RECOMMENDATION OF THE PERITONEUM NEOPLASMS SERVICE OF ``HOSPITAL SANTA RITA DA SANTA CASA DE MISERICORDIA`` AT PORTO ALEGRE – CECAL APPENDIX MUCOCELE – LAPAROSCOPIC OR LAPAROTOMICAL APPROACH?

• DOI: https://doi.org/10.22533/at.ed.1594292420034

• Palavras-chave: Cecal Appendix Mucocele; Laparoscopy; Laparotomy.

• Keywords: Cecal Appendix Mucocele; Laparoscopy; Laparotomy.

• Abstract:

  Introduction: Cecal appendix mucocele is complete or segmental dilatation of the cecal appendix full filled by mucus ou mucin. There isn't a radiologic characteristic that can define or suggest histologic alterations associated, different of another neoplasms. They range from cystadenoma, transient mucus accumulation for fecalith, benign or malign neoplasm. In up to 20% of cases there is association of this rare condition with an appendicular Mucinous Neoplasm, whose mucin leakage in to peritoneal cavity may progress for Peritoneal Pseudomyxoma (PSP) - catastrophic situation. There isn't consensus in the literature whether laparoscopic approach would be safe on this scenario. 
  Objective: systematically review the literature in order to determine oncological safety regarding the access route for treating cecal appendix mucocele: laparoscopic or laparotomic. 
  Methods and Results: the key words "appendix mucocele", "laparoscopic", "laparoscopy", “pathology” was searched on the PubMed and LILCAS, including review articles, reviews and series of cases since January/1900 until November/2023, relate of case was excluded. The results were tabled and the articles were discussed in routine multidisciplinary meetings. Total of 36 articles were included: 17 case series, 10 histopathological reviews and 9 literature reviews. 
  Discussion: In 1997 Sugarbaker described the case of a female of 37 years who underwent a laparoscopic appendectomy for mucocele of appendix whose associated histology was mucinous neoplasia. In 9 months, the patient developed peritoneal pseudomyxoma being submitted to a cytorredutive surgery and HIPEC. He attributed to laparoscopic manipulation of the lesion the rapid spread and progression for PSP. He concluded that the presence of appendix mucocele contraindicates laparoscopic approach. Since then, numerous articles have been published describing laparoscopic approach to mucocele/clinical changes of the appendix as feasible and oncologically safe. All series of cases analysed were retrospective, few cases, post operative diagnosis, limited and inadequate follow up - considering peritoneal pseudomyxoma is a long-time developing disease. There is also biologic plausibility as LACC TRIAL suggested. At trial, group submitted to laparoscopic approach had worse oncologic outcomes when compared to another group - laparotomic ones – for radical hysterectomy for cervical cancer. Pneumoperitoneum, biologic behavior under CO2 tension, tumoral manipulation could explain the worst outcomes. Characteristics specific to the surgical technique of laparoscopic appendectomy imply manipulation of the cecal appendix – and of the lesion in turn – which can increase tumor exfoliation or fragmentation – as well as not guaranteeing adequate surgical margin in the cecum; It is also known that laparoscopic surgery increases the chance of mucocele rupture. There are no studies that describe the biological behavior of these cells when exposed to pneumoperitoneum, CO2 and increased intra-abdominal pressure. Therefore, it is not possible to consider laparoscopic appendectomy oncologically safe, despite being technically feasible. 
  Conclusion: In light of the best existing evidence gathered in this review, it is not possible to consider laparoscopic appendectomy oncologically safe. We recommend that cecal appendix mucoceles be approached by laparotomy.