A Beaurocrat 62 years on his annual checkup found to have a cystic leision in the pelvis reaching up to the Right Iliac fossa on U/S.Suspected as a case of Enteric duplication cyst, hence he was referred for further management.He is a Hypertnsive on medication.Clinical exam was normal , could not feel any mass.
Rest of the work up was normal except cect showed tubular cystic structure measuring 15cmsx6.2 cmsx6.3 cms extending from the Right iliac fossa .Endoscopic and colonoscopic assessmennt was not done.would a simlpe appendicetomy suffiecient !
Mucocele of appendix in itself is not common. Most of the cases remain silent till they present as acute appendicitis and diagnosis is per-op or HPE. But to such a giant lump lying asymptomatic without any mass effect or pain, and not ruptured till this size is reached, is very uncommon.
Not that rare now; along with other incidentalinomas found on imaging...
If it is a real mucocele of the appendix without perforation, appendectomy is sufficient.
Thankyou,Giant mucocele of the Appendix is RARE .what is important is careful manipulation to prevent leak and suitable procedure like partial resection.With the previous experience in mind our pt.underwent Limited resection of Caecum and Ileum.Histopathology reported as cysadenoma base of the Appendix with adjacent 13 nodes negative for tumour.It was a Lap assisted procedure.Pt was discharged on 4th post operative day.
If the diagnosis was made preoperatively, then what was the reason for a limited resection instead of an appendectomy?
Read the question and history,then you will,in the international fora better to read well before answering.
apologies; if deemed necessary, but your comment in no way answers my query.
Underlying adenocarcinoma needs to be ruled out in such a situation. Right hemicolectomy should be the procedure of choice in a 62 years old gentleman.
Put bluntly I am querying the modalities used in the routine "work-up" of an incidental finding. For, I presume we would all agree in practices where "annual checkups" are performed, surgery should rarely be an investigation, if at all possible. Hence, the tone of your response is intriguing, Dr Reddy
Appendiceal mucocele is a rare clinical entity comprising 8% of all appendiceal tumors, and it is seen in 0.2-0.3% of all appendectomy specimens. Without perforation, appendectomy is sufficient. Although synchronous colorectal neoplasia has been reported in 3-5% of the cases,the synchronous occurrence of mucinous cystadenoma of the appendix and colorectal cancer is rare. Clinical care should be taken when mobilising the tumour to avoid rupture of mucocele and subsequent spillage of mucin into the peritoneal cavity, resulting in the development of pseudomyxoma peritonei.
Is't a very rare condition. As for the treatment as long as there is no perforation appendectomy is sufficient. I belive that the open approch is better than the laparoscopic one because it limits the risc of splillage of mucin into the peritoneal cavity. However the presence of local invasion and cecal involvement are two indications in the literature that warrant employment of right hemicolectomy . An open approach has been favored by some authors as being a definitive and safe maneuver which allows better visualization of the abdominal cavity - the incidence of peritoneal implants and inadvertently missed lesions after laparoscopy is sometimes high. The pelvis, omentum, the perihepatic space and paracolic space should be inspected for mucinous fluid collection. long-term follow-up is warranted in such patients to evaluate the risks of pseudomyxoma peritonei.
In fact, with accepted appropriate staging ie CT colonography or colonoscopy along with lap appendicectomy with retrieval in a bag, there should be no reason to perform an open procedure, unless there is any doubt at any stage in the work-up. However, it is imperative to remember that surgery is not about technical skills, but is all about diagnostic paranoia with appropriate individualistically tailored intervention. I think the crux has been missed in the question and that is the duty of a surgeon as a healer and not a mere technician!
If you have the experience and the equipment and you have enough distance between the mucocele and the base of the appendix, you can do it as a simple lap. appendectomy. If the distance to the base of the appendix is to small, you can perform a wedge resection of the cecum. In other cases you need to perform for technical reasons an ileocecal resection. Using a retrieval bag is neccessary and I prefer to use a stapler for appendectomy as the closure of the mucocele is as important as the closure of the base of the appendix at the cecal site.
I think that appendectomy is sufficient, if the base of the appendix is not involved. It is crucial to prevent spillage, concerning the preferance between laparoscopic and open method.
My last two colleagues are absolutely correct; the crux in any case is an appropriate work-up. Beyond that, the management is based on the individual findings, choosing the simplest intervention that applies. This should hold true whilst managing every case, incidental finding or not.
I agree with a simple appendectomy. Then request your friendly pathologist to check the margin of resection.
Dear DrFrancisco,
It is very difficult to convince for second surgery,if it required as per the Histo pathology in some parts of the Globe.However I appreciate the answer.
Surely, whichever part of the world one works in, management is dependent on pathology? If the pathology is not going to affect your decision-making and expensive investigations are, why would you send specimens for histology? The organisation whose tag you use is hardly paradigmatic of the parts of the globe you refer to, particularly if the patient was undergoing annual check-ups with such investigations, given there is no international evidence that suggests annual pelvic ultrasounds should be performed. If one is going to go out of one's way to detect incidentalinomas, then it is necessary to ensure one has a plan as to how to manage them - surely this should include robust discussions with patients? Irrespective of location and circumstances, our professional principles do not alter! In fact, Dr Francisco's advice has probably not been mentioned to date as we all took that for granted!
I have never forgotten a case of Pseudomyxoma Perotonei that I saw once. We physicians and surgeons are not only products of our own experiences but are inherently always reminded that we only help the body cure itself to the best that knowledge has to offer. In times past in another locale where I did not have a local pathologist, I always took the effort ( and sometimes the expense) to send my specimens for confirmatory diagnosis to the pathologist to finalize the surgical exercise. "Nobility obliges"
Kudos, Dr Tirol! Well-said! I always say to surgical trainees there is no such thing as good or bad postings; but there are those who are good or bad learners from any experience. Particularly for surgeons, the post-op pathology defines our professional prowess; only partially, thru assessing our technical skills, but mainly assessing the relevance of those skills. You will agree there is nothing more disheartening than producing a "perfect" resection specimen, only to find some possible microscopic neoplasia at that resection margin! On a personal note, I called my senior pathologist my "work father" - now that he's retired, he calls me his adopted daughter; I mention this as this is one of the most gratifying relationship any surgeon can have!!
This is a very good question for discussion. Usual the lumen of appendix is very narrow; therefore if any mucin producing tumor grows, it eventually ruptured when the tumor, even small and unnoticeable, has completely obstructed the lumen. The clinical presentation is a ruptured appendicitis with some mucin around the peri-appendix or the Douglas pouch in the first operation. To recognize this kind of mucin accumulation, especially in the Douglas pouch, is very crucial to prevent the formation of pseudomysoma peritonei. The other crucial step is to check the remnant appendix and completely remove the appendiceal root or adjacent tissue for radical resection and for pathologic proven.
I had the experience to find remnant appendiceal root, when dealing with pseudomyxoma peritonei 10 years later after the previous appendectomy for a ruptured appendicitis, and the pathology revealed it was a cystoadenocarcinoma. This scenario has not been described or published before. My presumption is that It needs about 10 years for the presentation of pseudomyxoma peritonei becoming apparent if not treated radically at the first operation.
Our publication of pesudomyxoma peritonei is as followed:
Hsu KH, Chou CY, Chang YC. Intraperitoneal hyperthermia in the management of pseudomyxoma peritonei. Hepatogastroenterology 2007;54:47-52. (Correspondence)
Dr Chang, a ruptured lesion presenting many years later as pseudomyxoma is the actual definition of the pseudomyxoma; finding a carcinoma in the remanents of an adenoma will only increase, given the increase in stump-appendicitis we find related to lap appendicectomies. I guess it depends on how extensive any disease is to be able to find a primary focus e.g. Similar to the situation of aabdominal carcinomatosis with an unknown primary. If it truly hasn't been published; I would suggest doing so now!
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