There is increasing evidence that pseudomyxoma peritonei is a neoplastic condition which usually arises from a primary adenoma or adenocarcinoma of the appendix. Reported series include a spectrum of pathological lesions, from entirely benign ruptured mucocele to advanced carcinoma. This, and the rarity of the condition, limit the conclusions that can be drawn regarding its treatment and prognosis. Most authorities agree that a thorough surgical debulking should be made. In most cases this will be a difficult and time-consuming undertaking, possibly requiring cooperation between two or more specialists and consideration of delivering intraperitoneal adjuvant therapy during or immediately after surgery. Treatment therefore requires a planned approach with accurate preoperative assessment of the diagnosis and the extent of the condition. There is some largely anecdotal evidence in favour of intraperitoneal chemotherapy and radioisotope treatment. Ultraradical surgery, with heated intraoperative and further postoperative chemotherapy, is strongly advocated by one group but remains contentious. The majority of patients will eventually suffer recurrence. The 5-year survival rate ranges from 53 to 75 per cent, but outcomes vary widely between relatively benign and malignant subgroups.
Non-targeted CT that is negative for colorectal malignancy is usually reassuring but the decision for further investigations should be made on a case-by-case basis, taking into account of the likelihood of underlying colorectal malignancy and the underlying co-morbidities of the patient. However, video colonoscopy is usually necessary to assess positive CT findings.
CorrespondenceReturn to work after inguinal hernia repair La pa rosco pic c holecystectomy Sir We read with interest the Review on laparoscopic cholecystectomy by MessrsMacintyre and Wilson (Br JSurg 1993; 80: 552-9). The authors state that one of the generally agreed contraindications to laparoscopic cholecystectomy is the presence of a cholecystoenteric fistula.We have encountered five cholecystoduodenal fistulas in a series of 300 laparoscopic cholecystectomies, which we are reporting in Surgical Laparoscopy and Endoscopy. Of these, two were diagnosed before operation. One patient had a previous cholecystoduodenostomy and another had aerobilia on computed tomography. It was possible to deal with four fistulas laparoscopically. The fifth patient had to undergo conversion to laparotomy as the duodenum was inadvertently perforated during dissection. In the remainder it was possible to display the cholecystoduodenal fistula with a combination of careful blunt and sharp dissection. The fistula was divided and stapled at the same time by a single firing of an Endo-GIG30 stapler (US Surgical, Norwalk, Connecticut, USA) through an epigastric 12-mm cannula. Intraoperative cholangiography was performed in each patient to confirm biliary anatomy and detect bile duct stones.We maintain that, with increasing expertise, better imaging and improved instrumentation, it is feasible to repair most cholecystoduodenal fistulas laparoscopically.
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