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ASMBS: Gastric Banding Less Effective than Other Procedures (CME/CE)

DALLAS (MedPage Today) -- Patients who underwent laparoscopic adjustable gastric banding achieved less weight loss and less improvement in comorbid conditions than those who had gastric bypass or sleeve gastrectomy.

Clinical Pathways Improve Joint Replacement Outcomes (CME/CE)

RIDGEWOOD, N.J. (MedPage Today) -- Organizational strategies known as clinical pathways can significantly improve the quality of care, shorten hospital stays, and reduce the cost of hip and knee joint replacements, a meta-analysis found.

ASMBS: Modest Data Suggest Bariatric Surgery Durability (CME/CE)

DALLAS (MedPage Today) -- Obese patients can achieve long-term weight loss with bariatric surgery, although follow-up remains problematic, according to studies reported here.

ASMBS: Obesity Surgery Resolves Diabetes but for How Long? (CME/CE)

DALLAS (MedPage Today) -- Weight-loss surgery allowed a majority of obese type 2 diabetes patients to stop or reduce medical therapy, but questions persisted about the durability of the effects, according to three studies reported here.

Ketamine Safe for Endrotracheal Intubation (CME/CE)

CLEVELAND (MedPage Today) -- Ketamine, an old drug commonly used for induction of anesthesia, appears to be a safe and effective alternative to etomidate for endotracheal intubation in critically ill patients.

ASMBS: Electrical Stimulation Helps Diabetes, Obesity (CME/CE)

DALLAS (MedPage Today) -- Overweight patients with type 2 diabetes had significant short-term improvement in glycemic control when implanted with electronic nerve stimulators.

Spinal Fusion Agent Raises Costs, Complication Rates (CME/CE)

PRINCETON, N.J. (MedPage Today) -- A bone growth agent increasingly used during spinal fusion operations raises medical costs and the risk of complications related to anterior cervical fusion surgery, according to a new study.

Ultrasound-Guided Treatment Effective in Rotator Cuff Tendonitis (CME/CE)

LITTLE FALLS, N.J. (MedPage Today) -- A nonsurgical, ultrasound-guided needle treatment relieves pain and restores mobility for patients with calcific tendonitis of the rotator cuff, researchers said.

ASMBS: High BMI Not Needed to Benefit from Bariatric Surgery (CME/CE)

DALLAS (MedPage Today) -- Obesity surgery led to substantial weight loss and resolution of comorbidities in a small group of patients whose body mass index did not meet current criteria for the surgery.

ASMBS: Bariatric Surgery Safe, Effective in Older Patients (CME/CE)

DALLAS (MedPage Today) -- Older age and a greater comorbidity burden don't increase the risks of bariatric surgery or worsen the outcomes, a retrospective comparison of older and younger patients showed.

ASMBS: No Red Flags in Obesity Surgery for Kids (CME/CE)

DALLAS (MedPage Today) -- Obese adolescents get the same benefits from bariatric surgery as their older counterparts, data from two studies showed.

ASMBS: Gastric Bypass Linked to Abnormal Glucose Tolerance (CME/CE)

DALLAS (MedPage Today) -- Patients who undergo gastric bypass surgery often have undiagnosed glucose abnormalities that can lead to bad eating habits and regained weight, a small clinical study suggests.

ASMBS: VTE Risk Persists for a Year After Bariatric Surgery (CME/CE)

DALLAS (MedPage Today) -- The risk of venous thromboembolism (VTE) after bariatric surgery persists for at least a year after the procedure, according to a review of medical records on 17,000 patients.

ASMBS: Like Mother, Like Baby, Obesity Surgery Benefits Both (CME/CE)

DALLAS (MedPage Today) -- Bariatric surgery before pregnancy significantly improves an obese woman's chances of giving birth to children who don't have obesity-related metabolic disorders, according to a study reported here.

Obesity Surgery Reduces Cancer Risk in Women (CME/CE)

HOUSTON (MedPage Today) -- Obese women had a 42% reduction in cancer risk following bariatric surgery, data from a Swedish study showed.

ABOUT THIS JOURNAL: About This Journal

EDITORIAL: Should We Not Strive for a Balance Between Procedure Fee and Overall Cost?

CALL FOR PAPERS: Devices, Products, and Other 1-Time-Use Items in the Operating Room

COMMENTARY: General Surgeons: A Dying Breed?

ORIGINAL ARTICLE: Risk Factors for Recurrence After Repair of Enterocutaneous Fistula

Objectives To assess outcomes after repair of enterocutaneous fistulae (ECF) and identify factors that predict mortality and recurrence. Design Retrospective study. Setting University hospital. Patients One hundred thirty-five patients undergoing ECF repair between 1989 and 2005. Main Outcome Measures Mortality and recurrence of ECF. Results Definitive operation for ECF was attempted in 135 patients. Mortality was 8%, recurrence was 17%, and 84% of patients eventually survived with a closed fistula. The primary determinant of mortality was ECF recurrence (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.9-23.4). Factors independently associated with ECF recurrence by multivariate logistic regression included the presence of inflammatory bowel disease (OR, 4.9; 95% CI, 1.5-16.1), interval between diagnosis and operation of 36 weeks or longer (OR, 5.4; 95% CI, 1.8-16.4), location of fistulae in the small intestine (OR, 9.8; 95% CI, 1.7-57.6), and resection with stapled anastomosis (OR, 4.1; 95% CI, 1.3-13.2). Recurrence of ECF was 35% with resection and stapled anastomosis, 22% with simple oversew, and 11% with resection and hand-sewn anastomosis. Recurrence of ECF was 12% when operation was performed prior to 36 weeks from diagnosis, compared with 36% if performed at or beyond 36 weeks. Conclusions The primary determinant of mortality after ECF repair is a failed operation leading to recurrence of the fistula. Risk factors for ECF recurrence include inflammatory bowel disease, fistula located in the small intestine, an interval of 36 weeks or longer between diagnosis and operation, and resection with stapled anastomosis.

CALL FOR PAPERS: Maintenance of Certification

ORIGINAL ARTICLE: Extreme Aggressiveness and Lethality of Gastric Adenocarcinoma in the Very Young

Objective To determine whether very young patients with gastric adenocarcinoma as compared with older patients with the disease have a biologically more aggressive form of the disease, presenting at an advanced stage and conferring unusually poor perioperative and long-term outcomes. Design, Setting, and Patients A 15-year, single-institution, retrospective review and analysis of demographic and outcomes data for 350 patients diagnosed with gastric adenocarcinoma. Main Outcome Measures Histologic features, frequency of stage IV disease, frequency of curative gastric resection, postoperative mortality, and long-term survival in very young and older patient groups. Results Of 350 total patients, 30 (9%) were aged 35 years or younger. Very young patients (aged ≤35 years) as compared with older patients (aged >35 years) more often had diffuse-type tumor histologic findings (93% vs 69%, respectively; P = .003), adjacent organ invasion (74% vs 29%, respectively; P = .001), nodal metastases (94% vs 70%, respectively; P = .046), distant metastases (81% vs 50%, respectively; P = .003), and stage IV disease (90% vs 64%, respectively; P = .007). Potentially curative gastrectomy was accomplished in 58% of older patients but only 17% of very young patients (P = .001). Nontherapeutic operations were performed in only 6% of older patients but 33% of very young patients (P = .002). Very young patients as compared with older patients had high postoperative mortality (22% vs 2%, respectively; P = .003) related to advanced-stage disease. Mean survival was 33.4 months among older patients compared with only 11.6 months for very young patients (P = .02). Conclusions Very young patients (aged ≤35 years) with gastric adenocarcinoma have significantly higher incidences of diffuse-type tumor histologic findings and both locally advanced and metastatic disease at presentation. These findings confirm a more aggressive tumor biology that results in often futile surgical interventions and an unusually grave prognosis. Strategies for earlier diagnosis together with effective new therapies are desperately needed to attenuate the extreme lethality in these uniquely unfortunate patients.

ORIGINAL ARTICLE: Combination of Microsatellite Instability and Lymphocytic Infiltrate as a Prognostic Indicator in Colon Cancer

Background Microsatellite instability (MSI) is a genetic aberration associated with less aggressive tumor biology. Some tumors with MSI also have lymphocytic infiltrate (LI), which suggests a heightened immune response against the tumor. Objective To evaluate the combined prognostic significance of MSI and LI in a colon cancer population. Design Colon cancers were prospectively evaluated for MSI by assessing 11 satellite markers and were classified as MSI+ if 2 or more satellite markers displayed instability. Tumors were classified as LI+ if at least 5 lymphocytes were observed per 10 high-power fields. Setting Community hospital system. Patients Individuals undergoing definitive surgery for colon cancer. Main Outcome Measures Overall and disease-free survival were compared according to combined MSI and LI status. Results In 150 patients, tumors were classified as follows: 95 were MSI–/LI–, 9 were MSI–/LI+, 30 were MSI+/LI–, and 16 were MSI+/LI+. Median follow-up was 40.6 months. Five-year disease-free survival was 56.7% for patients with MSI–/LI– tumors and 88.9% for those with MSI+/LI+ tumors (P = .01). Patients with MSI+/LI– and MSI–/LI+ tumors had 5-year survival of 75.4% and 75.0%, respectively. Conclusions Patients with colon cancer and MSI–/LI– tumors have worse disease-free survival rate regardless of stage at diagnosis. Patients exhibiting both MSI+ and LI+ tumors have more favorable disease-free survival rates. Both MSI and LI show promise as a combined prognostic marker and with further study may prove to be particularly useful in selecting patients with stage II disease for adjunctive therapy.

ORIGINAL ARTICLE: The Use of a Spring-Loaded Silo for Gastroschisis: Impact on Practice Patterns and Outcomes

Objective To evaluate the impact of the use of a bedside-placed spring-loaded silo (SLS) on practice patterns and on outcomes for infants with gastroschisis. Design Retrospective review comparing neonates with gastroschisis treated before and after the implementation of selective SLS placement. Setting Tertiary referral center. Patients Of 91 consecutive neonates admitted for initial treatment of gastroschisis between January 1998 and August 2007, 45 were admitted before and 46 were admitted after implementation of the SLS. Main Outcome Measures Immediate fascial closure rate, infection rate, time to fascial closure, time to initiation of enteral feeding, time to achievement of full enteral feeds, time of hyperalimentation requirement, and length of hospital stay. Results The rate of immediate fascial closure was lower in the postimplementation group (58% before vs 20% after implementation, P < .001). Overall length of stay, time to enteral feeding, and infection rates were not significantly different between the 2 groups. Conclusions The use of an SLS placed at the bedside has resulted in lower immediate fascial closure rates for infants with gastroschisis without significant detrimental clinical outcome. The main benefit of using the bedside-placed SLS is the avoidance of urgent surgical intervention. For patients undergoing delayed fascial closure, use of the bedside SLS resulted in shorter times to definitive fascial closure.

ORIGINAL ARTICLE: Portomesenteric Venous Thrombosis After Laparoscopic Surgery: A Systematic Literature Review

Background Portomesenteric venous thrombosis (PVT) is an uncommon but potentially lethal condition reported after several laparoscopic procedures. Its presentation, treatment, and outcomes remain poorly understood, and possible etiologic factors include venous stasis from increased intra-abdominal pressure, intraoperative manipulation, or damage to the splanchnic endothelium and systemic thrombophilic states. Design Systematic literature review. Setting Academic research. Subjects We summarized the clinical presentation and outcomes of PVT after laparoscopic surgery other than splenectomy in 18 subjects and reviewed the treatment strategies. Main Outcome Measures Systematic review of the literature on PVT after laparoscopic procedures other than splenectomy. Results Eighteen cases of PVT following laparoscopic procedures were identified after Roux-en-Y gastric bypass (n = 7), Nissen fundoplication (n = 5), partial colectomy (n = 3), cholecystectomy (n = 2), and appendectomy (n = 1). The mean patient age was 42 years (age range, 20-74 years). Systemic predispositions toward venous thrombosis were identified in 11 patients. Clinical symptoms consisted primarily of abdominal pain manifested, on average, 14 days (range, 3-42 days) after surgery. Thrombus location varied, but 8 patients had a combination of portal and superior mesenteric venous thrombosis. Sixteen patients were treated with anticoagulation therapy. Ten patients underwent major interventions, including exploratory laparotomy in 6 patients and thrombolytic therapy in 4 patients. Six patients had complications, and 2 patients died. Conclusions Portomesenteric venous thrombosis following laparoscopic surgery usually manifests as nonspecific abdominal pain. Computed tomography can readily provide the diagnosis and demonstrate the extent of the disease. Treatment should be individualized based on the extent of thrombosis and the presence of bowel ischemia but should include anticoagulation therapy. Venous stasis from increased intra-abdominal pressure, intraoperative manipulation of splanchnic vasculature, and systemic thrombophilic states likely converges to produce this potentially lethal condition.

ORIGINAL ARTICLE: Neuroendocrine Tumors of the Ampulla of Vater: Biological Behavior and Surgical Management

Objectives To describe the biological behavior and surgical management of ampullary neuroendocrine tumors in 7 patients. Design Case series and literature review. Setting University hospital. Patients Seven patients with ampullary neuroendocrine tumors. Main Outcome Measures Clinical presentation, pathologic findings, and survival. Results The patients presented with jaundice (3 patients), anemia (1 patient), gastric outlet obstruction (1 patient), or incidental discovery (2 patients). No patients had neurofibromatosis. Preoperative biopsy was diagnostic in 5 of 6 patients. All of the tumors expressed chromogranin and synaptophysin. Even when the tumor expressed gastrin, vasoactive intestinal peptide, or somatostatin, no patient had a hypersecretion syndrome. Five patients were treated by pancreaticoduodenectomy, 4 for low-grade neuroendocrine tumors and 1 for high-grade neuroendocrine carcinoma. The lesions measured 1.0 to 3.5 cm in diameter. Computed tomographic scans failed to detect nodal metastases that were present in 4 patients. One patient with a high-grade malignant neoplasm died after 15 months. The rest were disease-free after 19 to 48 months. Two patients had transduodenal local resections, one for a 1.1-cm paraganglioma (disease-free, 11 years) and the other for a 0.6-cm carcinoid tumor (disease-free, 7 months). Conclusions This is one of the largest series of neuroendocrine tumors of the ampulla. Preoperative biopsy was accurate, but computed tomographic scans were insensitive in detecting nodal metastases. Unlike duodenal carcinoid tumors, hypersecretion syndromes were absent and small tumor size did not preclude locoregional metastases. Tumor grade predicted survival. We recommend pancreaticoduodenectomy for this disease, with local resection reserved for mobile, superficial lesions.

ORIGINAL ARTICLE: Racial Clustering and Access to Colorectal Surgeons, Gastroenterologists, and Radiation Oncologists by African Americans and Asian Americans in the United States: A County-Level Data Analysis

Background Minority groups have poor access to quality health care services. This is true of colorectal cancer care and may be related to both geographical proximity and use of surgical, gastroenterology, and radiation oncology services. Without suitable access, many minority patients may present with advanced colorectal cancer and be less likely to receive appropriate adjuvant therapies. We sought to examine the variations in geographical access among minorities at a county level. Design A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists. Setting All counties in the United States. Participants Prevalence rate of African Americans and Asian Americans within a county. Main Outcome Measure Rate of colorectal surgeons, gastroenterologists, and radiation oncologists. Results Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13). Conclusion Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.

ORIGINAL ARTICLE: Preventable Morbidity at a Mature Trauma Center

Objective To analyze the preventable and potentially preventable complications occurring at a mature level I trauma center. Design Retrospective review. Setting Academic level I trauma center. Patients The study included 35 311 trauma registry patients. Main Outcome Measures The cause, effect on outcome, preventability (preventable, potentially preventable, or nonpreventable), and loop closure recommendations for all preventable and potentially preventable complications, and clinical data related to each complication retrieved from the trauma registry and individual medical records. Results Over the 8-year study, 35 311 trauma registry patients experienced 2560 complications. Three hundred fifty-one patients (0.99% of all patients) had 403 preventable or potentially preventable complications. The most common preventable or potentially preventable complications were unintended extubation (63 patients [17% of complications]), surgical technical failures (61 patients [15% of complications]), missed injuries (58 patients [14% of complications]), and intravascular catheter–related complications (48 patients [12% of complications]). These complications were clinically relevant; 258 (64% of complications) resulted in a change in management, including 61 laparotomies, 52 reintubations, 41 chest tube insertions, and 19 vascular interventions. Conclusions The incidence of preventable or potentially preventable complications at an academic level I trauma center is low. These complications often require a change in management and cluster in 4 major categories (ie, unintended extubation, surgical technical failures, missed injuries, and intravascular catheter–related complications) that must be recognized as critical areas for quality improvement initiatives.

INVITED CRITIQUE: Preventable Morbidity at a Mature Trauma Center--Invited Critique

ORIGINAL ARTICLE: Survival Analysis in Amputees Based on Physical Independence Grade Achievement

Backgound Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. Objectives To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. Design Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. Setting Ninety-nine US Department of Veterans Affairs Medical Centers. Patients Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. Main Outcome Measure Cumulative 6-month survival after rehabilitation discharge. Results The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P ≤ .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. Conclusions Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

INVITED CRITIQUE: Survival Analysis in Amputees Based on Physical Independence Grade Achievement--Invited Critique

ORIGINAL ARTICLE: Surgical Glove Perforation and the Risk of Surgical Site Infection

Hypothesis Clinically apparent surgical glove perforation increases the risk of surgical site infection (SSI). Design Prospective observational cohort study. Setting University Hospital Basel, with an average of 28 000 surgical interventions per year. Participants Consecutive series of 4147 surgical procedures performed in the Visceral Surgery, Vascular Surgery, and Traumatology divisions of the Department of General Surgery. Main Outcome Measures The outcome of interest was SSI occurrence as assessed pursuant to the Centers of Disease Control and Prevention standards. The primary predictor variable was compromised asepsis due to glove perforation. Results The overall SSI rate was 4.5% (188 of 4147 procedures). Univariate logistic regression analysis showed a higher likelihood of SSI in procedures in which gloves were perforated compared with interventions with maintained asepsis (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4-2.8; P < .001). However, multivariate logistic regression analyses showed that the increase in SSI risk with perforated gloves was different for procedures with vs those without surgical antimicrobial prophylaxis (test for effect modification, P = .005). Without antimicrobial prophylaxis, glove perforation entailed significantly higher odds of SSI compared with the reference group with no breach of asepsis (adjusted OR, 4.2; 95% CI, 1.7-10.8; P = .003). On the contrary, when surgical antimicrobial prophylaxis was applied, the likelihood of SSI was not significantly higher for operations in which gloves were punctured (adjusted OR, 1.3; 95% CI, 0.9-1.9; P = .26). Conclusion Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI.

INVITED CRITIQUE: Surgical Glove Perforation and the Risk of Surgical Site Infection--Invited Critique

ORIGINAL ARTICLE: Actual 3-Year Survival After Laparoscopy-Assisted Gastrectomy for Gastric Cancer

Objective To analyze 3-year actual disease-free survival after laparoscopy-assisted gastrectomy for gastric cancer on the assumption that 3-year disease-free survival may represent 5-year overall survival. Design Retrospective analysis. Setting Department of surgery of a university hospital. Patients A total of 197 patients who underwent laparoscopy-assisted gastrectomy for gastric cancer from May 1998 to September 2007 and who were followed up for more than 3 years. Main Outcome Measures Feasibility and long-term survival rate with survival analysis by the Kaplan-Meier method. Results Subtotal and total gastrectomies were performed in 178 and 19 patients, respectively. The scope of the lymph node dissections were D1 + β (n = 152) and D2 (n = 45). There were 153, 28, 8, 6, 1, and 1 patients in stages Ia, Ib, II, IIIa, IIIb, and IV, respectively. The median follow-up was 45 months (range, 1-113 months), and there were 7 recurrences. Multivariate analysis of disease-specific survival showed that depth of invasion and lymph node metastasis influenced the prognosis independently. The actual 3-year disease-free survival rate for all patients was 96.9%. The 173 patients with early gastric cancer and 24 with advanced gastric cancer showed 98.8% and 79.1% actual 3-year disease-free survival rates, respectively. Conclusions Laparoscopy-assisted gastrectomy is acceptable oncologically in early gastric cancer if 3-year disease-free survival represents 5-year overall survival. Laparoscopy-assisted gastrectomy may also play an important role in the treatment of advanced gastric cancer.

INVITED CRITIQUE: Actual 3-Year Survival After Laparoscopy-Assisted Gastrectomy for Gastric Cancer--Invited Critique

OPERATIVE TECHNIQUE: Operative Technique for Modified Radical Neck Dissection in Papillary Thyroid Carcinoma

Background Papillary thyroid carcinoma is the most common endocrine malignancy. Recently, controversy has focused on the management of lymph node metastases, which represent approximately 90% of disease recurrences and may require considerable time, effort, and resources to diagnose and treat. Current intense postoperative surveillance by endocrinologists nationwide has the sensitivity to detect even minute lymph node metastases using ultrasonography, radioactive iodine scan, and thyroglobulin monitoring. Objectives To (1) present a succinct synopsis of the rationale and elements of our current surgical management strategy for papillary thyroid carcinoma and, within this context, (2) provide a detailed stepwise description of a compartment-oriented modified radical neck dissection. This description is combined with intraoperative photographs and a medical artist's illustrations to enhance and emphasize the most important points. Conclusions With anatomically defined precise dissection, following the steps outlined and illustrated, a thorough lymphadenectomy can be accomplished safely, with reasonable cosmetic results, minimizing disease relapse.

INVITED CRITIQUE: Operative Technique for Modified Radical Neck Dissection in Papillary Thyroid Carcinoma--Invited Critique

REVIEW ARTICLE: Hepatic Portal Venous Gas: The ABCs of Management

Objective To review the use of computed tomography (CT) and radiography in managing hepatic portal venous gas (HPVG) at a university-affiliated tertiary care center and in the literature. Hepatic portal venous gas is frequently associated with acute mesenteric ischemia, accounting for most of the HPVG-associated mortality. While early studies were necessarily dependent on plain abdominal radiography, modern high-resolution CT has revealed a host of benign conditions in which HPVG has been reported that do not require emergent surgery. Data Sources Patient records from our institution over the last 10 years and relevant studies from BioMed Central, CENTRAL, PubMed, and PubMed Central. In addition, references cited in selected works were also used as source data. Study Selection Patient records were selected if the CT or radiograph findings matched the term hepatic portal venous gas. Studies were selected based on the search terms hepatic portal venous gas or portal venous gas. Data Extraction Quantitative and qualitative data were quoted directly from cited work. Data Synthesis Early studies of HPVG were based on plain abdominal radiography and a literature survey in 1978 found an associated mortality rate of 75%, primarily due to ischemic bowel disease. Modern abdominal CT has resulted in the detection of HPVG in more benign conditions, and a second literature survey in 2001 found a total mortality of only 39%. While the pathophysiology of HPVG is, as yet, unclear, changing abdominal imaging technology has altered the significance of this radiologic finding. Hepatic portal venous gas therefore predicts high risk of mortality (>50%) if detected by plain radiography or by CT in a patient with additional evidence of necrotic bowel. If detected by CT in patients after surgical or endoscopic manipulation, the clinician is advised that there is no evidence of increased risk. If HPVG is detected by CT in patients with active peptic ulcer disease, intestinal obstruction and/or dilatation, or mucosal diseases such as Crohn disease or ulcerative colitis, caution is warranted, as risk of death may approach 20% to 30%. Conclusion The finding of HPVG alone cannot be an indication for emergency exploration, and we have developed an evidence-based algorithm to guide the clinician in management of patients with HPVG.

INVITED CRITIQUE: Hepatic Portal Venous Gas--Invited Critique

RESIDENT'S FORUM: A Merkel Cell Carcinoma Treatment Algorithm

Merkel cell carcinoma is a rare and aggressive malignancy of the skin. Approximately 2000 cases of Merkel cell carcinoma have been reported since its first published description in 1972. Owing to its rarity, scientific studies have been difficult. Our current knowledge is based on retrospective case studies and case reports. Although many treatment modalities have been used, no definitive management strategy has yet been elucidated. Current strategies include local excision, Mohs surgery, sentinel lymph node biopsy, lymph node dissection, irradiation, and chemotherapy. We present several recent cases to demonstrate the heterogeneity of this cancer, then we review the literature to suggest a treatment algorithm for this rare but aggressive cancer.