domestic exchanges, with more than 180 on the American stock exchange and over 100 on the New York Stock Exchange. Investors were attracted to ETFs when they debuted a decade ago because of their low fees and low turnover and the way they track the benchmarks of the top markets, such as the Dow and the S&P 500. Total assets in US-listed ETFs have surged from $80 billion in 2001 to $324.7 billion in May 2006. In 2006, over 70 new ETFs were listed, but many of these new funds are based on complex benchmarks, which try to identify outperforming stocks and sectors that have been historically difficult for individual investors to access. Because of this, some experts argue that these ETFs are confusing to investors and have higher turnovers and fees, which is the opposite of why ETFs became popular in the first place. Other experts say that ETFs are experiencing overload, but the industry is simply in a rapid development phase, much like mutual funds in the 1990s.

 The average American's savings rate has declined to below 0%, compared to a savings rate of 10% in the early 1980s. This downward trend could spell trouble for our economy in the years ahead if it is not reversed.

? What has caused this shift? Much can be attributed to easier credit policies by financial institutions. Lenders pitch so many credit cards, retail store cards, and mortgage loan offers that everyone gains access to additional sources of funding for consumer purchases. Perhaps most insidious are the new mortgage lending policies. Mortgage lenders now offer no closing costs,?interest-only, equity-line-of-credit loans for 80% to 100% of the value of your home (less your first mortgage). Today, many people view their home equity as another source of funding for every kind of consumer purchase, from cars to appliances to vacations. Consequently, people are saving far too little for retirement and other long-term objectives.

	So how are you doing? If your answer is "I don't know," you need my ?Financial Health Checkup.' The first step is to determine your current net worth by completing a financial net worth statement. On the top half of a sheet of paper, list all your assets at their current market value and add them. On the bottom half of the page, list everything you owe and total this to determine your liability. Now, subtract your total assets from your total liabilities; the result is your financial net worth. For a financial net worth statement form, go to the Resource Center at 

	The next step is to measure your current net worth against a benchmark formula to see how ?healthy' you are. Here is a simple formula to assist you: divide the number of years you have been working by 2.5 and multiply this figure by your current annual income. This result indicates how large your net worth should be to consider yourself on track to accumulating enough money for your retirement, assuming you will work approximately 40 years.

? For many of you, this will be an eye-opening exercise that shows just how far behind you have fallen. Nevertheless, don't throw in the towel. Do something positive: increase your IRA contributions; reduce expenses and start an automatic investment program; get a second job that makes use of your medical knowledge. One of your best options is to seek the advice of a qualified professional advisor, preferably a Certified Financial Planner? practitioner. To find one near you, visit 

. Be sure to ask how the planner is compensated. A fee-only planner never receives commissions from clients. ? ? ?

Kick your portfolio in the assets by diversifying 

 Surgeon investors are always looking for portfolio diversity but often do not know which direction to look. A current 

?article delves into some assets that have been touted as "hot buys," but may prove to be potential traps. The following are investments to approach with caution:

	Timber looks like an attractive commodity because of stable logging income and the value of growing trees. Investors should remember, however, that tree growth will never speed up so you can cash out, and timber investments require heavy management and capital gains.

	Rare coins, like timber, move in opposition with bonds and have little in common with stocks. Coins must be kept safe from theft or damage at all times, incurring extra costs, like deposit box fees. Coins also require costly expert appraisals and are subject to a capital-gains tax rate.

	Gold is a classic commodity for alternative investors, and it seems like an appealing option. But gold can maintain a steady value for years, without fluctuating. That means you can get stuck holding onto gold and realizing no gain for a duration that exceeds your long-term goals.

	International real estate could be the most lucrative alternative to stocks and bonds, but the travel expenses, foreign connections, and resources it requires often negate its overall value. 

Don't get snared in the alternative minimum tax web 

 For generous surgeons over age 701/2, the Pension Protection Act may not be protecting your charity donations from taxes as well as you thought. The Act prevents charity donations up to $100,000 made from an IRA from being taxed, but the alternative minimum tax (AMT) can throw a wrench into that sanctuary. According to a recent Gregory/FCA press release, AMT victims are required to pay taxes on their IRA withdrawals for charity. The AMT was created to ensure that the wealthy could not avoid taxation, but because of its complicated method of calculation, an increasing number of people are subject to the tax. AMT is computed similarly to regular income taxes, except that certain deductions you could claim on your standard tax form are not subject to AMT exemption. AMT does not allow for state and local income taxes or personal deductions (ie, medical bills, dependents, etc), so the most susceptible are those with large capital gains, an income between $100,000 and $500,000, or large families. Any combination of these factors increases your chances of paying taxes on your IRA charity donation because of AMT, but there is no way of knowing for certain until you or your financial advisor runs the numbers.

529 savings plans for middle-aged students

 While many adults consider opening a 529 college savings plan account for their children, adults who are contemplating a return to school may wish to open a 529 plan for themselves. Perhaps you want to go back and get a teaching degree after you retire from your practice or maybe your spouse wants to further his or her education. According to Bankrate.com, placing money into a 529 plan before you or your spouse even settle on enrolling in college courses may spur you to do so down the road. But if you ultimately decide against it, you can always maintain the account for your children or grandchildren. You can also transfer your 529 money to another family member simply by changing the beneficiary on your account or making a partial rollover into their 529 account. If the account is never used for educational purposes and is withdrawn on a nonqualified basis, the account growth will be subject to regular income tax plus a 10% penalty tax.

Listen in on sound financial advice, not just sound bites

 Don't let the beeps and buzzers of minute-by-minute financial news updates on your BlackBerry interfere with your practice. Surgeons are busy enough without running to check their e-mail for Internet warnings about dumping stocks or must-buy investments. A recent 

 article says that complying with all those red-flagged alerts could hurt more than help. Timely information is important to investors, but surgeons know that not all information?especially delivered as hype?is relevant or truthful. Surgeon investors should be aware of news and trends, but altering paths on a whim can hurt long-term returns. Keep in mind that electronic alerts are sent en masse, so the information may be irrelevant to your personal situation. The best advice is to do your homework before making any investment decision and do not allow emotional or impulsive trading to be a factor in your financial future.

Surgeon's Bulletin Board

								Assistant Professor of  Radiology

Isolated melanoma metastases to the spleen are encountered infrequently, although they have been detected with concomitant disseminated malignant melanoma or at autopsy.

 Scanning with F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET)  has been shown to be quite sensitive in detecting melanoma metastases

 and providing guidance for appropriate surgical intervention.

 Because there is a paucity of effective systemic therapies for disseminated malignant melanoma, metastectomy or even oligo-metastectomy remain viable treatment options. The authors report a case of isolated splenic metastasis discovered by FDG-PET scanning that was amenable to complete extirpation by laparoscopic-assisted splenectomy.

	The spleen is an uncommon but recognized site for hematogenous metastases in patients with advanced melanoma.

 Advances in imaging techniques such as computed tomography (CT) and F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) can help identify isolated lesions and result in the provision of more effective local and regional therapies.

 FDG-PET scanning revealed isolated metastases in our patient’s spleen more than 5 months after he was classified as having treated stage IIIB melanoma. We present this patient’s case and review the literature regarding isolated splenic melanoma and the associated use of FDG-PET scanning.  

 A 55-year-old white man presented to our clinic 1 month after having an incisional biopsy to remove a primary melanoma from his mid-back. The melanoma was 6.4 mm in depth and without ulceration.

	On physical examination, obvious swelling was noted in the patient’s left posterior neck, and he reported intermittent left subcostal pain. Other than palpable nodes in the left neck, the examination was unremarkable. A fine needle aspiration of the neck mass revealed metastatic melanoma. Blood chemistry revealed a normal lactate dehydrogenase.

	The patient underwent magnetic resonance imaging of his head; CT scanning of his chest, abdomen, and pelvis; and FDG-PET scanning for preoperative staging. The FDG-PET scan showed disease in the left neck and left colon.

	During a subsequent colonoscopy, a large pedunculated adenomatous polyp in the left colon was removed, and no other abnormalities were observed. Following the colonoscopy, the patient underwent a wide local excision with 2-cm margins at the primary site and a modified radical left neck dissection. Because the patient had obvious macroscopic nodal involvement, he received adjuvant radiotherapy. At this point, the patient was identified as treated stage IIIB melanoma (T4a N2b M0). He declined interferon-based chemotherapy but was considered later as a potential candidate for a therapeutic trial. More than 5 months after his initial staging, the patient was restaged using CT axial imaging and FDG-PET scanning. This FDG-PET scan identified significant uptake of 2-deoxy-2[F-18] fluoro-D-glucose in the spleen, with a standard uptake value (SUV) of 6.4 above baseline (Figure 1), which represented a change from his previous FDG-PET scan (Figure 2). The rest of his work up showed no other evidence of metastatic disease.

	It was thought that the patient would benefit from a splenectomy, and a laparoscopic approach was used. The spleen had obvious peripheral abnormalities on initial inspection but was removed without difficulty (Figure 3). No other intra-abdominal disease was observed. The patient tolerated the procedure well and was discharged home on postoperative day 3. The patient was alive and had no evidence of disease 9 months after his splenectomy.

 A statistical analysis of approximately 18,000 patients with localized melanoma determined that the two most powerful predictors of recurrence and death are tumor thickness and ulceration. Patient age, anatomic site, and sex are additional statistically significant prognostic factors.

  Because our patient is a male with a deep melanoma on the trunk, he is clearly at high risk of distant failure.

	In 2006, a large unselected autopsy series involving 8,563 patients showed splenic metastases were relatively uncommon, occurring in approximately 3% of the 1,898 patients discovered to have solid tumors.

 Patients with splenic metastases were generally younger and had an average of six separate metastatic sites. After lung cancer, malignant melanoma was the second most common solid tumor to metastasize to the spleen, but this still occurred relatively infrequently, affecting only nine patients (15.8% of all splenic metastases in this series).

 It can be concluded that the spleen is a rare but known site for hematogenous metastases in patients with advanced-stage melanoma. The prognosis for these patients is poor; patients with non-lung visceral metastases have a 1-year survival rate of 40%, with a median survival of 6 to 8 months.

	Theoretically, improved imaging techniques (ie, CT and FDG-PET scanning) should help identify new, isolated lesions so local and/or regional therapies can be employed more frequently and effectively. In particular, it appears that FDG-PET scanning is quite sensitive (92%), specific (88%), and accurate (91%) on a lesion-by-lesion basis for evaluating patients with stage III and stage IV melanoma.

 At this time, FDG-PET scanning does not accurately identify microscopic disease and cannot assist in determining treatment for patients with stage I and stage II melanoma.

	FDG-PET scanning has been particularly useful in determining treatment for asymptomatic patients. The finding of metastatic disease, especially multiple non-lung visceral metastases, might lead one to forgo a potentially morbid therapy such as lymphadenectomy. Tyler and colleagues reported that FDG-PET scanning affected patient care in 15% of cases where operations were considered for stage III patients,

 whereas Mijnhout and associates reported a change in therapy for up to 40% of patients in their series who were suspected to have recurrent melanoma.

	Despite the poor prognosis for patients with isolated splenic metastases, surgery may provide long-term benefits in terms of overall and disease-free survival. A study from the Sydney Melanoma Unit included 113 patients treated for splenic melanoma between 1990 and 2001.

 Fifteen (13%) of these patients underwent splenectomy with acceptable rates of morbidity and no mortalities. Median survival of patients in the group that underwent surgery with intention to cure was 23 months, compared with 4 months for patients in the conservatively treated group.

	Moreover, resection of the first metastatic lesion may delay the metastatic cascade that leads to involvement of new organ sites. It is postulated that macroscopic metastases elaborate immunosuppressive factors that blunt the host response and allow for dissemination of additional metastatic disease.

 Metastectomy removes the inimical tumor microenvironment and restores immune function.

 Complete surgical resection of all clinically evident disease with tumor-negative margins can yield a median survival of 20 months and increase the overall survival rate by 20%. These numbers compare favorably with conventional nonoperative management, where the median survival is 6 to 8 months with an overall survival rate of 6%.

 In addition to potential survival benefits, surgical resection of distant metastases confined to a single site may yield better quality of life compared with the systemic toxicities belonging to chemotherapeutic and  biochemical therapies.

 Besides the possible oncologic benefits, splenectomy for bulky metastatic disease is recommended for palliation of visceral pain and to prevent spontaneous splenic rupture.

 With the use of appropriate imaging modalities for staging, such as CT and FDG-PET scanning, and laparoscopic techniques, patients with isolated splenic melanoma likely will benefit from laparoscopic-assisted splenectomy. As operative techniques become more refined and imaging techniques improve, aggressive treatment of solitary splenic metastases and metastectomies likely will increase.

 1. Schon CA, Gorg C, Ramaswamy A, et al. Splenic metastases in a large unselected autopsy series. 

	2. Harris MT, Berlangieri SU, Cebon JS, et al. Impact of 2-deoxy-2[F-18]fluoro-D-glucose positron emission tomography on the management of patients with advanced melanoma. 

	3. Tyler DS, Onaitis M, Kherani A, et al. Positron emission tomography scanning in malignant melanoma. 

	4. Balch CM, Soong SJ, Gershenwald JE, et al. Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. 

	5. Mijnhout GS, Comans EF, Raijmakers P, et al. Reproducibility and clinical value of 18F-fluorodeoxyglucose positron emission tomography in recurrent melanoma. 

	6. Hsueh EC, Essner R, Foshag LJ, et al. Prolonged survival after complete resection of disseminated melanoma and active immunotherapy with a therapeutic cancer vaccine. 

	7. Buzbee TM, Legha SS. Spontaneous rupture of spleen in a patient with splenic metastasis of melanoma. A case report. 

	Choose the best answer for each of the following questions.

1. Cutaneous melanoma with a depth greater than 4 mm needs a margin size greater than or equal to:

 2. What is the proper melanoma staging for skin lesions that are 6.4 mm deep and associated with palpable lymph nodes? 

 3. Cutaneous melanomas with organ metastases appear to benefit from: 

Katherine Y. Kane, Resident in Surgery, Department of Surgery; Jason B. Fleming, Associate Professor of Surgery, Department of Surgery; Irfan M. Farukhi, Assistant Professor of Radiology, Department of Radiology; Carlton C. Barnett, Jr, Assistant Professor  of Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, TX

Can Fdg-pet Scanning Detect Melanoma Metastases to the Spleen?

								Saint Louis University  School of Medicine

	Primary gastrointestinal (GI) sarcomas are uncommon tumors that account for 1% to 2% of all GI cancers.

 Of these sarcomas, about 33% occur in the small bowel.

 Because these malignancies are rare, few data have been collected regarding their clinical presentation, management, histologic variability, and prognosis. We report the case of a 42-year-old man who presented with primary small bowel sarcoma that metastasized to the right lower lobe of his lung and left temporal lobe of his brain. We discuss the implications of this case regarding the diagnosis, treatment, and classification of small bowel sarcomas.

	A 42-year-old African-American man with a 2-week history of intermittent abdominal pain, nausea, and vomiting was admitted to an outside hospital. He reported a 4-year history of epigastric pain that improved with lansoprazole and became worse upon alcohol consumption. Laboratory tests revealed a hemoglobin level of 8.3 g/dL (normal, 13.6—17.2g /dL). After a computed tomography (CT) scan of his abdomen showed a small bowel obstruction due to intussusception, he was transferred to our hospital.

	On admission, physical examination revealed a mildly distended abdomen with no palpable organomegaly or intra-abdominal masses. There were also no palpable masses on rectal examination. A stool specimen was guaiac-positive, however, and colonoscopy with biopsy and esophagogastroduodenoscopy were performed. The colonoscopy revealed diffuse mucosal edema, sigmoid colon hemorrhages, and a rectal polyp. A chest radiograph revealed a 5-cm lesion in the right lung. CT scans of the patient’s abdomen and thoracic cavity revealed intussusception and a 5-cm solid lesion in the right lower lobe of the lung (Figure 1).

Marsha S. Kadze, Medical Student III; Scott R. Lauer, Medical Student IV; Beth Levy, Professor of Pathology, Department of Pathology; Eddy C. Hsueh, Associate Professor of Surgery, Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO

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