Our predicament in the operating room (OR) reminds me of an analogy I heard many years ago about a chicken and a pig who wish to reward their farmer for taking such good care of them. "Let's make him breakfast," suggests the chicken, "perhaps some bacon and eggs."  "Bacon and eggs!" exclaimed the pig. "You are offering a donation, but from me you want a commitment!"

Each time a surgeon takes responsibility for a patient in the OR, he makes just such a commitment. Infinitely more than any malpractice burden, it is the level of commitment wherein he lives and dies with the success and failure of each patient. While we work as a "team" in the OR, surgeons stand alone when facing a heartbroken family to answer not only for our own errors but also for the errors of others.

It is truly an insult to equate this commitment to the donation offered by the ancillary services in the OR. They do not, nor can they ever, understand the responsibility the surgeon takes upon himself with each case. When has any circulating nurse explained to a patient's family that he or she caused a procedure to be delayed because of opening the wrong instruments or because he or she was on break? How many OR administrators visit the wards to follow up on patients postoperatively? How many scrub nurses lay awake at night worrying about a patient's outcome?

Until the day comes when all members of the OR team carry the same burden as the surgeon, I reserve the right to express myself. If I demand bacon for my patients, it is because eggs just won't do.

Our profession is sinking, and it seems that little that can be done to reverse the descent. Dr. Jaffe discusses contrived and fictitious reports, often unverified and undiscoverable, that are generated by unidentified sources and used by hospital administrators to enforce "corporate compliance." The shared goal of physicians and hospitals is purportedly excellent patient care, and we are supposedly symbiotic partners. Unfortunately, [hospital administrations are] strengthened by financial advantage, legal apathy and support, organizations such as JCAHO, state and national medical societies, and fellow physicians whose only allegiance is to their own advancement. Those individual physicians who sincerely attempt to fulfill their sworn oath are easy prey.

Individuals who feel they are being victimized unfairly should consider contacting the Semmelweis Society (

). The only alternative may be to move one's practice to another facility or community.

Your editorial was very insightful. The subject of "sham peer review" is well reviewed on Wikipedia at 

. This fascinating subject is an indicator of what has happened to medicine now that lawyers and politicos have replaced physicians in the mechanics of medicine.

You really hit the nail on the head. A physician or surgeon is now presumed guilty until proven innocent after any accusation. Only the lawyers win, and the patients suffer. This philosophy holds true for the Texas Medical Board, where many good doctors are being found guilty or paying a fortune in legal fees to prove their innocence. This secret, negative approach must be stopped or it will ruin medicine.

Look at the socialistic countries; innovation will stop, and high quality medical care will disintegrate. We have already seen this in our clinic. It is extremely difficult to find people who strive for quality and will work hard enough to maintain it. We have several generations to re-educate in quality care and top flight medicine and surgery.

As an example of why Dr. Jaffe stresses the importance of documenting claims of disruptive behavior, I will recount a Kafkaesque incident from a few years ago, when I was called before the Chairman of Surgery and the OR Nursing Director for an investigation into my disruptive behavior. After greeting my two grim-faced inquisitors and inquiring as to the nature of my disruptive behavior, I was told that I had used "obscene language" in the operating room (OR). This complaint originated from an anonymous "TIPS" report to the medical staff from an OR nurse. I asked for the specific obscenity alleged and was told that it was "the C-word." A quick mental search through my extensive vocabulary of salty language could match only one crude term, which referred to the female  anatomy. Puzzled, I stated that, to the best of my knowledge, I had never used that particular C-word inside the OR and again asked for the specific word in question. The OR Director became flustered and would not speak the word. I then asked whether the anonymous complaint had specified the exact nature of the putative C-word, and she admitted that it did not but that it was "clear" what it must have been. I asked her to find the nurse who initiated the complaint and determine precisely which C-word I had used. The OR Director returned, red-faced, a few minutes later to inform me that the C-word in question was "crap." (Pardon my French.)

The meeting ended, and I hope that the allegation of obscene language and disruptive behavior was expunged from my personnel file. I certainly learned a valuable lesson regarding the importance of documenting disruptive behavior.

Articles

Surgical Rounds

	International trading from the comfort of home

	Even after the late February 2007 market meltdown triggered by a 9% one-day drop in Shanghai, investors continue to seek higher returns in emerging markets. Given the much higher growth rates in places like India and China, US investors are asking how they can participate. There are a number of ways to invest in these hot markets without you or your money leaving home. One is through an American Depositary Receipt (ADR).

	Like exchange-traded funds or mutual funds, ADRs trade on US exchanges and are denominated in US dollars, which means you can trade them through your brokerage account, IRA, or 401(k).

	Unlike domestic stocks, ADRs are based on the underlying stock in the country of origin. This means that it will enjoy any rise (or suffer any fall) in the stock, and since the underlying is traded in a foreign currency, changes between that currency and the US dollar are also included in the calculation. If the US dollar drops compared with the origin country's currency, the ADR enjoys an added benefit.

	For example, the Australian All Ordinaries Index has more than doubled since the beginning of the global bull rally in mid-March 2003. Additionally, the Australian dollar has appreciated 50% against the US dollar over the same period. The US investor who bought the Australian All Ordinaries in March 2003 would be up a total of 188% over the US investor who did nothing, or more than double the 74% gain for the investor who stayed at home and invested in the S&P 500 over the same period.

	The Australian dollar has been a strong performer over the past 4 years, gaining 50%. So let's take a look at an Australian ADR over the same period. Mineral exploration and processor BHP Billiton Group (BHP) is a great example. In mid-March 2003, it was trading just around $11. By February 26, 2007, this ADR was trading above $46 on the New York Stock Exchange with roughly half of that 330% gain thanks to appreciation in the Australian dollar.

	Buying just any ADR is not a good idea. Holders of Thailand stocks found this out the hard way in December 2006, when the Thai government brought in myopic lockup rules restricting foreign investment. Thai stocks dropped 18% in one day as investors fled en masse.

	Thanks to a river of liquidity flowing through global markets together with the explosion in the number of hedge funds, more dollars are chasing fewer opportunities, creating overheated markets. Even after a global correction, investor complacency remains high as measured by a number of indicators, increasing the chance of a more protracted meltdown in the future—if history is any guide. The big question is when.

	It could be months or even years. Do investors sit on their hands waiting? The other option is a number of markets offering good appreciation potential, and these include those rich in commodities, such as Australia, Canada, and New Zealand. Other promising candidates include emerging economic powerhouses, such as China and India, as well as some smaller countries, such as Taiwan. And, after more than 15 years of recessions and deflation, Japan is again looking good.

	With odds of US dollar weakness continuing, ADRs provide a great vehicle for diversifying your nest egg while not having to leave the safety and comfort of the stock markets at home.

, a free educational Website for traders and investors, is a technical trader, author, reviewer, and keynote speaker. He is also the host of 

, which is devoted to tracking the impact of the election cycle on markets. Matt is a member of the Market Technicians Association and the Technical Securities Analysts Association.

	Exchange-traded funds (ETFs) may be all the rage, but savvy investors might find some hidden treasure in closed-end funds. Closed-end funds have a fixed number of shares with specialized portfolios and are traded on a stock exchange at a price determined by the number of buyers and sellers. Plagued by limitations, such as a lack of interest by research firms, a history of mediocre performance, trade discounts off net asset values, high fees, and a lack of high return, closed-end funds lack the popularity of ETFs. However, closed-end funds may offer investment opportunities for those who take a patient, yet aggressive, approach.

	By anticipating shareholders losses, investors can take advantage and gain a profit. 

 suggests that investors jump on closed-end funds when they are most vulnerable: when discounts widen due to market downturns, tax-loss selling, or rising interest rates; and, when dissident shareholders try to convert or liquidate the fund. Basically, investors can steal a deal by buying shares when the fund is vulnerable and waiting for the possible rise. It's important, however, to keep an overall diversified portfolio to limit the risk associated with closed-end funds.

	Are you interested in investing but don't know where to start? Do you miss the intellectual discussions from your college days? Do you yearn to do some investing outside of your carefully structured portfolio but don't know how? If you answered "yes" to any of these questions, you may want to join an investment club.

	Investment clubs have become a popular way for individuals to get together to discuss the always complex world of investing. Clubs discuss hedge funds, review investment books, and host professional lecturers. Some clubs pool together a small amount of money and decide where to best invest it. The agenda of most investment clubs, however, is to educate. It's a safe, open arena for peers to come together to learn and give each other advice. You can also start your own investment club; however, when starting such an endeavor, it's advised that the purpose of the club is clearly stated and, if fees are involved, a lawyer should be hired to draft up a member agreement. For more information about investment clubs, visit 

	The 50-doctor poll: Fair pay, flirting, and other fun topics

	Are you paid fairly? Are you sure of your answer? In a recent survey of 50 physicians from the New York region by 

, exactly half (n = 25) felt that physicians are paid fairly. Yet when the same physicians were asked if they personally are paid fairly, 40 answered "no." That's just one of the more amusing and interesting findings of this poll.

	Approximate physician annual salaries ran across the board: 4 made less than $50,000; 15 made between $50,000 and $99,000; 4 made between $100,000 and $149,000; 10 made between $150,000 and $249,000; 8 made between $250,000 and $499,000; 2 made between $500,000 and $999,000; and 2 made more than $2 million. Reasons given for undercompensation were listed as: "HMO policies," "I work 100 hours a week," "Residents equal slave labor," and "The money goes to insurance companies, lawyers, and pharmaceutical companies with good lobbyists."

	While most physicians felt the worst parts of being a physician were the hours (n = 30) and hospital politics (n = 22), they felt the best parts were the intellectual challenge (n = 40) and helping people (n = 33); more than one answer could be chosen for this question. Money also was included as a choice for these questions, and 9 physicians included it under the "worst part of being a physician" compared with 2 including it under the "best part." Clearly, money is not a large motivating factor in the profession! In fact, the number-one choice to "Why did you become a doctor?" revealed the essentially altruistic side of medicine, with the majority (n = 44) answering, "Wanted to help people."

	Other questions, like the fair pay issue, revealed "everyone but me" mindsets. For instance, while more than half (n = 29) felt physicians in general don't spend enough time with patients, the great majority (n = 35) said they personally spend enough time; only 12 physicians admitted they didn't.

	The greatest contrast was observed when the physicians were asked if those in their profession have "God complexes." While more than half of those surveyed (n = 28) said "yes, physicians fall prey to this ego condition," only 2 physicians admitted to having such a complex.

	Other questions in the survey covered taboo topics. When asked if physicians ever get turned on by patients, 26 responded "never," yet 22 admitted "sometimes." Another 35 confessed that doctors and nurses "sometimes" flirt in the operating room. And when asked, "Do you ever get grossed out?" 15 of the 50 physicians answered "yes." Reasons cited were: "Bad smells," "Autopsies," "Had to remove someone's eyes because of cancer."

. While there, be sure to also check out "The 50-Nurse Poll" for nurses' real opinions of physicians.

	Steps 20-somethings can take to retire rich

	You're in your 20s, just graduated medical school, and have started your residency. You've got medical school loans, rent/mortgage, credit card balances, and assorted bills to pay. Why think about retirement now? Because saving now ensures you will be able to retire later.

	Time is your best friend! If you start at age 25 and invest $1,000 per year in a tax-deferred account that earns 7% annually, you'll have accumulated $199,635 by age 65. The same amount invested every year starting at age 40 will only earn you $63,249 at age 65.

	If a 401(k) is available to you, jump in as soon as possible and make sure to get the full company-match benefit. That's free money working for you. If you leave your company, be sure to carry that 401(k) over to an IRA, so it can continue to grow.

	Most important, be proactive now. Contact an investment advisor and plan ahead. If you set aside as much as you can now, you can avoid investing more of your income later in life, when you may need it most.

	Think owning an airplane is a bit out of your price range? Think again! Hedge funds, capitalizing on a trend by airlines to switch from owning to leasing their aircrafts, have bought into the airplane leasing business. Sensing that global demand for aircraft would increase, hedge funds began buying individual aircraft and storing them until they had amassed a fleet. The funds then created airplane leasing companies. Cerberus Capital Management and Fortress Investment Group have capitalized on the growing trend.

, Fortress leasing company, Aircastle, raised $240 million during its initial public offering in August of 2006, and 8 months later their shares were up about 30%. Cerberus bought DaimlerChrysler's stake in Debis AirFinance leasing firm when the carmaker made company cutbacks. Private-equity firms are also joining in on the plane game. In May 2007, private-equity firm Terra Firma purchased Pegasus Aviation Finance for $5.2 billion and now owns the world's third-largest plane leaser. Hedge funds and private-equity firms now own approximately 17.8% of the world's airplanes.

Gain insights on investment clubs, closed-end funds, international trading, and more.

Surgeon's Bulletin Board

The hemodynamic value characteristic of septic shock is

 	Systemic vascular resistance index,350 dynes cm-5 sec/m

 	Pulmonary capillary wedge pressure, 6.0 mm Hg

 	Can be prevented by administering prophylactic antibiotics

 	Are the most common causes of death due to nosocomial infections

 	Can invariably be diagnosed by chest radiographs

	 Are the most common postoperative nosocomial infections

 	Are generally caused by gram-negative organisms

Compared with open mesh repairs, laparoscopic inguinal herniorrhaphies

 	Can be prevented by using a long(40 cm) afferent loop

 	Is more common after retrocolic gastrojejunostomy

 	Is caused by partial obstruction of the afferent loop

 	Cause damage because of the hygroscopic nature of alkaline solutions

 	Can rapidly be aborted by the addition of water

In patients with breast cancer, sentinel lymph node biopsies are indicated

 	If the patient has undergone prior axillary operation

 	If there are clinically positive axillary lymph nodes

Dysphagia after laparoscopic Nissen antireflux procedures 

 	Occurs transiently in virtually all patients

 	Requires endoscopic dilation in 5% of patients

 	Can be avoided by doing the wrap over a large bougie

 	Is frequently due to delayed gastric emptying

Small intestinal GISTs (gastrointestinal stromal tumors) 

 	Require extensive lymph node dissections for cure

	Have their prognosis determined by histologic grade

In patients with duodenal ulcers, antacids

Are as effective in healing the ulcer as H2 blockers

Occur more frequently in the posterior than the anterior mediastinum

Constitute a majority of all mediastinal neoplasms

Are characterized as to cell type by monoclonal antibodies to cell-specific antigens

Are approached by dissecting between the triceps and deltoid muscles

Are the most frequent penetrating vascular injuries

Are best controlled at the medial border of the teres minor muscle

Three weeks after a motor vehicle collision, a patient is discovered by CT scanning to have a 3.0-cm pseudocyst in the pancreatic tail. The correct therapy is

The only accurate value is that of oxygen consumption, which is quite high. The characteristic values in septic shock for the other parameters are cardiac index, 3.0—5.6 L/min/m

 (elevated); systemic vascular resistance index, 675—1110 dynes cm-5 sec/m

 (markedly vasodilated); oxygen delivery, 340—575 mL/min/m

; and pulmonary capillary wedge pressure, 8—20 mm Hg.  The routinely reduced systemic vascular resistance and wedge pressure, as well as the elevated cardiac index, are due to uncontrolled vasodilation induced by sepsis.

Lower respiratory infections are the most common causes of nosocomial infectious deaths. Prophylactic antibiotics have not been shown to prevent them. Lower respiratory infections are difficult to document, particularly in postoperative patients. The most reliable diagnostic technique is bronchoalveolar lavage. Both urinary tract and superficial skin infections are more common than lower respiratory infections in postoperative patients. These infections are generally caused by gram-positive organisms.

The major advantage of laparoscopic hernia repair is the associated lower rate of wound and mesh infections. Laparoscopic hernia repairs are more expensive, have identical recurrence rates, and take longer to perform. Since open herniorrhaphies are routinely done in the outpatient setting, it is not possible to achieve shorter hospital times.

Afferent loop syndrome is a mechanical complication caused by obstruction of the afferent loop. Using a long loop and antecolic anastomosis increases the frequency of this complication by increasing the likelihood of kinking. Characteristically, patients vomit bile but no food. By the time the obstruction empties retrograde (by vomiting), the food is well beyond the efferent loop, so only bile is vomited. The only treatment for persistent and severe afferent loop syndrome is operative revision, and identifying and eliminating the site of obstruction.

Following alkali burns, the resultant extraction of water from cells causes cellular damage. Alkali burns usually occur in infants and children who accidentally spill strong bases. When they occur in adults, they are usually due to prolonged contact with cement, calcium oxide. The alkaline solutions bind to skin proteins, and the alkaline proteinates penetrate deeply into tissue, making them difficult to wash off. The heat from neutralization reactions increases tissue damage, so the addition of weak acid is detrimental. Debridement should be delayed, at least until the tissue pH is <8.

Bilateral disease mandates the identification of nodal disease in both axillae. The remaining distracters are contraindications, because they will not change the treatment plan. Prior axillary procedures distort the anatomy, making identification of the sentinel node difficult.

Although 20% of patients complain of dysphagia, only 5% have symptoms severe or persistent enough to warrant endoscopic dilation. Dysphagia is due to postmanipulation edema or hematoma and occurs despite routine use of a large bougie. Finally, delayed gastric emptying, which occurs commonly in patients with reflux disease, causes nausea, vomiting, and early satiety, but not dysphagia.

Even though GISTs are intramural lesions, they ulcerate the overlying mucosa and present with bleeding. These tumors generally arise in the jejunum and ileum. Since GISTs do not metastasize to lymph nodes (they usually spread to the liver, lungs, and bones), lymph node dissections are not effective. GISTs are radioresistant, and radiation therapy plays little role in their treatment. The prognosis is determined by tumor size and the number of mitoses.

While antacids are effective in healing ulcers, the ulcers recur rapidly after cessation of therapy, and patients have to take a large number of pills (low-dose therapy is ineffective). Antacids have to be taken on a full stomach; on an empty stomach, the medication is evacuated very rapidly, before it can be effective. All antacids have side effects, which vary among preparations. Magnesium preparations, the most effective, cause diarrhea and are not well tolerated. Antacids stimulate acid secretion by a feedback mechanism stimulated by increased gastric pH.

Immunocytochemistry is used to identify the cell type of mediastinal malignancies. Malignancies constitute 25% of all mediastinal neoplasms. These lesions occur mainly in patients 25 to 40 years of age, corresponding to the most common age of occurrence of lymphomas. The tumors are generally lymphomas and malignant thymomas.

The brachial artery is the vessel most commonly injured by penetrating trauma, followed by the femoral artery. The vessel is approached by separating the biceps and triceps muscles, and the vessel is exposed at the lateral border of the teres major muscle. The median nerve is just superficial to the brachial artery, so it is in maximal jeopardy, and not the ulnar artery, which is much better protected. Ligation results in ischemia, because there is relatively little collateralization in the upper arm.

Eighty percent of small (<4 cm) traumatic pseudocysts resolve spontaneously within 6 to 8 weeks. There is an excellent chance these lesions will resolve without operative or interventional therapy, so observation is indicted with subsequent repeat CT scans. The other procedures are too aggressive at this post-injury stage. Stenting of the pancreatic duct is rarely effective in this scenario, even if the cyst communicates with the pancreatic duct.

 Lymphangiomas of the head and neck are sometimes referred to as cystic hygromas and result from abnormal growth of the lymphatic vessels. Lymphangiomas are most commonly found in children and rarely observed in adults. Most lymphangiomas are congenital, but they have also been reported to arise from infections, neoplasms, trauma, and iatrogenic injuries.

 The authors report the case of an adult woman with a slowly enlarging neck mass that was resected and identified by pathology as a lymphangioma. She had a lymphangioma excised from the same location more than a decade earlier. The literature is reviewed and the classification, symptoms, diagnosis, and treatment of lymphangiomas are discussed.

 Observation is recommended for small, nonexpanding lesions. Surgical resection is recommended for lesions that persist, enlarge, or produce obstructive symptoms. Careful surgical planning is critical to avoid injury to adjacent neurovascular structures, and a multidisciplinary approach is warranted.

	Lymphangiomas are benign lymphatic malformations that occur most commonly in children.

 Some authors refer to these lesions as cystic hygromas, a term first used by Wernher in 1843.

 The term cystic hygroma refers to the cystic nature of these lesions and their mass effect; hygroma means "moist tumor."

 Lymphangioma, however, is the more appropriate nomenclature because it denotes the tissue of origin.

 Lymphangiomas are thought to arise from an embryologic defect that consists of an abnormal connection from the jugular sacs to the peripheral lymphatic system.

	The etiology of these lesions has been debated, but it centers predominantly on two theories. The centrifugal theory proposes an abnormal sequestration of primitive lymphatic buds instead of the endothelial channels that proliferate centrifugally from the venous system to become the lymphatic system.

 The centripetal theory discusses aberrant congenital lymphatic development.

 The end result for both theories is the inability of the peripheral lymphatics to drain into the jugular sacs. In adults, lymphangiomas may occur from delayed proliferation of cell rests, either spontaneously or in response to infection or trauma.

	A 42-year-old woman presented to the hospital with a slow-growing left neck mass in the same location from which one had been surgically removed over a decade earlier. The original mass was identified when she was 30 years old and monitored for 2 years. After it failed to resolve, she underwent resection of the mass, which was diagnosed as a lymphangioma on histopathology examination. The patient remained asymptomatic for 10 years before noticing a recurrence of the mass.

	Upon presenting to our hospital, the patient noted only slight discomfort in her neck, which occurred with movement. She reported experiencing no shortness of breath, dysphagia, dysphonia, or pain. On physical examination, the mass was soft and nonmobile. It extended from below the angle of the mandible to the supraclavicular region by tracking along the anterior border of the sternocleidomastoid muscle. Magnetic resonance imaging (MRI) of the neck revealed a large, left-sided supraclavicular cystic lesion in the base of the neck (Figure 1). There was no enhancing portion, and the lesion measured approximately 7 x 9 x 4 cm.?The trachea was shifted to the right, with no compromise of the patient's airway (Figure 2).

	A multidisciplinary approach for surgical resection was undertaken. Because these lesions are typically found in children, this included general and pediatric surgeons. The mass was reached through a 7-cm transverse skin incision along the anterior border of the sternocleidomastoid muscle. Although the lesion was in close proximity to nerves, vessels, and muscles, there was no invasion into these structures, and the mass was circumferentially dissected and removed in its entirety. Final pathology revealed a lymphangioma with a few small, adjacent benign lymph nodes.?The patient tolerated the procedure well and was discharged from the hospital on postoperative day 1 in good condition.

	Lymphangiomas are relatively rare congenital lesions that result from abnormal growth of the lymphatic vessels. It is rare for lymphangiomas to make their initial presentation during adulthood, and fewer than 100 such cases have been reported. Approximately 60% of lymphangiomas are present at birth, and up to 90% are detectable by 2 years of age.

 Although more than 90% of lymphatic malformations are clearly congenital, later presentations may occur as a result of trauma, infection, neoplasms, or iatrogenic injuries.

 The pathophysiology of adult lymphangiomas is not clearly understood, but these lesions may occur secondary to induction of dormant rests of embryonic lymphatic tissue that are stimulated to differentiate and grow.

	Lymphatic malformations can be categorized as superficial cutaneous lymphangioma, cavernous lymphangioma, cystic hygroma, or diffuse systemic lymphangioma.

 They are also classified according to size: capillary lymphangiomas contain microscopic cavities, and cavernous lymphangiomas contain cystic cavities that are usually larger than 1 cm.

	Most lymphangiomas are asymptomatic. They have no gender predilection and present as a painless mass that progressively enlarges. Typically, the mass is soft, nontender, and ill-defined. Symptoms may develop when the lymphatic malformation enlarges to where it compresses surrounding tissue. Obstructive symptoms of dysphagia, dyspnea, or emergent airway compromise may develop. Cervical lymphangiomas have not been shown to lateralize to any particular side of the neck.

	Ultrasonography and computed tomography (CT) scanning have been used extensively to evaluate the anatomy of lymphangiomas. On ultrasound examinations, these lymphatic malformations appear as thin-walled, multiseptate, multicystic, hypoechoic masses.

 Lymphangiomas appear as multiloculated cystic lesions on CT scanning. On T2-weighted MRI, lymphangiomas appear isointense to cerebrospinal fluid, whereas their intensity varies on T1-weighted images due to variable protein content.

	Fine-needle aspiration (FNA) is routinely used to evaluate most neck masses, although it is almost never used in the pediatric population. In adults, where the risk of neoplasm is greater, there is no consensus in the literature concerning the use of FNA to diagnose these lesions. FNA findings include small and round lymphocytes with intermingling histiocytes without mitoses or atypia. In adults with compromised airways, FNA may be therapeutic, as well as diagnostic.

 Immunohistochemistry may reveal polyclonal B lymphocytes mixed with T cells.

 Microscopically, these lesions appear as endothelial-lined lymphatic spaces with intervening fibrous tissue and lymphoid aggregates.

	Observation is frequently the first step for small, nonexpanding lesions. Those that persist, continue to grow, or present with obstructive symptoms should be resected. To avoid injuring adjacent neurovascular structures, surgical planning is crucial before resection. Some surgeons prefer to use MRI to facilitate resection because it allows improved anatomical demarcation.

 Ultrasonography has limited ability to delineate the anatomical planes of resection or the extent of structural involvement.

	Complications of resection include infection, bleeding, hematoma, and postoperative seromas. Injury to facial, hypoglossal, glossopharyngeal, recurrent laryngeal, and lingual nerves has been reported.

	Complete excision of a cystic hygroma has been shown to have an 81% cure rate. When only part of the lymphatic malformation is excised, there is an 88% recurrence rate.

 Several studies have shown an increase in rates of recurrence, morbidity, and complications for lymphangiomas located in the suprahyoid versus infrahyoid region,

 whereas one study found no difference in recurrence rates when comparing these locations.

	Charabi and associates conducted a 35-year follow-up on 44 adult patients who were treated surgically for macrocystic lymphatic malformations of the head and neck.

 Fifty percent of these patients had residual or recurrent disease, and 40% had complications involving speech, food intake, breathing, or swallowing. A direct correlation was observed between the extent of the lesion and the number of operations performed, rate of recurrence, and residual disease. Charabi and associates state that nonencapsulated lesions recur more frequently because of their tendency to infiltrate major neurovascular structures.

	Sclerosing agents and radiation therapy have not been shown to play a role in the primary treatment of cystic hygromas. They may be indicated in lymphatic malformations that are macrocystic and not amenable to surgical resection.

 Sclerotherapy with OK-432, a lyophilized, low-virulence SU strain of group A Streptococcus pyogenes, has been suggested as a possible therapy for macrocystic lesions. To date, however, the efficacy of OK-432 has not been proven in prospective, controlled trials.

	Surgical excision remains the treatment of choice for lymphangiomas. Despite possible complications, operative management can allow for complete resection, which affords lower rates of recurrence when compared with less invasive treatments. In cases that prove to be unresectable at the time of surgery, intraoperative treatment using sclerosing agents may help decrease the rate of recurrence.

	The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

		Kennedy TL, Whitaker M, Pellitteri P, et al. Cystic hygroma/ lymphangioma: a rational approach to management. 

		Wernher A. Die angeborenen Zysten-Hygrome und die inhen verwandten Geschwulste. In: 

Anatomischer, Diagnostischer und Therapeutischer Beziehung

		Mulliken JB, Young AE. Lymphatic malformations. In: 

Vascular Birthmarks: Hemangiomas and Malformations

. Philadelphia, Pa: WB Saunders; 1988:41.

		Cheng LH, Wells FC. A multidisciplinary approach to recurrent cervicothoracic cystic hygroma in an adult. 

		Sabin FR. The lymphatic system in human embryos, with a consideration of the morphology of the system as a whole. 

		Sichel JY, Udassin R, Gozal D, et al. OK-432 therapy for cervical lymphangioma. 

		Aneeshkumar MK, Kale S, Kabbani M, et al. Cystic lymphangioma in adults: can trauma be the trigger? 

		Karmody CS, Fortson JK, Calcaterra VE. Lymphangiomas of the head and neck in adults. 

		Kennedy TL. Cystic hygroma-lymphangioma: a rare and still unclear entity. 

		Stromberg BV, Weeks PM, Wray RC Jr. Treatment of cystic hygroma. 

		Machado LE, Osborne NG, Bonilla-Musoles F. Three-dimensional sonographic diagnosis of a large cystic neck lymphangioma. 

		Imhof H, Czerny C, Hormann M, et al. Tumors and tumor-like lesions of the neck: from childhood to adult. 

		Naidu SI, McCalla MR. Lymphatic malformations of the head and neck in adults: a case report and review of the literature. 

		Bosch-Princep R, Castellano-Megias VM, Alvaro-Naranjo T, et al. Fine needle aspiration cytology of a cervical lymph node lymphangioma in an adult. A case report. 

		Fliegelman LJ, Friedland D, Brandwein M, et al. Lymphatic malformation: predictive factors for recurrence. 

		Fung K, Poenaru D, Soboleski DA, et al. Impact of magnetic resonance imaging on the surgical management of cystic hygromas. 

		Ricciardelli EJ, Richardson MA. Cervicofacial cystic hygroma. Patterns of recurrence and management of the difficult case. 

		Charabi B, Bretlau P, Bille M, et al. Cystic hygroma of the head and neck?a long-term follow-up of 44 cases. 

		Chong KT, Ong CL. Cystic hygroma in adulthood. Singapore Med J. 1997;38(6):261-262.

		Mikhail M, Kennedy R, Cramer B, et al. Sclerosing of recurrent lymphangioma using OK-432. 

		Luzzatto C, Lo Piccolo R, Fascetti Leon F, et al. Further experience with OK-432 for lymphangiomas. 

Marlon A. Guerrero, Chief Resident, Michael E. DeBakey Department of Surgery; Mufaddal M. Gomberawalla, Medical Student IV; Mary L. Brandt, Associate Professor, Michael E. DeBakey Department of Surgery; F.Charles Brunicardi, Chairman and Program Director, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX

Recurrent cervical lymphangioma of the neck in an adult

 Gallstone ileus is a rare cause of nonstrangulated bowel obstruction. It results when there is fistulization between the gallbladder and the gastrointestinal tract, and it is usually found in patients with a history of cholecystitis. Squamous cell carcinoma of the gallbladder (SCCG) is rarer than gallstone ileus and has a poorer prognosis than the more common adenocarcinoma of the gallbladder.

 This paper describes the case of a 75-year-old woman who presented to the hospital with signs and symptoms of gallstone ileus and a liver mass. The patient underwent a one-stage procedure consisting of enterolithotomy, cholecystectomy, and cholecystoduodenal fistula excision and repair. A wedge resection of the liver mass was also performed.

Pathology identified two nodules of tumor in the body and neck of the patient's gallbladder as SCCG; the hepatic lesion was determined to be either metastasis or direct extension of the gallbladder tumor. The presence of large gallstones, which this patient was known to have, is considered a risk factor for SCCG. Although there is some controversy over treating such patients with a one-step procedure, the patient in this case had a positive outcome.

	Gallstone ileus reportedly accounts for 25% of nonstrangulated bowel obstructions in patients older than 65 years.

 This rare mechanical bowel obstruction is seen in less than 1% of patients identified as having gallstones.

 It is atypical to find gallstone ileus in the setting of squamous cell carcinoma of the gallbladder (SCCG). SCCG is an aggressive tumor that makes up only 1% to 12% of all gallbladder cancers and generally has a poorer outcome than adenocarcinoma of the gallbladder.

 We were able to diagnose our patient's gallstone ileus preoperatively, and a postoperative pathology examination identified the SCCG.

	A 75-year-old African American woman presented to the hospital with a 3-day history of colicky midepigastric abdominal pain, which was accompanied by intermittent nausea and abdominal distention. She reported no recent emesis, fever, or chills, and had continued to pass flatus until 24 hours before her presentation. The patient's abdomen was tender to palpation at the right- to mid-periumbilical region. Her history was notable for a poor appetite and an unintentional 50-lb weight loss over the previous 4 years. Her medical history was significant for cholelithiasis, congestive heart failure, type 2 diabetes mellitus, and an open appendectomy in the distant past.

	On physical examination, the patient had stable vital signs, with a temperature of 37.6°C, heart rate of 95 beats per minute, blood pressure of 116/50 mm Hg, and respiratory rate of 18 breaths per minute. No clinical jaundice was observed. Significant laboratory values included a white blood cell count of 17.1 x 109/L (normal, 4.5—11.0 x 109/L), hematocrit of 28% (normal, 35%&mdash;45%), platelet count of 442 x 109/L (normal, 150?450 x 109/L), blood urea nitrogen of 7.85 mmol/L (normal, 2.9&mdash;8.2 mmol/L), creatinine of 124 ?mol/L (normal, 53&mdash;106 ?mol/L), total bilirubin of 6.84 ?mol/L (normal, 5&mdash;21 ?mol/L), aspartate aminotransferase of 14 U/L (normal, 20?48 U/L), alanine aminotransferase of 15 U/L (normal, 10&mdash;40 U/L), and alkaline phosphatase of 81 U/L (normal, 50&mdash;120 U/L).

	Ultrasonography of the right upper quadrant demonstrated gallstones, a thickened gallbladder wall, intrahepatic ductal dilatation, and a dilated common bile duct that measured 1.8 cm. Computed tomography (CT) scanning of the patient's abdomen and pelvis confirmed the ultrasonography findings (Figure 1). A right hepatic lobe lesion that measured 3.7 x 2.1 cm was also seen; this lesion was not observed on a CT scan taken 4 months earlier. A large gallstone in the distal ileum was visualized, and a diagnosis of gallstone ileus was made.

	The patient underwent an exploratory laparotomy for gallstone ileus. After entering the abdomen, we palpated a large gallstone in the distal ileum, which was removed through a proximal enterotomy. The stone was faceted. We biopsied the liver mass (segment V), and this revealed poorly differentiated adenosquamous carcinoma. The gallbladder appeared chronically inflamed, and we observed additional residual, large gallstones, but no gross mass was palpated. The intraoperative differential diagnosis included a primary hepatic malignancy because we observed no evidence of any masses, ascites, or lymphadenopathy outside of the liver. We thought that the patient's cholecystoduodenal fistula was attributable to gallstones and chronic cholecystitis and did not suspect gallbladder cancer.

	Our patient remained hemodynamically stable during the entire operation, which allowed us to perform a one-stage procedure consisting of enterolithotomy, cholecystectomy, and cholecystoduodenal fistula excision and repair. A wedge resection of the liver mass was also performed. On running the entire small intestine, we found another large gallstone in her proximal jejunum, which was removed through a separate enterotomy. The patient lost less than 200 cc of blood and was extubated after the surgery was completed.

	Pathology found two nodules of tumor, whose greatest dimensions were 4.5 cm and 1.0 cm, respectively, in the body and neck of the gallbladder (Figure 2A). The liver lesion, which was 4.5 cm at its greatest dimension, could represent metastasis or direct extension of the gallbladder tumors (Figure 2A). Two multifaceted gallstones were present in the gallbladder (Figure 2B). Microscopically, the gallbladder lesion was a poorly differentiated SCCG, with invasion into the gallbladder subserosa and angiolymphatic system, which may have resulted from squamous metaplasia (Figure 3).

	The poor differentiation of our patient's tumor lends itself to scrutiny of being a mixed adenosquamous-cell carcinoma. Early descriptions of SCCG were of the well-differentiated keratinizing variety.

 The identification, however, of squamous metaplasia, dysplasia, or carcinoma in situ associated with SCCG, as it was in this case, was useful in making this rare diagnosis and excludes the more common adenocarcinoma.

	Postoperatively, the patient received a short course of perioperative antibiotic to prevent intra-abdominal infection, and her postoperative pain was managed through patient-controlled analgesia. She received total parenteral nutrition until postoperative day 7, when an upper gastrointestinal study revealed no leak at the duodenal repair and her diet was advanced. A postoperative chest CT scan revealed no radiographic evidence of pulmonary metastases. The patient was discharged from the hospital on postoperative day 14. Although her recovery from surgery was uneventful, she died from hypercalcemia 7 months later. None of her follow-up bone scans or CT scans had demonstrated recurrence, osseous or otherwise.

	Gallbladder cancer is the fifth most common gastrointestinal malignancy in the United States. The incidence increases after the fifth decade of life, with a reported incidence of 1.2 cases per 100,000 persons annually.

 Adenocarcinoma is the most common gallbladder malignancy, and SCCG accounts for very few cases. The presence of large gallstones is known to be a risk factor for developing gallbladder cancer.

Squamous cell carcinoma of the gallbladder 

	Most literature records SCCG as accounting for approximately 1% of all gallbladder malignancies.

 To date, more than 146 cases of SCCG have been reported in the English-language literature.

 The majority of these rare tumors occur in older women, with a female predominance of 3:1.

	SCCG is an invasive and aggressive tumor that has a high incidence of local infiltration and hepatic metastases. Patients with these tumors are considered to have a worse prognosis than those with adenocarcinoma of the gallbladder. Some researchers have suggested that this histological tumor may arise from squamous differentiation of adenocarcinoma of the gallbladder.

	Surgical treatment of SCCG consists of cholecystectomy with wedge resection of adjacent liver tissue or direct liver resection combined with regional lymphadenectomy and skeletonization of the hepatic hilum. Radiotherapy and chemotherapy are considered palliative treatments. Prognosis without radical surgery is poor, with patients surviving an average of 6 months.

 Oohashi and colleagues retrospectively reviewed 29 gallbladder cancer cases, of which 28 involved adenosquamous carcinoma and 1 involved SCCG.

 Based on their analysis, patients who underwent radical cholecystectomy with extended resection and regional lymphadenectomy had an increase in median survival to 18 months. Residual tumor status was their only significant independent prognostic factor.

	Gallstone ileus is a fistulization between the gallbladder and the gastrointestinal tract. It is usually found in patients who have a history of cholecystitis. Stones larger than 2.5 cm may lodge in the distal ileum (60.5%), jejunum (16.1%), stomach (14.2%), colon (4.1%), or duodenum (3.5%).1 Patients usually present with a "tumbling" course of intermittent bowel obstruction as the stone passes slowly into the distal bowel and becomes lodged at the terminal ileum. Gastric outlet obstruction may also occur when a large gallstone passes into the duodenal bulb through a biliogastric or bilioduodenal fistula. This has been described as Bouveret's syndrome. Endoscopic lithotripsy with stone extraction has been reportedly successful at treating Bouveret's syndrome.

 Our patient's large gallstones predisposed her to getting gallbladder cancer. The combination of gallstones and gallbladder cancer likely led to chronic cholecystitis and the development of gallstone ileus.

	Enterolithotomy is the standard operative treatment for gallstone ileus. There is controversy over whether cholecystectomy and the resultant duodenal fistula repair are beneficial. Comorbidities and hemodynamic instability at the time of surgery, which are often found in patients with this disease, force surgeons to operate quickly.

 In the largest retrospective review to date, consisting of 1,001 patients, Reisner and Cohen promoted simple enterolithotomy as a safe and effective management for gallstone ileus.

 Their study found that recurrence of gallstone ileus after enterolithotomy was less than 5%, and only 10% of their patients required reoperation for biliary tract symptoms. Concerns over recurrent cholecystitis, cholangitis, gallstone ileus, and the risk for gallbladder cancer have resulted in controversy among proponents of a one-stage procedure consisting of enterolithotomy, cholecystectomy, and cholecystoenteric fistula repair. Tan and associates retrospectively compared 19 patients who were treated urgently for gallstone ileus and found that in their one-stage surgical group (n=12), patients had lower American Society of Anesthesiology grades, no preoperative hypotension or shock, and no mortality.

 This study, however, still recommended enterolithotomy as the surgery of choice because it is less demanding technically, requires less operative time, and has no delayed complications from a remnant fistula. Rodriguez-Sanjuan and colleagues retrospectively reviewed 35 patients with gallstone ileus and concluded that a one-stage procedure resulted in slightly higher morbidity, mortality, and reoperation rates.

 Their study could not support a one-stage procedure as an operation of choice for patients with gallstone ileus, but they suggested it might be acceptable for low-risk patients. A retrospective review of 34 patients treated for gallstone ileus found that all three patients who underwent one-stage procedures survived.

 In our patient's case, the presence of a faceted stone, which was extracted by enterolithotomy, suggested the need to search for other stones and to perform a cholecystectomy for residual cholelithiasis.

	Our patient's case was unconventional because she presented with gallstone ileus and underlying metastatic SCCG. Despite her advanced age and comorbidities, she tolerated a one-stage procedure well. This case adds to the body of literature confirming successful management using a one-stage procedure of gallstone ileus in the setting of SCCG.

		Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. 

		Waisberg J, Bromberg SH, Franco MI, et al. Squamous cell carcinoma of the gallbladder. 

		Karasawa T, Itoh K, Komukai M, et al. Squamous cell carcinoma of gallbladder—report of two cases and review of literature. 

		Mingoli A, Brachini G, Petroni R, et al. Squamous and adenosquamous cell carcinomas of the gallbladder. 

Sonny S. Wang, Chief Resident in General Surgery, Department of Surgery; Philip J. Katzman, Associate Professor of Pathology and Laboratory Medicine, Department of Pathology; Luke O. Schoeniger, Associate Professor of Surgery and Oncology, Department of Surgery, Division of Surgical Oncology, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY

November 2007

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