	A 52-year-old man presented to the hospital due to increasing shortness of breath and significant weight loss over the previous 3 to 4 months. The patient could not lie on his back secondary to his shortness of breath. Posteroanterior and lateral chest radiographs were performed, followed by contrast-enhanced computed tomography scans of the neck and thorax (Figures 1-4). The mass was determined to be a fibrovascular polyp.

 What is the "dreaded" complication associated with this esophageal mass?

Asphyxiation due to laryngeal obstruction

Recurrence if the mass is not completely resected

a—Asphyxiation due to laryngeal obstruction

		A fibrovascular polyp is a rare, benign, intraluminal esophageal tumor. It is composed of a varying amount of fibrous tissue, adipose fat, and vascular structures, and is covered with squamous epithelium. Several terms have been used throughout the literature to describe these lesions, depending on their composition. Terms include 

		Fibrovascular polyps can result in all of the complications listed in the question; however, the most dreaded is asphyxiation from impaction in the larynx.

 These lesions are typically asymptomatic until they become large. The average length of a fibrovascular polyp at diagnosis is 15 cm, and the average duration of symptoms is 17 months.

 Other reported symptoms include dysphagia, respiratory complications, and regurgitation of the polyp into the mouth.

		Fibrovascular polyps can be challenging to diagnose, and up to 30% are misdiagnosed.

 These lesions can be missed on imaging studies and during endoscopy because they are soft, covered by normal mucosa, and can be displaced easily.

		In a review by Levine and colleagues of 16 patients with fibrovascular polyps, chest radiographs demonstrated a right-sided superior mediastinal mass, anterior bowing of the trachea, or both in 44% of the cases.

 Barium studies demonstrated a lobulated intraluminal mass originating from the lower cervical esophagus, and computed tomography (CT) demonstrated an intraluminal esophageal mass that was heterogeneous to soft tissue and fat density, depending on the tissue content.

		In our patient, the chest radiograph demonstrated an upper esophageal mass with an air fluid level suggesting esophageal obstruction (Figures 5 and 6). Consolidation in the left perihilar/lingular lobe from obstructive atelectasis was also visible. The contrast-enhanced CT scan confirmed a heterogeneous intraluminal mass with near complete esophageal obstruction (Figures 3 and 4). The patient was in a lateral position because his shortness of breath prevented him from laying supine.

		Surgical resection is the treatment of choice. Care should be taken to completely resect the stalk so that recurrence can be avoided.

			Ozcelik C, Onat S, Dursun M, et al. Fibrovascular polyp of the esophagus: diagnostic dilemma. 

			Levine MS, Buck JL, Pantongrag-Brown L, et al. Fibrovascular polyps of the esophagus: clinical, radiographic, and pathologic findings in 16 patients. 

			Cochet B, Hohl P, Sans M, et al. Asphyxia caused by laryngeal impaction of an esophageal polyp. 

			Carrick C, Collins KA, Lee CJ, et al. Sudden death due to asphyxia by esophageal polyp: two case reports and review of asphyxial deaths. 

Articles

Surgical Rounds

What is the complication associated with this esophageal mass?

What is the "dreaded" complication associated with this esophageal mass?

	I have trained in three fairly respectable academic institutions and worked in several civilian and military hospitals. I have witnessed disruptive behavior in all these settings, by a variety of people, from professors down to interns. My sense has always been that despite their prestige, rank, and technical ability, these people were almost always insecure and lacked resourcefulness in resolving issues they felt adversely impacted the care of their patients. They became verbally abusive, offensive, and even violent in attempting to make everything conform to their standard of perfection. The surgical world is not perfect, and this includes nurses, administrators, laboratory personnel, and surgeons. The art of the surgeon should encompass dealing with less-than-ideal situations without humiliating and abusing other people (however you choose to define that). Pare said, "He who would be a surgeon should find an army and follow it." I recommend that, as penance, any surgeon found to be consistently disruptive should join the army, where he or she will practice surgery in an austere environment in which everything is always less than perfect and less than desirable. Then, these surgeons can return to the general hospitals in the United States and realize just how good they—and their patients&mdash;have it, even when it is discovered that the nurse who was supposed to have the stapler ready in the operating room has gone on break.

	Robin Hood and the health insurance crisis (Oct. 2007)

	The insurance industry giant Lloyd's of London was born in a coffee shop that operated on the docks of London, where ship owners gathered and often lamented the loss of a ship. Several owners united and devised a system whereby an individual loss would be dispersed among the lot of them rather than becoming one owner's catastrophe. Insurance has journeyed a long way from the idea of sharing losses and now exists to profit the insurance company. Protecting the insured is low on the list of priorities. Examining the language insurance companies have developed to hide their activities (consider "whole life" versus "term") is enough to prove what a dishonest school of piranha they constitute. A vascular surgeon since 1977, I have been fighting them for more than 30 years to get what I am due.

	My very first interaction with the insurance industry was in 1965, when I elected to drive my 1959 Ford over a dead deer in my lane rather than swerve into traffic. The deer ripped off the exhaust manifold, and although my insurance policy covered damages caused by acts of nature, the company refused to pay for my repairs. The agent explained that while hitting a 

 animal was covered, hitting a dead deer was more like hitting a tree and was therefore not covered.

	Not long ago I received two letters from Blue Cross on the same day. The first notified me that my employees' health insurance premiums were increasing due to increased costs; the other explained that payment for my professional services would be decreasing due to increased costs. It brought to mind an article in the

 15 years earlier, which stated that Blue Cross had listed its overhead as 7% of costs when it was a not-for-profit company, but as a for-profit HMO, it claimed overhead expenses of 35%. Perhaps these overhead costs explain why my wife and I were paying around $1,400 monthly for our Blue Cross health insurance.

	I recently used our Blue Cross insurance to cover minor foot surgery at a San Francisco hospital. The hospital bill exceeded $30,000, but for this outpatient procedure, Blue Cross allowed only $2,000. My benefit from the insurance company, therefore, was the $2,000 it paid and not the $30,000 billed originally. If the hospital offered private patients the same fees it gives insurance companies, it would make financial sense for many people to forego insurance or at least purchase only catastrophic coverage.

	There are so many problems with the insurance industry, including the workers compensation and disability insurance fiascos, malpractice insurance, and the way the legal system and the insurance industry feed each other. I could write for a year on this subject and never finish detailing the great injustice I feel Americans have been dealt by the insurance industry.

	I wish to call your attention to an error in the Superficial Palmar Arch anatomical chart. In the palmar (ventral) view, the "cut" tendon was labeled "plantaris tendon (cut)," when it should have been labeled "palmaris (longus) tendon (cut)."

We regret the typo. The corrected chart is now online at 

 for a number of reasons, including the extremely well done anatomical charts. I have a binder where I keep the charts, and they have been invaluable over the years to illustrate surgical sites to my patients. You can imagine my disappointment when I found the chart in the November 2007 issue was just on plain paper and not really conducive to saving. Hope you go back to the previous format.

We regret that we had to make this change, but the charts are now accessible on our Website as PDFs and can be printed on any paper stock desired. You can even print copies for your patients.

Disruptive behavior 

Congress temporarily turns the tide on scheduled 10.1% cut to Medicare physician fees

Physicians concerned about an impending 10.1% reduction in physician fees from the Centers for Medicare and Medicaid Services (CMS) can breathe a little easier"--"for the next 6 months. After several weeks of wrangling among Congressional Republicans, Democrats, and the White House, Congress passed the Medicare, Medicaid, and SCHIP Extension Act of 2007, which President George W. Bush signed into law on December 23, 2007. The legislation authorizes a 0.5% increase in physician payments from the government-funded Medicare program. This minimal 0.5% increase expires June 30, 2008, at which time the statutory 10.1% cut goes back into effect, absent further legislative intervention.

Since 1999, CMS has calculated physician fees using the Sustainable Growth Rate (SGR) system. The SGR system establishes annual spending targets for various items provided in connection with physician's services, such as office visits, laboratory tests, durable medical equipment, outpatient therapy, and physician-administered drugs. According to the US Government Accountability Office, "the SGR system is designed to apply financial brakes whenever spending for physician services exceeds predefined spending targets?by reducing physician fees or limiting their annual increase."

 The complex formula bases yearly increases in target spending on a combination of factors, which include inflationary adjustments for physician services, projected fluctuations in Medicare enrollment, changes to the Medicare plan, and the estimated 10-year average real gross domestic product (GDP) per-capita, which currently is slightly above 2%. The system evaluates Medicare spending cumulatively, beginning with 1996, which means that underspending one year would be offset by any overspending in subsequent years.

 If cumulative spending targets are exceeded, the SGR system requires corresponding reductions in physician fees to counter prior and future overspending. 

Several physicians' advocacy groups have been urging Congress to replace the SGR system with one tied to physicians' actual costs rather than the GDP. The GDP fails to account for some of the root causes of rising fees: hikes to malpractice insurance rates, personnel additions to accommodate a growing number of patients, and the costs of implementing new technology. Instead of creating a long-term solution, Congress enacts stopgap legislation each year to forestall the mandatory physician fee reductions. These cuts are likely to get deeper as the number of individuals enrolled in Medicare continues to grow. 

In a ruling last month, the Equal Employment Opportunity Commission established that companies which provide health care benefits for retired employees are not obligated to offer coverage for retirees aged 65 or older who are eligible for Medicare. A corresponding influx of enrollees in the Medicare system will increase the volume of services provided and, under the SGR formula, mandate even steeper reductions in physician reimbursements down the line. Sixty percent of physicians responding to a May 2007 survey of American Medical Association (AMA) members said that further cuts in Medicare reimbursements would force them to "limit the number of new Medicare patients they treat."

 This adds up to bad news for America's baby boomers, now approaching retirement age. 

With 2008 being an election year, Congress likely will not allow CMS to scale back physician fees this year, but that does not mean doctors should rest easy. The AMA encourages physicians to get involved and contact their elected officials. Unless the SGR system is changed or modified, physicians who treat Medicare patients will be forced to continue floating their financial security on the political tides. SR

Medicare, Medicaid, and SCHIP Extension Act of 2007, Stat 2499 (2007).

Medicare physician payments: Considerations for reforming the Sustainable Growth Rate system

. Washington, DC: US Government Accountability Office; 2005. Testimony GAO-05-326 T.

Medicare physician payments: Concerns about spending target system prompt interest in considering reforms

. Washington, DC: US Government Accountability Office; 2004. Report GAO-05-85.

American Medical Association. Member Connect? Survey: Physicians' reactions to the Medicare physician payment cuts. Available at: 

www.ama-assn.org/ama1/pub/upload/mm/31/highlights.pdf

As a result of changes to the 2008 Medicare Physician Fee Schedule rates, CMS has extended the participation decision period for physicians to February 15, 2008. Participating status changes, however, will be effective as of January 1, 2008.

On October 17, 2005, the Bankruptcy Abuse Prevention and Consumer Protection Act went into effect. One of the major goals of the legislation, according to US Senator Jeff Sessions (R, Alabama), was to disallow people from filing bankruptcy simply for the sake of taking advantage of a financial opportunity provided by the government. 

"People who can afford to pay all or a part of their debts over a limited period of time should not get off scot-free," Sessions explained.

One year later, the number of bankruptcy filings for the first three quarters of 2006 fell by nearly one million from the previous year. For the time being, at least, the new law was making an impact.

But for the month of June 2007, consumer bankruptcy filings increased nearly 37% over the previous year, according to the American Bankruptcy Institute. And for the first quarter of 2007, filings were up 66% over the same period in 2006.

While the 2007 numbers are down from the all-time high figures of 2005, they're still a sad reminder that bankruptcy—for a wide range of reasons&mdash;is widespread in the United States. It can happen to anyone, at any time. Even to doctors.

Just how vulnerable are physicians? Consider these case histories.

In the process of opening a medical clinic in town, Kevin Jensen, MD, a family physician practicing in Carson City, Nevada, and his wife, Lois, borrowed all they could borrow and mortgaged everything they could mortgage in order to come up with the equipment necessary to open the clinic. They spent the next several years working between 60 and 90 hours a week to get the clinic off the ground. 

Then, just when it started to look like their life's effort and sacrifice would pay off, Dr. Jensen decided to purchase an airplane. He learned how to fly and obtained his pilot's license.

One September morning in 2001, Dr. Jensen and his wife climbed into their airplane and took off from the Carson City Airport. Just after takeoff, the plane's engine cut out. Dr. Jensen tried to turn the plane around and bring it in for a landing at the airport but, without power, he was unable to make it back. The low-flying plane clipped a tree and fell into the backyard of a home near the airport.

Miraculously, no one was killed. Dr. Jensen shattered a leg and his wife had minor bumps and bruises. But the plane had fallen on the owner of the home and inflicted serious back injuries. Litigation followed. The homeowner sued Dr. Jensen, his wife, the airplane mechanic, and the mechanic's shop. Everyone began pointing fingers at someone else.

"It was a horrible tragedy," recalls Derek Rowley, a friend of Dr. Jensen's and cofounder of Nevada Corporate Headquarters, a premier business formation and small business consulting firm. "For the next several years, it took everything Dr. Jensen had to defend the lawsuits. He lost his practice, and all of his savings and retirement."

Dr. Jensen ended up selling his practice to a company that hired him on as a staff physician—but with a contract containing a no-compete clause stating he couldn't practice in competition anywhere within 50 miles of the clinic. A few months later, when Dr. Jensen was let go, he found himself unemployed and unable to practice medicine in his hometown.

Dr. Jensen had to relocate, and began serving as an emergency department physician at a rural Nevada hospital in Mesquite. Shortly thereafter, he called Rowley and asked if they could have lunch. "I've lost everything once, and I'm in the process of trying to get my feet under me again," Dr. Jensen told his friend. "I want to rebuild my life, and I don't want to make the mistakes I made before. What do I need to do to protect myself?"

Rowley explained how Dr. Jensen needed to organize and structure his business, and how he needed to be careful about the way he held assets so that they weren't exposed.

Dr. Jensen has since begun rebuilding his life, only this time he's doing it with some planning and foresight. He has several business entities that he uses not only for his practice, but as building blocks toward his retirement.

"I'm very pleased to say that he's going to recover from this, but he's 50 years old and he's starting from scratch," Rowley says. "But at this point, I think he's counting his blessings."

Maurice Ramirez, DO, BCEM, CNS, CMRO, is a highly regarded physician in south Florida. He is also the founding chairperson of the American Board of Disaster Medicine, and a senior physician-federal medical officer for the Department of Homeland Security. When trouble calls, he responds.

"My equipment is in the back of my car," Dr. Ramirez explains. "I can leave on 2 hours' notice from anywhere inside the continental United States. If I travel on vacation, I carry 200 lb of gear with me."

Dr. Ramirez and physicians like him deploy any time there is a nationally declared disaster, an event of national significance, or in anticipation of a potential terrorist attack, as an advance field medical team. Part of his team was at the New Orleans Superdome following Hurricane Katrina.

"We are effectively the M.A.S.H. units within the continental United States," says Dr. Ramirez, who, during the 2004 and 2005 hurricane seasons, spent 12 weeks away from his practice. Dr. Ramirez has seen what lack of financial preparation can do to a physician's practice.

"A member of my disaster response team had to resign his commission, and this is a guy who held the third highest rank you can get," Dr. Ramirez explains. "He's an anesthesiologist, and all of the hospitals where his group had contracts had terminated the contracts because he wasn't around. He had become, in their words, unreliable, because over a 14-month period of time, he had been gone 12 weeks."

Dr. Ramirez explains that financial and business preparation is critical to physicians who volunteer their time as he does. But he adds a third, and maybe even more important element—relationship preparation, or what he likes to call physician self-disclosure.

"I know a physician assistant who was not just Army Reserve but he was Army Ranger Reserve, and every one of his patients knew that he was a Ranger, and knew that as we were ramping into the potential for a second Gulf War, every one of his people knew that at some point he would probably get a deployment call up," Dr. Ramirez explains. "He was in-country for a solid year before he went back to that practice. And when he came back, his patients didn't migrate, every one of them insisted on going back to Dr. Rob. Because he told them in advance that he was going. And the patients actually brought him cake and cookies. I swear, the guy actually gained 5 lb before he left. And I think that's the relationship issue."

Dr. Ramirez advocates financial resilience, or good money management. He says that there are many physicians who end up losing their practices because of being called up for National Guard deployments. And the only thing they've done wrong is that they've failed to provide for their own financial security.

"If you know that you're going to go from a business income of $750,000 a year to captain's pay, which if I remember correctly is somewhere around $78,000 a year, taxable, it's going to be less than 12% of what your business usually brings in," Dr. Ramirez says. "And yet your expenses are not going to go down that much. You need to have a year's worth of capital in place if you know you could be gone for a year. And you must have projects for everyone in the office. That way, on days when you don't have cross-coverage in the office, your people have something to do. They can follow up on past due accounts or catch up on the conversion to electronic records."

Dr. Ramirez saw this very principle in practice when his own doctor recently took a 1-month vacation. "He came back to an office that was clean, everything was done, everything was filed, and they had their best month of collection the month that he got back, because they had been able to chase accounts that nobody had the time to hunt down," Dr. Ramirez says. "It's about financial preparation, relationship preparation, and business preparation."

Don Saelinger, MD, and two other physicians founded Patient's First Physician Group (PFPG) in the 1970s, and over time built it into the practice to be associated with the Cincinnati-northern Kentucky market.

In 1993, with managed care beginning to roll into the local market, PFPG was looking for capital in order to grow its business. After considerable investigation into practice management companies, Dr. Saelinger and his partners sold their practice to Health Partners, a privately held company, for stock and cash, but they maintained their own infrastructure.

Then, in 1995, Health Partners was sold to a publicly traded company called FPA, which, in 1999, filed Chapter 11.

"That made our management company bankrupt, and essentially, our practice bankrupt," says Dr. Saelinger, adding that he and his colleagues could see the handwriting on the wall. "The leadership of FPA began pushing us for our cash, which they had not done before. They tried to get us to move our infrastructure to their national infrastructure, which we steadfastly refused to do. And I guess the advice to physician groups that want to survive to the end of the day is don't give up your infrastructure."

The next 2 years took "a couple of years off my life," Dr. Saelinger recalls, but in the end, he and his colleagues banded together to repurchase their management company from bankruptcy court and have continued straight uphill ever since—adding new doctors, new sites, a new surgery center, and a variety of other capabilities.

One of the key elements to the practice's success, says Dr. Saelinger, is "aligning the physician incentives so that when push comes to shove, there's not a lot of pulling apart in your organization. You don't have disruption in the ranks. And as we moved forward in our new model after the bankruptcy, physician ownership of the organization was a key element in building the group."

PFPG was recently acquired by St. Elizabeth Medical Center in Covington, Kentucky, the leading hospital in the area, a move that Dr. Saelinger says positions the practice for success no matter what health care reimbursement model comes down the pike. And he credits his solid physician organization with making it all possible.

"Doctors are usually not very readily convinced that they should pull money out of their pockets for their organization," Dr. Saelinger explains. "That's a difficult sell, generally. But we were able to do that, and that's what saved the day."

Should you invest in private equity firms?

Gain insights on bankruptcy, private equity firms, and more.

Surgeon's Bulletin Board

	A new year often brings change, and after 30 years in print, we felt it was time to make some improvements. As you peruse this issue of 

, you will no doubt notice several changes to our layout, all designed to enhance your reading experience. Articles now include headers so you can see what is covered at a glance, and each one has a highlighted abstract summarizing its scope and conclusions. We have also added Practice Points, which serve as snapshots of key diagnostic and therapeutic information. Department offerings have been expanded and now include radiology and transplantation sections (see our Radiology Rounds 

). The greatest change, however, is that we can now pack more content into each issue, simply because we have expanded our column widths. Our January 2008 edition includes 7 articles, more Recertification Practice Quiz questions, and a feature from the Surgeon's Bulletin Board, which many of you have written to say you miss! We still have Dr. Jaffe's candid editorials, our full-color anatomical charts, and the same quality articles you have come to expect from 

. We hope you enjoy the new format and would love to hear your thoughts about these changes. As always, you can write to us at 

A new year

	These questions are similar to those asked on the American Board of Surgery Recertification Examination. Use them to prepare for the examination, fulfill learning requirements for various maintenance of competence programs, or simply improve your surgical knowledge. Answers can be viewed by following the "Read the Answers" link at the end.

		The greatest improvement in breast cancer survival rates is due to		

Serum creatinine concentrations increase by 40%

		The most common soft-tissue sarcoma found in the lower extremity is		

Innervates the sternocleidomastoid muscle

Is commonly injured during carotid endarterectomy procedures

Is within the operative field during routine carotid surgery

Provides sensory fibers to the pharyngeal mucosa

		Malignant hyperthermia is associated with		

Uncontrolled accumulation of potassium in muscle cells

		In laparoscopic surgery, the vessel most likely to be punctured during trochar placement is the		

		Primary peritonitis (spontaneous bacterial peritonitis)		

Is generally caused by gram-negative bacteria

Is more likely to occur in patients with cirrhosis

Has a well-characterized genetic predisposition

Is associated with congenital cardiac lesions in 25% of patients

Should be repaired only in patients with decreased cardiac or respiratory reserve

		A patient with a head injury who opens his or her eyes in response to pain, exhibits withdrawal in response to stimulation, and utters inappropriate words has a score on the Glasgow Coma Scale of		

Synthesis requires cutaneous ultraviolet activation

Is the most common commercial form of vitamin D

		In grade II traumatic liver lacerations		

The abdomen should be packed and closed with the lap pads in place

There is no risk of hepatic ischemic injury if a Pringle maneuver is performed

Can be distinguished from bronchitis on bronchoscopy

Primarily affects the apical segments of the upper lobes

Can occur distal to a bronchial obstruction

		All of the following statements about morbid obesity are correct, except:		

Life expectancy is decreased by an average of 6 years.

Operation is associated with a 4-fold increase in the rate of wound breakdown.

Each increment of 1.0 kg/m2 above 40 increases the likelihood of congestive heart failure by 6%.

Loss of 30% of body weight is necessary to improve associated comorbidities.

Pulmonary functional residual capacity is decreased by 66%.

Using screening mammography, most carcinomas of the breast can now be identified while they are stage I lesions. Tumors smaller than 1 cm that have no axillary node involvement are associated with a greater than 95% survival rate. There have been relatively few improvements in ablative surgery, other than a focus on minimalism, and enormous improvements in reconstructive techniques. Sentinel lymph node biopsy has facilitated axillary staging, but it has not improved survival rates, per se. Adjuvant chemotherapy has improved the survival chances of patients who have more advanced lesions, but screening mammography has decreased the incidence of these tumors. Fewer than 20% of breast cancers have a genetic basis, so the benefit of genetic screening, while important, is limited. Currently, genetic screening and counseling are not widespread, even among individuals with a strong family history of breast cancer.

The red cell mass increases significantly in pregnancy, despite the fact that the hematocrit generally falls. The increase (not decrease) in fibrinogen and the associated fall in protein S concentrations cause relative hypercoagulability. Serum creatinine levels fall by 20% as a result of dilution due to increased extracellular fluid volume. Gastric emptying is delayed (not accelerated), thereby increasing the risk of aspiration. Tidal volumes increase (not decrease), causing a compensatory respiratory alkalosis.

Malignant fibrous histiocytoma is the most common soft-tissue sarcoma found in the lower extremity, with liposarcoma, synovial sarcoma, and fibrosarcoma ranking second, third, and fourth, respectively, although the lower extremity is the most common site for all these lesions. Leiomysarcomas rarely occur in the lower extremity (but they do occur), and most originate from the viscera.

The spinal accessory nerve innervates both the sternocleidomastoid and trapezius muscles. It contains no sensory fibers; the glossopharyngeal nerve provides the sensory supply to the pharyngeal muscle. The spinal accessory nerve crosses superficial to the internal jugular vein; because it is so far cephalad, it lies outside the field of routine carotid surgery and thus is rarely injured. It can be injured, however, if the carotid artery must be dissected far cephalad to obtain proximal control.

Creatinine kinase levels peak 12 to 18 hours after the onset of malignant hyperthermia. The disease is associated with severe acidosis (not alkalosis), and calcium (not potassium) accumulates in muscle cells. Malignant hyperthermia is initiated by administration of succinyl choline, caffeine, halothane, and other halogenated anesthetic agents. This entity causes severe hyperkalemia (not hypokalemia).

The right common iliac artery lies directly beneath the umbilicus. The aorta and vena cava bifurcate just above this point. The left common iliac artery lies to the left of the umbilicus, and the right common iliac vein lies directly beneath the corresponding artery and is protected.

Patients susceptible to primary peritonitis include those with cirrhosis, nephrotic syndrome, and immunosuppression (either endogenous, which occurs with aquired immunodeficiency syndrome or malignancy; or exogenous, which results from the use of immunosuppressive medications). In primary peritonitis, the bloodstream acts as the portal of entry for bacteria; in peritoneal dialysis, the problem is that the peritoneal cavity is contaminated by dialysis fluid (this is considered iatrogenic peritonitis). The most common organisms are all gram-positive (

). Once the diagnosis of primary peritonitis has been made, treatment is administration of antibiotics. Primary peritonitis is far more common in children than adults.

More than 75% of those afflicted with pectus excavatum are males, in whom the condition is generally less psychologically disturbing. Although 30% of patients have a familial history of sternal abnormalities, no genetic predisposition has been identified. Surprisingly, only 1.5% of afflicted patients have concomitant congenital cardiac abnormalities. This lesion causes significant psychosocial problems and interferes with normal self-image, so repair is indicated even when there is no significant cardiac or respiratory compromise. Repair is recommended when patients are between 2 to 5 years old.

Opening the eyes in response to pain counts for 3, withdrawal for 4, and uttering inappropriate words for 3, for a total Glasgow score of 10.

Conversion of 7-dehydrocholesterol (not ergosterol, the predecessor of vitamin D2) to D3 requires ultraviolet light, generally sunlight. Vitamin D2 is the most common commercial form of the vitamin. Vitamin D3 stimulates calcium transport and is synthesized in the kidneys.

There are good data which document that there is no advantage to draining superficial hepatic lacerations. Closing the laceration creates an area of dead space, which permits the accumulation of blood and facilitates subsequent infection. The bleeding in grade II lacerations should be readily controllable, without the need for packing. Hemobilia occurs in fewer than 1% of grade II lacerations. The Pringle maneuver, while fairly safe for short periods of time, does cause ischemic injury, and this becomes particularly severe in the presence of hypothermia.

Bronchiectasis is a destructive process that involves the small bronchi and adjacent pulmonary parenchyma. It is initiated by localized bacterial infection and commonly occurs distal to a bronchial or bronchiolar obstruction caused by tumor, infected node, or foreign body. Diagnosis is made using imaging studies, not bronchoscopy; however, bronchoscopy is indicated to clear the bronchial tree of tenacious purulent secretions and rule out malignancy or foreign-body obstruction. The frequency of this disease has markedly decreased since the advent of antibiotics. Bronchiectasis affects the basal segments of the lower lobes, and 90% of cases can be successfully treated with antibiotics (and without surgery).

Accelerated acute rejection occurs regularly in patients with negative crossmatches. In fact, it often occurs in patients with low antibody titers and low PRA (panel reactive antibody) scores. This form of rejection is mediated by T lymphocytes, and is a form of cellular (not humoral) rejection. It occurs within 12 to 24 hours. Rejection that occurs immediately or within 1 hour of transplantation is hyperacute rejection; this is antibody mediated and caused by the recipient reacting to donor antigens to which they have been presensitized. Accelerated acute rejection occurs after 1% to 4% of transplants and carries a terrible prognosis (>e;40% organ loss).

Loss of as little as 5% to 10% of body weight causes significant improvement in comorbidities, such as diabetes, hypertension, and sleep apnea. The remaining statements are true.

American Board of Surgery Recertification Examination

 Multiple primary neoplasms identified within 6 months of one another are termed 

. Synchronous neoplasms are uncommon and present unique considerations for treatment and prognosis.

 This paper reports the case of a patient who was found to have simultaneous duodenal villous adenoma, hepatocellular carcinoma, and colon cancer. It also discusses the importance of considering associations between these cancers.

 When diagnosing any of the three cancers identified in this patient, it is important to screen for additional primary tumors. Patients have a good prognosis when colorectal cancers are diagnosed and treated in their early stages.

 describes multiple primary neoplasms discovered within 6 months of one another. This uncommon condition raises prognostic and treatment dilemmas. We report the case of a patient who presented with three distinct synchronous primary neoplasms, consisting of duodenal villous adenoma, hepatocellular carcinoma, and colonic adenocarcinoma. We also review the literature regarding synchronous neoplasms.

	An 83-year-old white man with a medical history of hypertension and diabetes presented to our institution reporting fatigue and a 3-month history of intermittently passing dark-colored stools. He said that his stools were not tarry and he had noticed no bright red rectal bleeding. He also reported experiencing no nausea, vomiting, jaundice, shortness of breath, dark urine, fevers, chills, or sweats. Routine laboratory evaluations revealed microcytic anemia and a hemoglobin level of 4.2 g/dL.

	Colonoscopy confirmed the presence of colorectal carcinoma, and an upper endoscopy study revealed an ampullar villous adenoma in the duodenum. Preoperative computed tomography (CT) scans showed a lesion in liver segments V and VI (Figure). Based on these findings, the patient was taken to the operating room for an exploratory laparotomy.

	Partial colectomy with ileocolonic anastomosis was performed, and a mobile spongiform lesion was resected from the distal second portion of the duodenum. A hard, 5-cm mass was palpated within hepatic segment V. Because there was no evidence of portal adenopathy or any other finding that would preclude resection, hepatic segmentectomy was undertaken, which achieved negative section margins. Intraoperative ultrasonography confirmed the absence of additional hepatic lesions.

	Subsequent pathological examination of the specimens revealed three distinct primary cancers: a 4 x 5 x 1-cm moderately differentiated adenocarcinoma of the transverse colon; a 4 x 3 x 1-cm villous adenoma from the distal second portion of the duodenum; and a 4.0 x 3.5-cm hepatic lesion that was determined to be a well-differentiated hepatocellular carcinoma. The patient did not receive adjuvant therapy. At 2-year follow-up, he had no evidence of recurrence or any metastatic disease.

	In addition to presenting a rare example of three synchronous primary cancers, our case report inspires clinicians to consider the associations between these cancers. Although numerous reports discuss the incidence of synchronous colonic neoplasms, few studies evaluate the relationship between colon cancer and synchronous, extracolonic primary neoplasms. One such study found that patients with colorectal cancer have extraintestinal primary cancers 1.4 times more often than expected.

 Mainwaring and colleagues concluded that the incidence of a synchronous, extracolonic primary neoplasm is at least equal to that of a second colonic lesion (between 4% and 5%).

 These reports emphasize the importance of evaluating patients with known colonic primary neoplasms for synchronous colonic and extracolonic tumors according to the recommendations set by the American Cancer Society. Investigations should include using diagnostic modalities such as mammography, colonoscopy, and prostate-specific antigen testing.

	Our patient underwent colonoscopy and upper endoscopy to ascertain the cause of his acute blood-loss anemia. Because his duodenal and colonic neoplasms were discovered at the same time, it was necessary to consider the relationship between duodenal adenomas and synchronous colorectal neoplasia. Neoplasia of the small intestine is rare compared with that of the colon.

			It is important to evaluate patients with known colonic primary neoplasms for synchronous colonic and extracolonic tumors according to the recommendations set by the American Cancer Society.

			Patients who have duodenal adenomas should undergo colonoscopy to determine whether a synchronous colonic neoplasm is present.

			Surgical resection is adequate for node-negative colorectal tumors; however, metastatic or node-positive tumors require adjuvant therapy.

	Murray and colleagues conducted a retrospective case control study evaluating the records of patients who visited their institution from 1992 to 2002.

 The authors observed that patients with duodenal adenomas were more likely to have associated colorectal neoplasia than the age- and sex-matched control group.

 Apel and associates examined the records of duodenal adenoma patients from 1990 to 2003 and concluded that their risk of concomitant colonic adenoma was 20 times higher than that of the general population (these patients did not have familial adenomatous polyposis).

 This suggests that patients who have duodenal adenomas should undergo colonoscopy to determine whether a synchronous colonic neoplasm is present.

	Is there any association between hepatocellular carcinoma and synchronous primary neoplasia? Nzeako and colleagues retrospectively reviewed a series of 1,349 hepatocellular carcinoma cases over a 14-year period and found that 5.5% of patients with these carcinomas had at least one other synchronous primary malignancy; the presence of extrahepatic primary malignancies had no effect on survival.

 It is also noteworthy that, in this North American series, the most common extrahepatic primary malignancies occurred in the gastrointestinal system, and colonic adenocarcinoma was the most common gastrointestinal tumor.

	Due to widespread screening programs, most colorectal cancers are diagnosed at an early stage, and patients have a good prognosis. Surgical resection is adequate for node-negative tumors; however, metastatic or node-positive tumors require adjuvant therapy.

	Our case presents an uncommon example of three synchronous primary malignancies and underscores the importance of evaluating patients for additional primary tumors when confronted with a colonic adenocarcinoma, duodenal adenoma, or hepatocellular carcinoma. Awareness of the associations between different cancers would enable earlier detection of additional synchronous tumors. Future studies of these associations may provide insight into carcinogenetic pathways and lead to new treatments and preventive stratagems.

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.

		Schottenfeld D, Berg JW, Vitsky B. Incidence of multiple primary cancers. II. Index cancers arising in the stomach and lower digestive system. 

		Mainwaring RD, Rivera J, Wilson W. Synchronous hepatocellular carcinoma and adenocarcinoma of the colon. 

		Arber N, Neugut AI, Weinstein IB, et al. Molecular genetics of small bowel cancer. 

		Murray MA, Zimmerman MJ, Ee HC. Sporadic duodenal adenoma is associated with colorectal neoplasia. 

		Apel D, Jakobs R, Weickert U, et al. High frequency of colorectal adenoma in patients with duodenal adenoma but without familial adenomatous polyposis. 

		Nzeako UC, Goodman ZD, Ishak KG. Association of hepatocellular carcinoma in North American patients with extrahepatic primary malignancies. 

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Steven E. Brooks, Surgical Resident; Reza F. Saidi, Chief Surgical Resident; Alasdair McKendrick, Consultant Colorectal Surgeon; Michael J. Jacobs, Consultant Surgeon, Department of Surgery, Providence Hospital and Medical Centers, Southfield, MI; Clinical Associate Professor, Wayne State University School of Medicine, Detroit, MI

Synchronous neoplasms: Duodenal villous adenoma, hepatocellular carcinoma, and colon carcinoma

 Breast cancer is one of the leading causes of death among women. Although metastatic spread of breast cancer to the abdomen and pelvis has been reported, metastatic disease to the rectum is unusual.

 This paper discusses the case of a breast and ovarian cancer patient who presented with an isolated, late metastasis to the rectum that was treated with en bloc low anterior resection. Histological evaluation revealed a poorly differentiated adenocarcinoma of the breast metastatic to the wall of the rectum, consistent with the patient's primary breast carcinoma. The authors review the literature and discuss breast cancer metastasis and its associated outcomes.

 Invasive ductal carcinoma of the breast metastasizes most commonly to the bones, lungs, liver, and brain; however, metastasis to the abdomen and pelvis is possible and should not be overlooked. The case reported in this paper was particularly complicated because of the patient's history of ovarian cancer and the possibility that the mass was a recurrence of the ovarian cancer. A longer median survival has been reported in abdominal and pelvic metastases patients who have received optimal debulking, and in those who experience an initial disease-free interval greater than 5 years before recurrence.

	Breast cancer is a common malignancy in women and most frequently metastasizes to the bones, lungs, liver, and brain. Metastatic disease to the pelvis is rare, with a reported rate of 0.5%, and most cases involve the adnexae.

 We report a case of invasive ductal carcinoma metastasizing to the wall of the rectum in a patient with a history of breast and ovarian cancer. Because of the location of the mass, recurrent ovarian cancer was suspected. Histopathology revealed the mass to be a poorly differentiated adenocarcinoma of the breast metastatic to the wall of the rectum. We discuss metastatic disease from breast cancer and the factors that affect patient prognosis.

	A 40-year-old woman with a history of breast and ovarian cancer presented for routine post-treatment follow-up. Her stage IIB breast cancer had been diagnosed 10 years earlier. She underwent mastectomy and received postoperative adjuvant chemotherapy at that time. Seven years later, the patient developed stage IIIA ovarian cancer (Figure 1), which was treated with neoadjuvant chemotherapy, abdominal hysterectomy, bilateral salpingo-oophorectomy, and debulking of omental and peritoneal implants. The patient remained healthy and had no clinical or radiographic evidence of disease for an additional 3 years. She then developed constipation, and rectovaginal examination noted a fixed, smooth, anterolateral rectal mass 6 cm from the anal verge. Colonoscopy revealed the mass to be submucosal without mucosal involvement. Computed tomography (CT) scanning showed a 5-cm extraluminal rectal mass and no evidence of metastatic disease (Figure 2). Her carcinoembryonic antigen level was normal, but her CA125 level was elevated at 526 U/mL (normal, <35 U/mL). The clinical and imaging findings were suspicious for recurrent ovarian cancer localized to the pelvis; there was no evidence of distant disease. The patient was advised to undergo surgical resection.

	Exploration of her abdomen and pelvis revealed a localized pelvic tumor emanating from the anterior rectal wall, without evidence of carcinomatosis. An en bloc low anterior resection was performed, which included a portion of the posterior vaginal wall to ensure negative margins. A primary stapled end-to-end colorectal anastomosis was performed without fecal diversion. Histopathologic evaluation of the surgical specimen revealed ductal carcinoma of the breast metastatic to the rectal wall (Figure 3). Lymphovascular infiltration was noted, and three lymph nodes were positive for metastatic disease. The tumor histology, including negative estrogen and progesterone receptor status and negative overexpression of HER2/

, were identical to the patient's primary breast cancer.

	The patient's postoperative course was uneventful and she was discharged from the hospital 4 days later. She underwent postoperative radiation therapy to the pelvis and received systemic chemotherapy. At 3-month follow-up, she showed no evidence of recurrent disease clinically (CA125 level, 22 U/mL) or radiographically on bone and CT scans (Figure 4).

	Metastatic disease from invasive ductal carcinoma of the breast usually involves the bones, lungs, liver, and brain, and involvement of the gastrointestinal tract is rarely encountered. Invasive lobular carcinoma of the breast, however, is known to metastasize to the gastrointestinal and genitourinary tracts in addition to the peritoneum and retroperitoneum.

 We could identify no other reports in the literature of a ductal breast cancer that metastasized solely to the rectum.

	In this particular case, it is important to note that our patient's presentation with ovarian cancer and ascites was complicated by her history of breast cancer. Her abdomen was explored only after she exhibited a near complete response to empiric chemotherapy directed against epithelial ovarian carcinoma. Because she had received chemotherapy preoperatively, the histologic diagnosis of ovarian carcinoma could not be made conclusively, and it was unclear whether her ovarian cancer was of breast or ovarian origin.

	Recurrence of advanced ovarian carcinoma is almost universal, which is why our patient's rectal mass was suspected to be of ovarian origin. Clinical complete response to therapy is associated with a 1-year recurrence rate of 50% and a 2-year recurrence rate of 80%.

 Treatment of recurrent disease is largely determined by the patient's disease-free interval. Multiple authors have found statistically significant survival advantages associated with a disease-free interval greater than 12 months.

 The lengthy disease-free interval between our patient's primary ovarian cancer therapy and the presentation of the isolated rectal mass made a surgical approach favorable, even though her lesion turned out to be metastatic breast cancer.

	The overall rate of pelvic metastases in patients with breast cancer is relatively low. Drotman and colleagues reviewed the pelvic CT scans of 2,426 breast cancer patients; the scans were taken over a 9-year period.

 Only 17 patients (0.5%) were found to have pelvic metastases, of which 11 cases were isolated to bone, 5 were adnexal, and 1 had multiple sites of involvement (bones, adnexa, and endometrium). The majority of patients in the study (65%) had an initial diagnosis of invasive ductal carcinoma.

		Treatment of recurrent ovarian disease is largely determined by the patient's disease-free interval.

	Abu-Rustum and colleagues reviewed breast cancer patients who underwent laparoscopy or laparotomy over a 15-year period.

 In this cohort of 821 patients, 59 (7%) had metastatic disease to the abdomen or pelvis. Of these patients, 42 (71%) had adnexal or endometrial involvement, 7 (12%) had bone metastases, 5 (8.5%) had liver involvement, and the remaining 5 (8.5%) had multiple metastatic sites. In the subgroup of 59 patients with abdominal or pelvic metastases, 43 (73%) had an initial diagnosis of invasive ductal carcinoma. Similar to our case, the majority of these patients (69%) had positive axillary lymph nodes and underwent adjuvant chemotherapy (90%) after the breast cancer was diagnosed. Following debulking surgery, patients with no gross residual disease survived longer than those who had grossly positive margins, with a median survival period of 36 months and 20 months, respectively. Furthermore, when the time from initial diagnosis to recurrence exceeded 5 years, the median survival after recurrence was longer (36 months vs 17 months for recurrence diagnosed before 5 years).

		In cases of early onset breast cancer, genetic mutations (namely BRCA1 and BRCA2) must be considered and genetic counseling should be encouraged.

	Our patient was found to have recurrent metastatic disease 10 years after the initial breast cancer diagnosis. We were able to achieve grossly negative margins and the patient was referred for pelvic radiotherapy followed by chemotherapy because of the poor histologic features of her tumor. Additionally, because of her age at initial presentation and strong family history of breast cancer, the patient had been previously referred for genetic counseling. In cases of early onset breast cancer, genetic mutations (namely BRCA1 and BRCA2) must be considered and genetic counseling should be encouraged.

Devin P. Puapong, Surgical Resident, Department of Surgery; Raquel Goldhardt, Surgical Resident, Department of Surgery; Scott E. Lentz, Staff Surgeon, Department of Gynecologic Oncology; Najeeb S. Alshak, Chief, Department of Pathology and Laboratory; Maher A. Abbas, Chief, Section of Colon and Rectal Surgery, Kaiser Permanente Los Angeles, Los Angeles, CA

January 2008

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Synchronous neoplasms: Duodenal villous adenoma, hepatocellular carcinoma, and colon carcinoma

Invasive ductal breast cancer metastatic to the rectum

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