APPENDIX James Taclin C. Banez, MD, FPSGS,FPCS
Anatomy / Function <ul><li>Location, position </li></ul><ul><li>Function: </li></ul><ul><ul><li>Immunologic organ   </li><...
Appendiceal Conditions of Surgical Importance <ul><li>Appendicitis: </li></ul><ul><ul><li>Inflammation of the appendix </l...
Appendicitis <ul><li>Pathogenesis: </li></ul><ul><ul><li>Obstruction  (dominant causal factor) </li></ul></ul><ul><ul><ul>...
Appendicitis <ul><li>Pathogenesis: </li></ul><ul><ul><li>Sequence of events in  Luminal Obstruction </li></ul></ul><ul><li...
Appendicitis <ul><li>Pathogenesis </li></ul><ul><ul><li>Inflammatory process involves the serosa of appendix and in turns ...
Appendicitis <ul><li>Pathogens: </li></ul><ul><ul><li>Anaerobes, aerobes </li></ul></ul><ul><ul><li>Bacteroides fragilis, ...
Appendicitis <ul><li>Clinical Manifestation: </li></ul><ul><ul><li>Abdominal pain: </li></ul></ul><ul><ul><ul><li>Classic ...
Appendicitis <ul><li>Signs:  PE depends on the location of the    appendix and presence of rupture </li></ul><ul><ul><li>D...
Appendicitis <ul><li>Laboratory Findings: </li></ul><ul><ul><li>WBC: leucocytosis  </li></ul></ul><ul><ul><li>  simple = 1...
Appendicitis <ul><li>Graded Compression sonogram: </li></ul><ul><ul><li>78–96% sensitivity; 85–98% specificity </li></ul><...
Appendicitis <ul><li>CT scan: </li></ul><ul><ul><li>Shd. not delay or substitute for prompt operative intervention when cl...
Appendicitis <ul><li>Laparoscopy  </li></ul><ul><ul><li>Diagnostic /therapeutic </li></ul></ul><ul><ul><li>Useful for fema...
<ul><li>Appendiceal Rupture: </li></ul><ul><ul><li>Increase morbidity / mortality </li></ul></ul><ul><ul><li>No accurate w...
<ul><li>Differential Diagnosis: </li></ul><ul><li>Most common erroneous pre-op diagnosis: </li></ul><ul><ul><ul><li>Acute ...
Differential Diagnosis: <ul><li>Acute gastroenteritis: </li></ul><ul><ul><li>Childhood, viral gastroenteritis </li></ul></...
Differential Diagnosis: <ul><li>Intussusceptions: </li></ul><ul><ul><li>Shd. Be differentiated pre-operatively due to diff...
Differential Diagnosis: <ul><li>UTI / Ureteral stone: </li></ul><ul><ul><li>Referred pain to the labia, scroyum or penis <...
TREATMENT <ul><li>Adequate hydration, correct electrolyte imbalance </li></ul><ul><li>Manage other medical problems </li><...
<ul><li>Open Appendectomy: </li></ul>
TREATMENT <ul><ul><li>Laparoscopy: </li></ul></ul>
TREATMENT <ul><ul><li>Phlegmon and small abscesses can be treated conservatively w/ IV antibiotic </li></ul></ul><ul><ul><...
PROGNOSIS <ul><li>Mortality: </li></ul><ul><ul><li>9.9% -------> 0.2% </li></ul></ul><ul><ul><li>Factors: </li></ul></ul><...
PROGNOSIS <ul><li>Morbidity: </li></ul><ul><ul><li>Simple  -  3% Ruptured  -  47% </li></ul></ul><ul><ul><li>Early: </li><...
PROGNOSIS <ul><li>Morbidity: </li></ul><ul><ul><li>Late: </li></ul></ul><ul><ul><ul><li>Adhesived bands </li></ul></ul></u...
Appendicitis in the Young <ul><ul><li>Difficult to establish diagnosis: </li></ul></ul><ul><ul><ul><li>Inability of a chil...
Appendicitis during Pregnancy <ul><ul><li>AP is the most frequent extra-uterine dse. requiring surgical Tx during pregnanc...
Appendicitis during Pregnancy <ul><ul><li>Dx is difficult due to displacement of the appendix </li></ul></ul>
Appendicitis during Pregnancy <ul><ul><li>Risk of surgery: </li></ul></ul><ul><ul><ul><li>Premature labor  -  10-15% both ...
Tumors of the Appendix <ul><li>Appendiceal malignancy is rare </li></ul><ul><li>Discovered during laparotomy or in associa...
Tumors of the Appendix <ul><li>ADENOCARCINOMA: </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Histologic type: </li...
Tumors of the Appendix <ul><li>MUCOCELE: </li></ul><ul><ul><li>Progressive enlargement of the appendix from the intralumin...
Tumors of the Appendix <ul><li>MUCOCELE: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Benign  -  append...
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Appendix, Surgery

  1. 1. APPENDIX James Taclin C. Banez, MD, FPSGS,FPCS
  2. 2. Anatomy / Function <ul><li>Location, position </li></ul><ul><li>Function: </li></ul><ul><ul><li>Immunologic organ </li></ul></ul><ul><ul><ul><li>Secrets IgA, component of the GUT associated lymphoid tissue (GALT) </li></ul></ul></ul><ul><ul><ul><li>Not essential; it’s removal ----> (-) sepsis </li></ul></ul></ul>
  3. 3. Appendiceal Conditions of Surgical Importance <ul><li>Appendicitis: </li></ul><ul><ul><li>Inflammation of the appendix </li></ul></ul><ul><ul><li>1500 – perityphlitis – inflammation of the cecal region </li></ul></ul><ul><ul><li>Most common acute surgical disease of the abdomen </li></ul></ul><ul><ul><li>Peak ----> puberty / early adulthood </li></ul></ul><ul><ul><li>Male > female (1.3 : 1) </li></ul></ul>
  4. 4. Appendicitis <ul><li>Pathogenesis: </li></ul><ul><ul><li>Obstruction (dominant causal factor) </li></ul></ul><ul><ul><ul><li>Fecalith – usual cause </li></ul></ul></ul><ul><ul><ul><li>Hypertrophy of the lymphoid tissue </li></ul></ul></ul><ul><ul><ul><li>Inspissated barium </li></ul></ul></ul><ul><ul><ul><li>Vegetable and fruit seeds </li></ul></ul></ul><ul><ul><ul><li>Intestinal worms (Ascaris) </li></ul></ul></ul><ul><ul><ul><li>Tumor </li></ul></ul></ul>
  5. 5. Appendicitis <ul><li>Pathogenesis: </li></ul><ul><ul><li>Sequence of events in Luminal Obstruction </li></ul></ul><ul><li>Proximal occlusion ---> Closed loop Obst. ---- ---> rapid distention due to: </li></ul><ul><ul><ul><ul><li>Continuing secretion of the mucosa </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rapid multiplication of normal flora </li></ul></ul></ul></ul><ul><ul><ul><li>---> elevate pressure ---> capillary/venous occlusion ( CONGESTION 1 st stage): </li></ul></ul></ul><ul><ul><ul><li>S/Sx: (+) visceral afferent pain fibers (vague, dull, diffuse pain in mid-abdomen or lower epigastrium. Increase peristalsis (crampy pain); N/V and anorexia </li></ul></ul></ul>
  6. 6. Appendicitis <ul><li>Pathogenesis </li></ul><ul><ul><li>Inflammatory process involves the serosa of appendix and in turns parietal peritoneum in the region. </li></ul></ul><ul><ul><li>Infiltration of PMN ( SUPPURATIVE 2 nd stage) </li></ul></ul><ul><ul><ul><li>Damage of the lining epithelium ---> entrance of bacteria to the wall. </li></ul></ul></ul><ul><ul><li>Impairment of blood supply (inc. pressure than arterial pressure)---> ellipsoidal infarct at antimesenteric border near the tip. ( GANGRENOUS 3 rd stage) ---> ( PERFORATION 4 th stage) </li></ul></ul><ul><ul><li>This process is not inevitable. Some subside spontaneously </li></ul></ul>
  7. 7. Appendicitis <ul><li>Pathogens: </li></ul><ul><ul><li>Anaerobes, aerobes </li></ul></ul><ul><ul><li>Bacteroides fragilis, Escherichia coli, Peptostreptococcus, Pseudomonas, Bacteroides splanchnicus, Lactobacillus </li></ul></ul>
  8. 8. Appendicitis <ul><li>Clinical Manifestation: </li></ul><ul><ul><li>Abdominal pain: </li></ul></ul><ul><ul><ul><li>Classic pain sequence ………. </li></ul></ul></ul><ul><ul><ul><li>Right lower quadrant pain </li></ul></ul></ul><ul><ul><ul><li>Others: </li></ul></ul></ul><ul><ul><ul><ul><li>Left lower quadrant pain (long appendix) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flank or back pain (retro-cecal) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Supra-pubic (pelvic) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Testicular pain (retro-ileal ----> irritates the spermatic artery and ureter </li></ul></ul></ul></ul><ul><ul><li>Anorexia: nearly always present </li></ul></ul><ul><ul><li>Vomiting 75% </li></ul></ul><ul><ul><li>Obstipation / diarrhea </li></ul></ul><ul><ul><li>Usual sequence (95%) : ANOREXIA ---> ABD. PAIN ---> VOMITING </li></ul></ul>
  9. 9. Appendicitis <ul><li>Signs: PE depends on the location of the appendix and presence of rupture </li></ul><ul><ul><li>Direct and rebound tenderness at Mc Burney’s point. ROVSING sign ---> indicate muscles peritoneal irritation. </li></ul></ul><ul><ul><li>Involuntary muscle guarding (true reflex rigidity). </li></ul></ul><ul><ul><li>Psoas / Obturator signs ---> retrocecal appendix </li></ul></ul><ul><ul><li>Para-rectal tenderness </li></ul></ul><ul><li>Stages I & II – uncomplicated </li></ul><ul><li>Stages III & IV – complicated </li></ul>
  10. 10. Appendicitis <ul><li>Laboratory Findings: </li></ul><ul><ul><li>WBC: leucocytosis </li></ul></ul><ul><ul><li> simple = 10,000 to 18,000/mm3 </li></ul></ul><ul><ul><li> perforated = >18,000/mm3 </li></ul></ul><ul><ul><li>Urinalysis : </li></ul></ul><ul><ul><ul><ul><li>Hematuria and pyuria due to irritation of the ureter and urinary bladder </li></ul></ul></ul></ul><ul><ul><ul><ul><li>w/o bacteriuria </li></ul></ul></ul></ul><ul><ul><li>FPA: rarely helpful; (+) fecalith – rare, </li></ul></ul><ul><ul><li>highly suggestive of the dx. </li></ul></ul>
  11. 11. Appendicitis <ul><li>Graded Compression sonogram: </li></ul><ul><ul><li>78–96% sensitivity; 85–98% specificity </li></ul></ul><ul><ul><li>(+) non-compressible appendix, 6mm or > at AP view </li></ul></ul><ul><ul><li>(-) easily compressible 5mm; not visualized a & (-) pericecal fluid or mass </li></ul></ul><ul><ul><li>False (-): </li></ul></ul><ul><ul><ul><li>Appendicitis confined at the tip </li></ul></ul></ul><ul><ul><ul><li>Retrocecal position </li></ul></ul></ul><ul><ul><ul><li>Perforated appendix </li></ul></ul></ul><ul><ul><li>False (+): </li></ul></ul><ul><ul><ul><li>Periappendicitis from surrounding inflammation </li></ul></ul></ul><ul><ul><ul><li>Dilated fallopian tube </li></ul></ul></ul><ul><ul><ul><li>Inspissated stool can mimic an appendicitis </li></ul></ul></ul><ul><ul><ul><li>Obese pt., appendix not compressed </li></ul></ul></ul>
  12. 12. Appendicitis <ul><li>CT scan: </li></ul><ul><ul><li>Shd. not delay or substitute for prompt operative intervention when clinically indicated </li></ul></ul><ul><ul><li>Used primarily for percutaneous drainage </li></ul></ul>
  13. 13. Appendicitis <ul><li>Laparoscopy </li></ul><ul><ul><li>Diagnostic /therapeutic </li></ul></ul><ul><ul><li>Useful for female to diferrentiate gynecological pathology </li></ul></ul>
  14. 14. <ul><li>Appendiceal Rupture: </li></ul><ul><ul><li>Increase morbidity / mortality </li></ul></ul><ul><ul><li>No accurate way to determine the occurrence of rupture </li></ul></ul><ul><ul><li>Suspected: </li></ul></ul><ul><ul><ul><li>Fever > 39 C </li></ul></ul></ul><ul><ul><ul><li>WBC of > 18,000/mm3 </li></ul></ul></ul><ul><ul><ul><li>Localized rebound, involuntary muscle guarding </li></ul></ul></ul><ul><ul><ul><li>Signs of genralized peritonitis </li></ul></ul></ul><ul><ul><ul><li>Ill defined mass (PHLEGMON – motted loops of bowel adherent to the inflamed appendix) </li></ul></ul></ul>
  15. 15. <ul><li>Differential Diagnosis: </li></ul><ul><li>Most common erroneous pre-op diagnosis: </li></ul><ul><ul><ul><li>Acute mesenteric lymphaditis </li></ul></ul></ul><ul><ul><ul><li>No organic pathologic condition </li></ul></ul></ul><ul><ul><ul><li>Acute pelvic pathologic condition </li></ul></ul></ul><ul><ul><ul><li>Twisted ovarian cyst / ruptured graafian follicle </li></ul></ul></ul><ul><ul><ul><li>Acute gastroenteritis </li></ul></ul></ul><ul><li>Acute mesenteric adenitis: </li></ul><ul><ul><li>w/ present or recent URTI </li></ul></ul><ul><ul><li>Diffuse pain, tenderness not sharp, (-) rigidity </li></ul></ul><ul><ul><li>Self limited -----> observe </li></ul></ul>
  16. 16. Differential Diagnosis: <ul><li>Acute gastroenteritis: </li></ul><ul><ul><li>Childhood, viral gastroenteritis </li></ul></ul><ul><ul><li>Chills, fever, profuse watery diarrhea, N/V </li></ul></ul><ul><ul><li>Hyper-peristaltic abdominal cramps w/o localizing sign </li></ul></ul><ul><li>Disease of the male: </li></ul><ul><ul><li>Torsion of the testes and acute epididymitis </li></ul></ul><ul><ul><li>Diagnosed by palpating the enlarged tender seminal vesicle </li></ul></ul><ul><li>Meckel’s diverticulitis: </li></ul><ul><ul><li>Same clinical picture w/ AP </li></ul></ul><ul><ul><li>Associated w/ same complication of AP, hence needs prompt surgical intervention. </li></ul></ul>
  17. 17. Differential Diagnosis: <ul><li>Intussusceptions: </li></ul><ul><ul><li>Shd. Be differentiated pre-operatively due to different management. </li></ul></ul><ul><ul><li>Char: </li></ul></ul><ul><ul><ul><li>Common under 2 y/o </li></ul></ul></ul><ul><ul><ul><li>Occur in well nourished infant who suddenly doubled up due to colicky pain. Hrs. later pass out bloody mucoid stool </li></ul></ul></ul><ul><ul><ul><li>Sausage shape mass in the RLQ </li></ul></ul></ul><ul><li>Regional enteritis (Crohn’s dse): </li></ul><ul><ul><li>s/sx is almost the same w/ AP this is dx. in celiotomy </li></ul></ul>
  18. 18. Differential Diagnosis: <ul><li>UTI / Ureteral stone: </li></ul><ul><ul><li>Referred pain to the labia, scroyum or penis </li></ul></ul><ul><ul><li>Chills, fever (+) R costo-vertebral angle tenderness, hematuria, leucocytosis </li></ul></ul><ul><ul><li>Dx: -----> pyelography </li></ul></ul><ul><li>Gynecological disorders: </li></ul><ul><ul><li>Rate of erroneous diagnosis of AP is highest in young adult female </li></ul></ul><ul><ul><li>Order of frequency: </li></ul></ul><ul><ul><ul><ul><li>PID -----> ruptured grafian follicle ----> twistd ovarian cyst or tumor -----> endometriosis -----> ruptured ectopic pregnancy </li></ul></ul></ul></ul>
  19. 19. TREATMENT <ul><li>Adequate hydration, correct electrolyte imbalance </li></ul><ul><li>Manage other medical problems </li></ul><ul><li>Pre-operative antibiotics: </li></ul><ul><ul><li>Simple AP - hrs antibiotic </li></ul></ul><ul><ul><li>Ruptured AP - antibiotic until fever </li></ul></ul><ul><ul><li>Peritonitis - 10 days antibiotics </li></ul></ul><ul><li>Surgery: </li></ul><ul><ul><li>Open appendectomy: </li></ul></ul><ul><ul><ul><li>McBurney (oblique); Rocky Davis (transverse); </li></ul></ul></ul><ul><ul><ul><li>right paramedian; midline incision </li></ul></ul></ul>
  20. 20. <ul><li>Open Appendectomy: </li></ul>
  21. 21. TREATMENT <ul><ul><li>Laparoscopy: </li></ul></ul>
  22. 22. TREATMENT <ul><ul><li>Phlegmon and small abscesses can be treated conservatively w/ IV antibiotic </li></ul></ul><ul><ul><li>Well localized abscess ---> percutaneous drainage </li></ul></ul><ul><ul><li>Complex abscess ---> surgical drainage </li></ul></ul><ul><ul><li>Interval appendectomy – 6 wks. Following an acute event treated either non-operatively or w/ simple drainage of an abscess. </li></ul></ul><ul><ul><ul><li>0-37% recurrent appendicitis </li></ul></ul></ul>
  23. 23. PROGNOSIS <ul><li>Mortality: </li></ul><ul><ul><li>9.9% -------> 0.2% </li></ul></ul><ul><ul><li>Factors: </li></ul></ul><ul><ul><ul><li>Ruptured prior to surgery </li></ul></ul></ul><ul><ul><ul><ul><li>Simple - 0.06% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ruptured - 3% </li></ul></ul></ul></ul><ul><ul><ul><li>Age of pt.: </li></ul></ul></ul><ul><ul><ul><ul><li>Ruptured - 15% </li></ul></ul></ul></ul><ul><ul><li>Death due to: </li></ul></ul><ul><ul><ul><li>Uncontrolled sepsis (peritonitis, intra-abdominal abscess, gm (-) septicemia. </li></ul></ul></ul><ul><ul><ul><li>Cardiac / pulmonary insufficiency (elderly) </li></ul></ul></ul><ul><ul><ul><li>Pulmonary embolism </li></ul></ul></ul><ul><ul><ul><li>aspiration </li></ul></ul></ul>
  24. 24. PROGNOSIS <ul><li>Morbidity: </li></ul><ul><ul><li>Simple - 3% Ruptured - 47% </li></ul></ul><ul><ul><li>Early: </li></ul></ul><ul><ul><ul><li>Septic : </li></ul></ul></ul><ul><ul><ul><ul><li>Wound infection / abscess </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intra-abdominal abscess (appendiceal fossa, pouch of Douglas, sub-hepatic space, multiple intestinal loops. </li></ul></ul></ul></ul><ul><ul><ul><li>Fecal fistula: </li></ul></ul></ul><ul><ul><ul><li>Wound dehiscence </li></ul></ul></ul><ul><ul><ul><li>Intestinal obstruction: due to locculated abscess & exuberant adhesive formation </li></ul></ul></ul>
  25. 25. PROGNOSIS <ul><li>Morbidity: </li></ul><ul><ul><li>Late: </li></ul></ul><ul><ul><ul><li>Adhesived bands </li></ul></ul></ul><ul><ul><ul><li>Inguinal hernia (3x greater in pt. who had appendectomy) </li></ul></ul></ul><ul><ul><ul><li>Incisional hernia (paramedian / midline incision) </li></ul></ul></ul>
  26. 26. Appendicitis in the Young <ul><ul><li>Difficult to establish diagnosis: </li></ul></ul><ul><ul><ul><li>Inability of a child to give accurate history </li></ul></ul></ul><ul><ul><ul><li>Diagnostic delays by both parents & physicians </li></ul></ul></ul><ul><ul><li>Rapid progression to rupture: </li></ul></ul><ul><ul><ul><li>Underdeveloped greater omentum ----> higher morbidity </li></ul></ul></ul><ul><ul><ul><li>< 8y/o had a twofold increase rate of perforation as compared to older children </li></ul></ul></ul>
  27. 27. Appendicitis during Pregnancy <ul><ul><li>AP is the most frequent extra-uterine dse. requiring surgical Tx during pregnancy </li></ul></ul><ul><ul><li>Most frequent during the 1 st & 2 nd trimesters </li></ul></ul><ul><ul><li>S/Sx: </li></ul></ul><ul><ul><ul><li>Abdominal pain, tenderness </li></ul></ul></ul><ul><ul><ul><li>Rebound tenderness and guarding less due to laxity of abdominal wall </li></ul></ul></ul><ul><ul><li>Increase WBC; abdominal ultrasound </li></ul></ul><ul><ul><li>Dx is difficult due to displacement of the appendix </li></ul></ul>
  28. 28. Appendicitis during Pregnancy <ul><ul><li>Dx is difficult due to displacement of the appendix </li></ul></ul>
  29. 29. Appendicitis during Pregnancy <ul><ul><li>Risk of surgery: </li></ul></ul><ul><ul><ul><li>Premature labor - 10-15% both for negative laparotomy and appendectomy for uncomplicated AP </li></ul></ul></ul><ul><ul><ul><li>Appendiceal perforation is significant factor associated w/ fetal and maternal death. </li></ul></ul></ul><ul><ul><ul><ul><li>Fetal mortality - 3-5% w/ early appendicitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>20% perforation </li></ul></ul></ul></ul><ul><ul><li>Suspicion of appendicitis during pregnancy shd prompt rapid diagnosis and surgical intervention </li></ul></ul>
  30. 30. Tumors of the Appendix <ul><li>Appendiceal malignancy is rare </li></ul><ul><li>Discovered during laparotomy or in association w/ acute inflammation of the appendix </li></ul><ul><li>CARCINOID: </li></ul><ul><ul><li>Firm, yellow, bulbar mass in the appendix </li></ul></ul><ul><ul><li>Located: appendix ---> small bowel ----> rectum </li></ul></ul><ul><ul><li>Carcinoid syndrome is rare in appendiceal carcinoid unless widespread metastases are present </li></ul></ul><ul><ul><li>Malignant potential related to it’s SIZE ---> > 2cm </li></ul></ul><ul><ul><li>Treatment: < 2cm appendectomy </li></ul></ul><ul><ul><li>> 2cm right hemicolectomy </li></ul></ul>
  31. 31. Tumors of the Appendix <ul><li>ADENOCARCINOMA: </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Histologic type: </li></ul></ul><ul><ul><ul><li>Mucinous adenocarcinoma </li></ul></ul></ul><ul><ul><ul><li>Colonic adenocarcinoma </li></ul></ul></ul><ul><ul><ul><li>Adenocarcinoid </li></ul></ul></ul><ul><ul><li>Manifestation: </li></ul></ul><ul><ul><ul><li>Acute appendicitis </li></ul></ul></ul><ul><ul><ul><li>RLQ mass </li></ul></ul></ul><ul><ul><li>Treatment: right hemicolectomy </li></ul></ul><ul><ul><li>Prognosis: </li></ul></ul><ul><ul><ul><li>55% ----> 5yr. survival </li></ul></ul></ul>
  32. 32. Tumors of the Appendix <ul><li>MUCOCELE: </li></ul><ul><ul><li>Progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance </li></ul></ul><ul><ul><li>Histologic type: </li></ul></ul><ul><ul><ul><li>Retention cyst </li></ul></ul></ul><ul><ul><ul><li>Mucosal hyperplasia </li></ul></ul></ul><ul><ul><ul><li>Cystadenomas </li></ul></ul></ul><ul><ul><ul><li>Cystadenocarcinoma </li></ul></ul></ul><ul><ul><li>Rarely occurs w/ gelatinous ascites (Pseudomyxoma Peritonei) usually associated w/ malignant ovarian or appendiceal mucinous CA. if present survival is decreased </li></ul></ul>
  33. 33. Tumors of the Appendix <ul><li>MUCOCELE: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Benign - appendectomy </li></ul></ul></ul><ul><ul><ul><li>Malignant - right hemicolectomy for cystadenoCA of the appendix; THABSO and appendectomy for ovarian cystadenoCA </li></ul></ul></ul><ul><ul><ul><ul><li>Adjuvant Tx: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Radiation, intraperitoneal and systemic chemotherapy recommended but it’s role is unclear </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>57% local recurrence at appendiceal primary site </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Death ensues due to progresive obstruction and renal failure </li></ul></ul></ul></ul></ul>
  34. 34. THANK YOU
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