Don?t let an old ID delay your Medicare payments

Could you be sued for Good Samaritan care?

Medicare pulls the plug on reimbursing hospitals for preventable errors

Lap band or lifestyle change to cure type 2 diabetes?

Conquering the communication gap: Understanding your patient

	Time is money, especially the time patients spend with their physicians, and that limited time should not be spent discussing what you did on your summer vacation. In a study published in the 

, researchers sent actors posing as new patients to 100 experienced, primary care physicians in the Rochester, New York, area who had agreed previously to take part in the study. Results showed that in 34% of these unannounced fake-patient visits, doctors wasted time talking about themselves instead of what ailed the patient.

	Talk ranged from discussion about the doctor?s own health problems to his or her personal political beliefs. Researchers concluded that 85% of these discussions were useless to the patient, and 79% of these conversations never returned to the reason for the patient?s visit. Eleven percent of doctors who engaged in these off-topic discussions became disruptive and argumentative with the patient during the appointment.

	Don?t let an old ID delay your Medicare payments

	On March 1, 2008, physicians who submit Medicare claims electronically will need to include their national provider identifiers (NPIs) in the primary fields on the claim form. NPIs may be used alone or in combination with the legacy identifiers (IDs), but claims that do not include an NPI in the primary fields will be rejected or returned as "unprocessable." After May 23, 2008, the Centers for Medicare & Medicaid Services (CMS) and all other payers will only process claims that include NPIs.

	To ensure a smooth transition to the new system and protect yourself from possible hiccups, the American Medical Association recommends you take the following four steps:

		Make sure that your new NPI information matches the information associated with your legacy identifier. In September 2007, CMS directed carriers to stop processing claims when an appropriate match cannot be made between a physician's NPI and his or her ID. Some physicians have experienced considerable delays in receiving payments and, in rare cases, their payments have stopped altogether. To keep this from happening to you, take the time to validate your NPI information before submitting any claims by visiting the NPI Website at 

, calling the NPI enumerator at (800) 465-3203, or sending an e-mail to 

		If you have not already done so, start testing your Medicare claims. Submit a few test claims that contain both NPIs and legacy identifiers. After these claims process successfully, send in another small batch of claims, but this time include only your NPI in the primary provider fields. If these get processed without a hitch, you can increase the number of claims you submit with NPIs incrementally, until you are confident that you are fully compliant.

		Always keep your NPI information current. Any changes to your NPI information must be reported to CMS within 30 days from the date of occurrence.

		Re-enroll in Medicare if needed. Remember, all single, incorporated surgical practices must have two NPIs: an individual number and a group or organization number.

	While there has been some speculation that the May 23 deadline may be extended, this seems unlikely, and physicians should accept the inevitable demise of legacy IDs. The sooner physicians begin using NPIs on claims, the sooner any payment wrinkles can be ironed out.

	Could you be sued for Good Samaritan care?

	With lawsuits an ever-present threat, physicians have become reluctant to offer emergency care in public. Even without emergency equipment, people expect physicians to administer care on site, but cautious physicians do not want to be held liable should their actions fail to produce a positive outcome. In most states, laws exist to protect emergency do-gooders in the majority of situations. Outside a physician's practice or hospital, Good Samaritan laws shield the physician from being sued for deeds or negligence. An article from 

 explains the law's basic requirements. Foremost is that treatment must be voluntary. If the treatment is provided in connection with a physician's employment or with the expectation of compensation, Good Samaritan laws do not apply. While a doctor who performs CPR on a flight may be given a complimentary upgrade to first class as a form of thanks, bumping a physician to first class in anticipation of an emergency constitutes a commission. Second, the patient must also consent; when a patient is unconscious or unable to respond, consent is implied. In the case of children, parents or guardians must consent to treatment, as usual. The third qualification under most Good Samaritan laws is that actions must be undertaken in a good faith effort to assist. In the case of emergency care, good intentions mean everything. Laws vary by state, so be sure you are up-to-date before traveling; some states actually fine physicians who do not assist during an emergency.

, hospital infections cause 90,000 deaths annually. With such a monster of a number looming over the medical community, more and more hospitals are adopting aggressive hand-hygiene surveillance and monitoring programs to stop the spread of bacteria on contaminated hands—some are even imposing penalties on medical staff who do not follow the rules. Despite strict guidelines issued by the Centers for Disease Control and Prevention (CDC), including wide adoption of alcohol- based hand-rub dispensers in patient rooms and hospital corridors, compliance rates remain stuck at 40% to 50%. The 

 reports that the CDC, the Institute for Healthcare Improvement (IHI), and two other leading infection control professional societies are collaborating on a program that uses behavior-modification techniques and guidelines to monitor and increase compliance. The IHI recommends implementing a program that holds hospital administrators and staffers responsible for noncompliance in their facility. This has led hospitals to adopt various strategies, such as including hand-hygiene compliance as a part of performance evaluations.

	Medicare pulls the plug on reimbursing hospitals for preventable errors

	Medicare regulations enacted in August 2007 dictate ending hospital reimbursement for treating patients for conditions or events that occurred during their hospital stay and are deemed preventable. These include health problems related to medical errors, injuries obtained at the hospital (for example, from falling), and infections that develop while hospitalized. Kenneth Kizer, MD, a patient safety advocate and former undersecretary for health at the Department of Veterans Affairs, predicts that this will "change how healthcare is provided in many institutions..."

	Starting October 1, 2008, the Centers for Medicare & Medicaid Services (CMS) will no longer reimburse hospitals for treating the following eight conditions:

		Mediastinitis after coronary artery bypass graft surgery;

		Urinary tract infections (UTIs) resulting from improper use of catheters;

		Vascular infection resulting from improper use of catheters;

		Objects left in the body during surgery;

	The last three conditions are considered "never events," meaning that everyone agrees they should never happen in a health care setting.

	When asked why these regulations are being enacted now, Dr. Kizer explained that this is just one more step in a series of steps that CMS is taking to try to improve the quality of care and make the system more accountable. "I think what [surgeons] need to understand is that there is more to come, that this is by no means the last of this sort of thing. And while they started with eight items, I will essentially guarantee you that the list will grow," he said.

	The new regulations include protective measures for Medicare subscribers that are designed to keep hospitals from billing patients for payments CMS withholds and to prevent hospitals from avoiding patients perceived to be at high risk for infection.

	The most common nosocomial infection is a catheter-related UTI. The Centers for Disease Control and Prevention (CDC) reports that 561,667 catheter-related UTIs occur annually. Bloodstream infections are also common in hospitals, and the CDC reports that there are 248,678 cases of center-line?associated bloodstream infections every year. The Institute for Healthcare Improvement estimates that at least 14,000 hospitalized patients die annually after contracting bloodstream infections.

	Many physicians claim that some conditions, such as bed sores, may occur even after the strictest precautions are taken. This argument, however, does not hold water with Dr. Kizer. "Bed sores, certainly the serious grade 3 and 4 ones, are preventable, even in very fragile patients. It's difficult, but it is doable. So I'm less sympathetic to that, because I know from clinical experience that it can be done."

	"Every year, millions of Americans suffer needlessly from preventable hospital infections and medical errors," said Lisa McGiffert, director of the Consumers Union's Stop Hospital Infections campaign. "These new rules are a good beginning for Medicare to use its clout to mobilize hospitals and improve care and keep patients safe."

	Although these regulations may indeed improve patient care, Dr. Kizer acknowledges that there are some real reservations. "Although people are reticent to discuss it in public, certainly in academic and some patient-safety circles, there is concern that this smacks of being punitive, and we've been trying to foster nonpunitive approaches to encourage openness and sharing of information and public dialogue of these errors when they occur. So I think there's some concern that this will not encourage open reporting," he explained.

	Dr. Kizer is more concerned about the possibility that these new regulations will inspire "creative coding," as hospitals hire consultants to find ways to circumvent coding the specified complications as preventable errors according to CMS guidelines. "The net effect is that [CMS] won't achieve its desired result, and you'll be driving information underground. It will be a lose-lose situation as opposed to what could be a win-win," he said. One way CMS could prevent this is by requiring hospitals to report all preventable errors. Dr. Kizer argues that "If it's mandatorily reportable by everyone, then it's out there, so one hospital is not going to be disadvantaged against another because one place found a way to code creatively and the one down the street didn't."

	The bottom line, according to Dr. Kizer, is that none of these errors should occur in the first place. "Everyone agrees you shouldn't operate on the wrong person. You can't justify that. You shouldn't give the wrong blood to somebody. You shouldn't lose babies. You shouldn't let old folks wander off and get hit on the highway. When they do, they should be reported, and someone should look into it. It's not a matter necessarily of trying to find blame, but it's a matter of trying to figure out what happened, so you can make the system work better the next time."

	For more information on the new Medicare regulations going into effect October 2008, as well as proposed additions to the list of hospital-acquired conditions for 2009, you can visit 

www.cms.hhs.gov/HospitalAcqCond/Downloads/hac_fact_sheet.pdf.

	Lap band or lifestyle change to cure type 2 diabetes?

	Many bariatric surgeons have long known what the 

Journal of the American Medical Association

 reported in January: obese patients with type 2 diabetes who undergo gastric banding often experience complete remission. An Australian study followed 60 patients who had type 2 diabetes and a body mass index (BMI) between 30 and 40. Thirty patients underwent gastric banding, while the remaining 30 were counseled on diet and lifestyle changes. It surprised no one when most patients who shed at least 10% of their body weight saw their diabetes improve or disappear. The real eye-opener was the stunning disparity between the gastric-banding group and the traditional diet-and-exercise group. Within 2 years, 73% of banded diabetic patients were cured compared with 13% of non-banded patients. Patients who underwent gastric banding lost an average of 20.7% of their body weight, whereas non-banded patients dropped only 1.7%.

	All the patients in this study had only mild cases of type 2 diabetes of relatively recent onset, and it is unknown whether gastric banding would produce the same results in patients with more severe disease. The study suggests, however, that treating diabetic patients with gastric banding while their condition is still mild would greatly reduce how many go on to develop more advanced disease. Complications associated with advanced diabetes include blindness, heart disease, kidney failure, and gangrene-related amputations. Thousands of people suffering from type 2 diabetes die each year.

	An uncomplicated gastric banding procedure costs between $17,000 and $25,000. Several major health insurance carriers refuse to pay for the surgery under any circumstances, whereas Medicare and some carriers cover gastric banding only for type 2 diabetic patients whose BMI exceeds 35. This study demonstrates that paying for gastric banding to treat diabetic patients with a BMI as low as 30 has the potential to save thousands of dollars down the road; the Center for Disease Control and Prevention lists the average healthcare cost for a diabetic patient at more than $13,000 annually.

	Conquering the communication gap: Understanding your patient

	The quality of health care balances on the edge of a growing rift in communication. Effective communication is the foundation of successful diagnosis and treatment and essential for ensuring superior patient care.

	Health care organizations are responsible for communicating complex medical information to a wide range of people, yet the idea that communication has been successful is often an illusion. Sometimes a physician mistakenly assumes there is mutual understanding, and other times a patient is too embarrassed to admit feeling confusion and pretends to understand. "Effective communication is at the heart of every health care interaction. Ineffective communication—for whatever reason&mdash;can lead to ineffective health care and bad outcomes, which means it's always an issue," suggests Matthew Wynia, MD, MPH, director of the Institute of Ethics at the American Medical Association (AMA).

	In an attempt to bridge the communication gap, the medical community has turned its focus on addressing the low health literacy level that plagues the United States. According to the AMA, nearly 90 million people in this country cannot read or comprehend the type of information physicians commonly provide, such as instructions printed on a pill bottle or patient education materials for postoperative care at home. There is no relationship between a low level of health literacy and intelligence. Often, the confusion results from language barriers, cultural differences, advanced age, or the patient's inattentiveness due to pain or discomfort. When you consider the vast and ever-increasing diversity among our country's population, the possibility of having patients whose health literacy is not up to par may be greater than most physicians imagine.

	"We've just gone through another national survey, and somewhere between 16% and 20% of the population has a really serious reading problem. They're saying below basic," says Joanne Schwartzberg, MD, Director of Aging and Community Health at the AMA. "So we know where we need to go, but we don't know how to get there," Schwartzberg adds. US Census Bureau statistics show that 1 in 5 Americans speaks a language other than English at home, and 8.1% of the population has limited English proficiency, which the Census Bureau defines as the ability to speak, read, understand, or write English "less than very well." This is projected to increase to 10% of the population by 2010. It is becoming more important than ever to find ways of breaking down language and cultural barriers to ensure that patient care is not compromised.

	Wynia cites informed consent as an area where cultural misunderstandings can come into play. "People who grew up in America know about the litigious climate of American medicine," Wynia says. "So physicians run this litany of 'well, you could have an infection, you could bleed, you could even die if that's the extreme'—and sign here." Someone raised in another culture may see the physician as being incompetent, while others may consider it bad luck to discuss bad outcomes.

	Schwartzberg says to make sure the patient is clear on what you are telling them. "Ensure the patient understands you by speaking simply and directly and by using what we are calling a ?teach back.' Ask the patient to summarize the key points that you've discussed. Make sure the patient understood them," Schwartzberg says. "The extent of the shame and embarrassment of these patients is another thing you want physicians to understand. These are very sensitive, very difficult issues," Schwartzberg adds. "Doctors are very skilled in talking about difficult issues with patients. The same kind of nonjudgmental ways they use to make people feel comfortable and bring up subjects that are very painful, they can use in terms of [fostering] patient understanding." It is important that patients do not feel disgraced when they do not understand, and they need to feel comfortable asking questions.

	The risk of facing a malpractice lawsuit is a significant enough reason on its own not to ignore this concern. "The responsibility to communicate successfully rests with the provider, not with the patient," says Steven Levin, MD, who was named 2007 Family Physician of the Year by the American Academy of Family Physicians. "It's not a legal excuse that the patient didn't understand." Schwartzberg cites the Joint Commission as reporting that 65% to 80% of all medical errors concern communication failures. Some cases involve provider-to-provider communication and others concern interaction between provider and patient. "Malpractice lawyers have told us it's primarily communication issues," Schwartzberg says.

—Percentage of Americans who feel that current American culture makes it hard to exercise regularly and maintain a healthy lifestyle.

(International Health, Racquet & Sportsclub Association, 2007)

—Percentage of consumers concerned about not being able to pay medical costs associated with a serious illness.

(Experian-Gallup Personal Credit Index Survey, 2007)

Articles

Surgical Rounds

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

Surgeon's Bulletin Board

	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.

		Breast cancer is identified on screening mammography in		

		In adults with cystic fibrosis, spontaneous pneumothorax		

Occurs more frequently than in the general population

Is generally caused by rupture of a bleb in the lower lobe of the lungs

Can be prevented by tight control of pulmonary infection

		Following renal transplantation, renal cell carcinoma		

Carries the same risk as in patients with normal renal function

Should be treated by heminephrectomy and transplant salvage

Occurs more frequently than among the general population

Is unrelated to acquired renal cystic disease

Occurs with normal frequency in native kidneys

		All of the following statements about morbid obesity are correct, 

Life expectancy is decreased by an average of 6 years

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

 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%

		All of the following statements about cryptococcosis are correct, 

Pulmonary involvement is generally self-limited

Meningeal involvement causes an acute illness

Prostatic involvement is fairly common in male patients

When properly treated, disseminated infection carries a 20% to 25% mortality rate

		In pleural effusions, transudates are characterized by		

Glucose levels lower than those found in serum

		Postoperative hyponatremia to 115 mEq/L		

Is usually due to SIADH (syndrome of inappropriate antidiuretic hormone secretion)

Should be corrected at the rate of 20 mEq/L daily

Should prompt conversion from hypotonic to isotonic saline infusion

Should be routinely treated with fluid restriction

Whipple's triad (symptomatic hypoglycemia, low blood sugar measurement, and relief of symptoms after the administration of glucose) is diagnostic

Low circulating levels of C-peptide are characteristic

Octreotide scintigraphy is effective in localizing tumors

Insulin to glucose ratios of >0.4 are specific

		In familial isolated primary hyperparathyroidism		

Calcium levels are usually between 10.5 mg/dL and 11.5 mg/dL

Minimally invasive parathyroidectomy is not indicated

A specific chromosomal abnormality has been documented

There is no increased risk of recurrent hyperparathyroidism after routine parathyroidectomy

Can easily be repaired successfully in Zone III

Require multiple interrupted sutures to repair

Should not be treated by proximal or distal extension of the skin incision

Require interposition tendon grafts if repaired more than 2 weeks after the injury

, Vol. 31, No. 1, the answer to Question 9 of the Recertification Practice Quiz, concerning the Glasgow Coma Scale, was identified incorrectly as b) 10. This was based on the erroneous statement that "Opening the eyes in response to pain counts for 3." The correct answer is c) 9, and the explanation to Question 9 on page 20 should have read as follows:

		Opening the eyes in response to pain counts for 2, withdrawal for 4, and uttering inappropriate words for 3, for a total Glasgow score of 9.

		We regret the mistake and appreciate all the 

 readers who took time to call this to our attention.

Breast cancers are identified in 1 in 1,000 studies.

Imatinib was discovered initially for use in treating chronic myelogenous leukemia. In further testing, it was also noted to be effective against gastrointestinal stromal tumors. Its effectiveness in treating other cancers is being investigated.

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, which 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 (≥40% organ loss).

Spontaneous pneumothorax occurs in 20% of cystic fibrosis patients as compared with <1% of otherwise healthy control patients. A bleb in the upper lung lobes (not the lower) is generally responsible. This entity is directly related to intensity of coughing and generally occurs or is recognized 12 hours after a bout of coughing. Only 15% of spontaneous pneumothoraces cause recognizable symptoms; this is because cystic fibrosis patients are always so short of breath that they do not recognize their symptoms worsening or they have well-developed compensatory mechanisms. In cases of total lung collapse, which is rare in this disease, the affected patients develop severe respiratory failure. Spontaneous pneumothoraces continue to occur despite best efforts to control pulmonary infections with long-term antibiotic therapy and chest physical therapy.

Renal cell carcinoma occurs 15 times as frequently in kidney transplant recipients than in patients with otherwise normal renal function, and the malignancy carries a much worse prognosis (5-year survival, <10%). The best treatment is radical nephrectomy followed by dialysis and, perhaps, subsequent retransplantation if the patient survives and remains disease-free for at least 2 or 3 years after resection. This lesion is directly related to acquired renal cystic disease and is the consequence of this nephropathy. In patients with end-stage renal disease, the frequency of renal cell carcinoma is increased (to 5%) in native kidneys.

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

 is either chronic or subacute. Symptoms generally include change in the level of consciousness, diplopia, and headache; these manifestations are generally present for some time before the diagnosis is made. Pulmonary disease patients usually present with an acute febrile illness associated with mild cough and chest pain. Symptoms last for a short period and then disappear. Prostatic involvement is relatively common, followed by meningeal, pulmonary, myocardial, and chorioretinal infections in frequency. With two-agent antifungal coverage, disseminated disease results in a 20% to 25% mortality rate. In contrast, the mortality rate increases to 35% in the presence of fungemia. Although there are many other species, 

 is the offending agent in humans. This disease is relatively common in immunosuppressed (endogenously or exogenously) surgical patients.

All of the characteristics are incorrect other than the low protein concentration. In transudates, the lactic dehydrogenase levels are low, glucose concentrations in pleural fluid are higher than those in serum, pH levels are >7.3, and leukocyte counts are <1,000/mm

Pontine myelinolysis is a dreaded complication of severe hyponatremia, particularly if corrected too quickly, manifesting spastic quadriplegia, pseudobulbar palsy, and decreased levels of consciousness. SIADH is rare, except in patients with carcinoids, small cell carcinomas of the lung, and intracranial lesions. Correction should not be accomplished any faster than by 8 to 12 mEq/L daily. The means of correction depends on the status of the extracellular fluid volume and total body sodium, both of which need to be assessed to determine whether fluid restriction or administration of additional sodium is indicated.

The hallmark of insulinomas is a high insulin level despite a low level of circulating glucose, which should normally suppress secretion of insulin. Whipple's triad is not very specific and is also seen in patients with reactive hypoglycemia, factitious hypoglycemia, and other conditions. The tolbutamide test causes such intense hypoglycemia that it is potentially dangerous and should not be routinely used. Insulinomas secrete proinsulin, C-peptide, and insulin; disproportionately low levels of C-peptide should arouse suspicion of surreptitious administration of insulin by the patient. Because insulinomas have low levels of somatostatin receptors, octreotide scintigraphy is ineffective in diagnosing or localizing these tumors.

Jaw tumors occur in 10% to 15% of patients with familial isolated primary hyperparathyroidism. Serum calcium levels are elevated to >2 mg/dL above normal, higher than observed in the sporatic form of the disease. Minimally invasive parathyroidectomy can be used, assuming localization studies are unequivocal. Unfortunately, the specific molecular abnormality has not yet been identified. Finally, there is an increased risk of persistent and recurrent hypercalcemia in this syndrome because of an increased incidence of both carcinoma and ectopic lesions.

Zone III is the region between the distal carpal ligament and the distal palmar crease. It includes the lumbrical muscles and is highly vascular, favoring successful repair. The treacherous zone is Zone II, between the distal palmar crease and the distal phalangeal joint, where the tendon pulleys are. Tendon repairs are most successful after primary repair (0 to 24 hours after injury) rather than delaying primary repair (24 hours to 10 days after injury). Rather than using interrupted sutures, the repair is best accomplished with a single "core" suture, which provides strength, followed by a running, very fine suture to oppose the epitenon. Often the tendons retract, and skin extensions must be extended to locate the severed ends. Interposition grafts are needed if repair is delayed by 6 or more weeks, the time required for the tendon units to be irreversibly shortened.

American Board of Surgery Recertification Examination Prep

 Surgeons are frequently asked to evaluate patients who experience chronic pain and have normal or equivocal findings on physical examination or imaging studies. It is important for surgeons to have a clear understanding of the indications for operative intervention in these patients.

 An algorithmic management approach is presented for groin, anal, breast, and right upper quadrant abdominal pain in patients whose clinical findings are ambiguous.

 Occult hernias and nonthrombosed hemorrhoids rarely cause pain, and other causes of the patient?s groin or anal pain should be investigated. In those with mastalgia, breast cancer must always be ruled out; once it is, reassurance is usually sufficient treatment. Patients who experience right upper quadrant abdominal pain and have a normal biliary ultrasound may benefit from cholecystectomy.

	Many surgeons quickly dismiss chronic pain patients as malingerers when objective findings fail to correlate with the patients' perceived level of pain. Rather than sending these patients straight back to their referring providers, surgeons can apply basic algorithms to ensure serious pathology is not missed and to determine whether surgery is indicated. Management can range from simple reassurance to a carefully planned operation. What follows is an approach for algorithmic management of groin, anal, breast, and right upper quadrant abdominal pain in patients who have unclear clinical findings.

	Most nonsurgeons ascribe groin pain to an inguinal hernia even if the physical examination is inconclusive. Patients may be convinced even before their surgical consultation that a simple operation is all they need to alleviate the pain. When no inguinal hernia is identified, it frustrates both patient and surgeon.

	Many patients who are referred to surgeons for chronic groin pain have undergone inguinal hernia surgery previously. Thirty percent or more of patients who have undergone hernia surgery experience groin discomfort 1 year postoperatively.

 In the majority of these cases, no recurrent hernia is identified, and the etiology of the pain is poorly understood. Nerve entrapment or mesh inguinodynia have been incriminated, and a systematic approach of nerve blocks, triple neurectomy (ilioinguinal, iliohypogastric, and genital branch of genitofemoral), and mesh removal has had variable success.

 Fortunately, reassurance that no hernia is present and that the condition is not medically dangerous is all many patients need. It is unwise to re-explore a groin to look for a hernia.

	Patients also can develop chronic groin pain without having undergone previous groin operations. Occult hernias are often suggested as the cause of groin pain, but reducible hernias rarely cause much pain. While occult hernias can be diagnosed using computed tomography, ultrasonography, or herniography, the significance of finding a small hernia on these examinations must be questioned. The best way to rule out an occult inguinal hernia is via transabdominal laparoscopic exploration. Laparoscopy is also a reasonable procedure to offer patients who report a history of a groin bulge but in whom no such bulge is palpable on physical examination.

	Lumbosacral spine and hip pathology, such as disc protrusion, vertebral spondilosis, and degenerative arthritis, can be found in up to 50% of patients with groin pain and no previous hernias.

 Magnetic resonance imaging and neurosurgery or an orthopedic referral should be considered before performing more invasive interventions.

	Sports "hernias" are wellknown among professional athletes, particularly hockey players when the conjoint tendon or the external oblique muscle is torn, which can result in nerve entrapment in 82% of cases.

 These patients may subsequently benefit from surgical intervention or trials of nerve blocks (Figure).

	According to the layman and many referring physicians, anal pain is usually attributable to hemorrhoids. In actuality, internal hemorrhoids cause pain only if they are incarcerated (fourth-degree prolapse), and external hemorrhoids are painful only if thrombosed. Both conditions will be evident on physical examination. A nonthrombosed external skin tag or minimal prolapsing hemorrhoid should not be excised with the expectation that a patient's anal pain will be alleviated.

	An occult anal fissure is the most common etiology of undiagnosed anal pain. Anal fissures may be extremely difficult to see on physical examination in patients with deep gluteal clefts or spastic internal sphincters. Often the only sign is exquisite focal tenderness to precise circumferential anal palpation. Deep anorectal abscesses may also demonstrate minimal external findings, and closer examination with the patient under anesthesia may be needed to make a diagnosis. Topical nitroglycerin ointment (0.2%) is a safe treatment for patients thought to have an anal fissure and spastic sphincter, even when those findings cannot be confirmed on physical examination.

	Other causes of anorectal pain, such as proctalgia fugax or coccygodynia, should be considered if more clear-cut etiologies are not apparent. Unfortunately, up to 50% of patients with intractable anorectal pain of poorly understood etiology are refractory to all treatment modalities (Figure).

	The etiology of breast pain is often poorly understood but frequently labeled as "fibrocystic breast disease," which is more appropriately termed "fibrocystic breast disorder." Pathology can include cyst formation, epithelial hyperplasia, metaplasia, and adenosis. Although a malignancy is usually painless, it must be carefully excluded as a possibility in any woman with breast pain. Mammography and ultrasonography, coupled with careful clinical examination, should help establish whether biopsy is needed. Suspicious radiographic lesions or dominant breast masses on physical examination warrant biopsy regardless of the patient's symptoms. Open biopsy or fine-needle aspiration of a tender area of the breast that has no radiographic or palpable lesions of significance is clearly not indicated. Simple reassurance that no cancer is present is all that 85% of patients with mastalgia need.

 More extensive surgery for mastalgia, such as subcutaneous mastectomy, quadrantectomy, or simple mastectomy, should be considered in only a minority of patients, because fewer than 50% will get relief from such procedures.

	Effective medical measures for mastalgia include use of a properly fitting bra; decreasing dietary fat and caffeine intake; and the administration of evening primrose oil, followed by danazol, bromocriptine, or tamoxifen. The significant side effects of some of the latter treatments, however, may outweigh any benefits. Ineffective treatments include vitamins A, B, or E, diuretics, levothyroxine, antibiotics, and surgery (Figure).

		Before considering cholecystectomy, it is important to rule out other upper gastrointestinal pathology.

	The term "biliary dyskinesia" was coined in 1953. At the time, a 60% improvement rate following cholecystectomy was reported for this poorly understood disease. Severe biliary colic in the absence of gallstones is a real entity; however, it is difficult to determine who will benefit from cholecystectomy. Once ultrasonography has ruled out gallstones, the most commonly used test is the CCK-HIDA (cholecystokinin- 99mTc hepatoiminodiacetic acid) scan, which assesses biliary function by measuring the gallbladder ejection fraction (EF). An EF below 35% is considered abnormal. A number of retrospective studies suggest that biliary colic symptoms improve in 60% to 100% of patients with a gallbladder EF below 35% who undergo cholecystectomy.

 Another study suggests that even those who have an EF above 35% may experience a 75% improvement in their symptoms 36 months following cholecystectomy.

	Before considering cholecystectomy, it is important to rule out other upper gastrointestinal pathology. This can be done using upper endoscopy or radiographic contrast studies. More complex studies are rarely productive, such as evaluating for biliary crystals using endoscopic retrograde cholangiopancreatography (ERCP) or performing sphincter of Oddi manometry.

	Patients may believe that simple gallbladder surgery will cure their condition. The number of cholecystectomies increased by 29% from 1986 to 1995, which coincides with the advent of a laparoscopic approach.

 Surgeons must not lower the clinical requirements for performing this procedure simply because the patient or the patient's referring physician perceives it to be safer (Figure).

	The wise surgical dictum "never operate for pain" can prevent misery from the surgeon's perspective. Patients with poorly understood pain syndromes involving the groin, anus, breast, and right upper abdominal quadrant, however, must be completely evaluated to exclude surgically correctable pathology or medically manageable problems. In these cases, surgeons should remember three important points: (1) occult hernias and nonthrombosed hemorrhoids rarely cause pain; (2) mastalgia cannot be cured surgically, and breast cancer must always be ruled out in these patients; (3) a select group of patients with right upper quadrant abdominal pain and a normal biliary ultrasound will benefit from cholecystectomy.

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.

		Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. 

		Amid PK. A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple neurectomy and proximal end implantation without mobilization of the cord. 

		Heise CP, Starling JR. Mesh inguinodynia: a new clinical syndrome after inguinal herniorrhaphy? 

		Deysine M, Deysine GR, Reed WP. Groin pain in the absence of hernia; a new syndrome. 

		Irshad K, Feldman LS, Lavoie C, et al. Operative management of "hockey groin syndrome": 12 years of experience in National Hockey League players. 

		Vincent C. Anorectal pain and irritation: anal fissure, levator syndrome, proctalgia fugax and pruitis ani. 

		Ger GC, Wexner SD, Jorge JM, et al. Evaluation and treatment of chronic intractable rectal pain—a frustrating endeavor. 

		Holland PA, Gateley CA. Drug therapy of mastalgia. What are the options? 

		Davies EL, Cochrane RA, Stansfield K, et al. Is there a role for surgery in the treatment of mastalgia? 

		Yost F, Margenthaler J, Presti M, et al. Cholecystectomy is an effective treatment for biliary dyskinesia. 

		Patel NA, Lamb JJ, Hogle NJ, et al. Therapeutic efficacy of laparoscopic cholecystectomy in the treatment of biliary dyskinesia. 

		Fuller RA, Kuhn JA, Fisher TL, et al. Laparoscopic cholecystectomy for acalculous gallbladder disease. 

		Johanning JM, Gruenberg JC. The changing face of cholecystectomy. 

James E. Wiedeman, Associate Professor of Surgery, Department of Surgery, University of California Davis, Chief, Department of General Surgery, Sacramento VA Medical Center, Sacramento, CA

Operating for pain: An algorithmic approach

	Lake Erie College of Osteopathic Medicine

 Pseudomyxoma peritonei (PMP) is a rare tumor that is characterized by its production of extensive gelatinous fluid and surface implants within the abdominal cavity. PMP typically originates from a cystadenoma or cystadenocarcinoma of the appendix or ovaries. In many cases, these tumors are discovered incidentally during surgery for other conditions. Despite its sometimes malignant nature and tendency to spread, solid organ invasion is rare, especially of the spleen. Only 20 cases of splenic invasion have been reported worldwide, with 6 appearing in the English-language literature.

 The authors report a case of PMP involving a 42-year-old woman who presented to the hospital with abdominal distention and generalized abdominal pain. They discuss the classification, diagnosis, and treatment of these tumors and provide an analysis of their patient?s case. They also examine the significance of splenic involvement.

 PMP tumors are rare and consequently poorly understood. Currently, PMPs are classified according to the tumor?s characteristics and extent of spread. Surgical debulking is the mainstay of treatment, with chemotherapy offered to patients whose tumors demonstrate malignant characteristics.

	Pseudomyxoma peritonei (PMP) is an extremely rare tumor that is generally discovered intraoperatively, with an incidence of 2 in every 10,000 laparotomies.

 It is characterized by the accumulation of extensive gelatinous fluid and implants within the abdominal cavity. Current evidence suggests that PMP results from the rupture of a mucinous cystadenoma or mucinous cystadenocarcinoma of the ovaries or appendix, with appendiceal involvement being more common.

 We report a case of splenic invasion by PMP in a woman who had been found to have a mucinous cystadenoma 8 years before she presented to our institution. We could find only 6 previous cases in the English-language literature that detailed splenic invasion by PMP.

	A 42-year-old white woman presented to the hospital reporting a 2-week history of vague left-sided abdominal pain and generalized distention. The patient had experienced minor weight gain despite a decreased appetite. Her surgical history was significant for laparoscopy and ablation of endometriosis, which a gynecologist from an outside institution had performed 8 years earlier. During the procedure, adhesions and mucinous pools were found in the patient's pelvis, and her appendix was noted to be thickened and edematous. A general surgeon was brought in to remove the appendix, which measured 6.0 cm in length and 1.5 cm in diameter. Macroscopic examination revealed an enlarged, edematous, red, soft-tissue mass in the distal half of the specimen. Serial sections of the appendix showed a dilated lumen that contained thick tenacious mucus, findings which were reported grossly as a mucocele. Microscopic evaluation suggested a mucinous cystadenoma with spillage of mucin into the periappendiceal area (Figure 1).

		The spleen is an unusual site for metastatic cancer of any origin, and splenic invasion by PMP is quite rare.

	Computed tomography (CT) scans obtained during the patient's current presentation revealed ascites; two coarse, calcified, round masses between the liver and abdominal wall; and an enlarged spleen, which was inferiorly replaced by a complex, cystic, partially calcified, 10-cm mass (Figure 2). Surgical exploration found mucinous ascites filling the abdominal cavity and three peritoneal implants above the liver on the right hemidiaphragm (Figure 3A). The spleen appeared cystic, and a large, deep hole was located inferiorly, suggestive of parenchymal invasion (Figure 3B). The omentum and left ovary appeared abnormal and were encased in mucin. The right diaphragmatic peritoneal implants were excised, and diaphragmatic repair, splenectomy, omentectomy, left salpingo-oophorectomy, and aggressive peritoneal irrigation were undertaken. All peritoneal implants were resected using peritonectomy procedures. At the conclusion of the operation, no macroscopic evidence of residual disease was found, suggesting adequate debulking of the tumor.

	The right hemidiaphragm implants, liver tissue, spleen, omentum, and left adnexa were sent for pathological evaluation. The three peritoneal implants measured 4.5 x 3.0 x 1.5 cm, 6.0 x 4.0 x 1.5 cm, and 9.0 x 5.0 x 2.5 cm, and were predominantly cystic, gray-tan masses containing gelatinous, yellow-pink material. The implants were subsequently identified as organizing mucinous ascites that had extensive chronic inflammation, adhesions, and calcification. The spleen weighed approximately 407 g, and its outer surface was coated with mucinous material up to 0.3 cm thick (Figure 4). Approximately 50% of the spleen consisted of cystic mucinous tumor. These cysts ranged from 0.3 cm to 9.0 cm in diameter and contained an abundance of yellow, mucinous material; the cyst walls showed extensive fibrosis and focal calcification (Figure 5). The left ovary measured 3.5 x 3.0 x 2.0 cm, demonstrated physiological changes, and contained a 1-cm benign cyst. The outer surfaces of both the left adnexa and omentum contained mucin but, as expected, no gross evidence of tumor invasion. The cystic nature of these specimens and the presence of mucinous ascites suggested a diagnosis of low-grade mucinous tumor, consistent with disseminated peritoneal adenomucinosis (DPAM). Immunohistochemical staining (negative cytokeratin 7, positive cytokeratin 20, and positive carcinoembryonic antigen) was consistent with PMP originating from an appendiceal adenoma.

	The patient's postoperative recovery was complicated by a small right pneumothorax, which resulted from excision of the tumors on the right hemidiaphragm. The pneumothorax was treated conservatively, and the patient was discharged to home on postoperative day 5. At 8-month follow-up, she was doing well and her functional capacity was nearly back to its preoperative state. Medical oncology did not recommend any further treatment.

—Intraoperative photograph demonstrating three, large calcified peritoneal implants above the liver on the right hemidiaghram (A). The spleen appears cystic, demonstrating invasion by mucinous ascites, and has a large, deep hole inferiorly, suggesting parenchymal invasion (B).

 to describe the mucinous material that had spread throughout a patient's peritoneal cavity in association with a ruptured cystadenoma of the ovaries. Werth theorized that metaplasia of the peritoneum resulted from an inflammatory reaction to the contents of the ruptured cyst.

 Evidence now suggests that PMP is not an inflammatory reaction but a consequence of a ruptured mucinous cystadenoma or mucinous cystadenocarcinoma of the appendix or ovaries, with appendiceal involvement being more common.

 Fraenkel discovered PMP to be associated with a ruptured mucocele of the appendix in 1901.

	PMP is a rare tumor that is generally discovered incidentally during approximately 2 of every 10,000 laparotomies.

 PMP appears to have a female predominance and patients usually present with an increase in abdominal girth. Extravasation from PMP causes mucin to migrate diffusely throughout the abdominal cavity, seeding the peritoneal surfaces of the viscera, abdominal wall, and peritoneum. The gelatinous material is mainly confined to a superficial level, and direct invasion is rare. Hematogenous or lymphatic spread is even less common.

	CT scanning is the radiographic modality of choice in illustrating intra-abdominal mucinous ascites in association with calcified cysts or masses. PMP is confirmed intraoperatively with the observation of extensive gelatinous fluid and implants throughout the abdominal cavity. Once diagnosed, treatment may consist of repeated abdominal explorations for radical cytoreduction. These procedures are debilitating and may eventually result in the patient's death. In addition to surgical debulking, heated intraperitoneal chemotherapy (IPHC) and systemic chemotherapy may be offered, depending on the type and amount of residual tumor.

	Since the time of Werth and Fraenkel, numerous researchers have attempted to classify PMP. Most recently, these tumors have been divided into two categories: DPAM and peritoneal mucinous carcinomatosis (PMCA). PMCA is subdivided into PMCA-I/D, which is defined as DPAM with focal areas of well-differentiated mucinous carcinoma (intermediate or discordant).

		Treatment includes surgical cytoreduction with or without intraperitoneal or systemic chemotherapy.

	DPAM tumors are peritoneal lesions comprising extracellular mucin that contains simple, proliferative mucinous epithelium and demonstrates little cytologic atypia or mitotic activity; an associated appendiceal mucinous adenoma may or may not be present. The spread of DPAM, also known as the "redistribution phenomenon," is characterized by superficial, noninvasive involvement of the omentum, undersurface of the diaphragm, pelvis, right retrohepatic space, left pericolic gutter, and ligament of Treitz. The peritoneal surfaces of the bowel are spared. DPAM is benign in nature and has a 5-year survival rate of approximately 75%.

	PMCA is characterized by peritoneal lesions composed of more abundant mucinous epithelium and demonstrating cytologic features of carcinoma; an associated appendiceal primary mucinous adenocarcinoma may or may not be present. PMCA tumors have malignant characteristics and demonstrate lymphadenopathy and invasive implantation on the bowel and other organs. The malignant features of PMCA contribute to its lower 5-year survival rate of 26%.

 PMCA-I/D, which shares some characteristics with DPAM, has a 5-year survival rate between 38% and 50%.

	Splenic metastases from mucinous neoplasms of the appendix are uncommon. The spleen is an unusual site for metastatic cancer of any origin, and splenic invasion by PMP is quite rare. One theory postulates that in these rare cases, mucin-producing epithelial cells become trapped in the trabeculae of the splenic capsule, congenital clefts, or microfissures, and they continue to produce mucin that can then expand inward into the soft splenic parenchyma.

	Clinical observations regarding our patient

	Our case demonstrates some interesting pathological features of PMP. First, following the patient's appendectomy 8 years earlier, the appendix specimen was found to contain a cystadenoma, and a pelvic biopsy was positive for mucin. These findings may have constituted early signs of PMP and raise the question as to whether the patient should have returned to the operating room for open exploration with aggressive washout and possible right colectomy. Whether this would have prevented tumor spread is unknown. Second, the final classification of this tumor was unclear. Thorough evaluation of the pathological specimens showed no evidence of vascular or lymphatic spread, which would be consistent with DPAM, yet there was gross splenic involvement that seemed to indicate a more malignant property, possibly consistent with PMCA. The tumor's spread was reminiscent of the "redistribution phenomenon," however; it acted like DPAM but with splenic involvement and was likely a variant of DPAM.

	We decided to treat our patient's tumor as DPAM. Both IPHC and systemic chemotherapy were discussed with the patient, but after consulting with the oncologist, she decided to forego these treatments. Because the tumor had grossly involved the spleen (which was removed), acted clinically and pathologically like DPAM, and had been adequately debulked, it was decided that chemotherapy was unnecessary. The patient showed no evidence of recurrence 8 months after surgery.

—Pathology image of the spleen illustrating parenchymal invasion with cystic mucinous tumor; the cyst walls demonstrate extensive fibrosis and focal calcification (hematoxylin and eosin staining, magnification x100).

	PMP defines the rare intraoperative discovery of extensive gelatinous fluid and implants within the abdominal cavity, typically originating from a cystadenoma or cystadenocarcinoma of the appendix or ovaries. These tumors are classified according to specific pathological findings and patterns of tumor spread. Treatment includes surgical cytoreduction with or without intraperitoneal or systemic chemotherapy. Our case is interesting because our patient had demonstrated evidence of an appendiceal cystadenoma with pelvic mucin 8 years before presenting to our institution. Her tumor featured some of the common characteristics of PMP, such as mucinous ascites and the "redistribution phenomenon," yet had uncommon splenic invasion. Comprehensively, these findings demonstrate qualities of both DPAM and PMCA; thus, chemotherapy was not advised.

	PMP is a rare disease that is poorly understood. As more cases are reported in the literature, perhaps knowledge of this disease will increase, corresponding to less debilitating treatment and improved patient survival rates.

		Shimoyama S, Kuramoto S, Kawahara M, et al. A rare case of pseudomyxoma peritonei presenting as an unusual inguinal hernia and splenic metastasis. 

		Du Plessis DG, Louw JA, Wranz PA. Mucinous epithelial cysts of the spleen associated with pseudomyxoma peritonei. 

		Mets T, Van Hove W, Louis H. Pseudomyxoma peritonei. Report of a case with extraperitoneal metastasis and invasion of the spleen. 

		Holder PD, Fehir KM, Schwartz MR, et al. Primary mucinous cystadenocarcinoma of the appendix with pseudomyxoma peritonei manifested as a splenic mass. 

February 2008

Surgeon's Bulletin Board

American Board of Surgery Recertification Examination Prep

Operating for pain: An algorithmic approach

Pseudomyxoma peritonei invading the spleen

Canine heartworm mimicking pulmonary metastasis in a liver transplant candidate

Right-sided Bochdalek hernia causing colon necrosis in a middle-aged woman

Using radiography to detect a biliary stent fracture and related bowel obstruction

Asphyxies et blesses

Abdominal impalement resulting in an isolated duodenal injury

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