0:01

So this is the same patient that presented

0:03

to our institution a few months later,

0:05

in regards to their presumed mucocele.

0:08

Remember too that mucoceles can range from

0:11

the benign mucinous cystadenoma to malignant

0:13

variety, which is the cystadenocarcinoma, with

0:17

any kind of level in between, including LAM,

0:19

which is a low-grade appendiceal mucinous tumor.

0:22

So same patient, you'll recognize this

0:24

mucocele, you'll see that calcification in the

0:26

center of it, some in the walls right here.

0:29

But something happened in the interim.

0:32

So we scroll through it.

0:33

It looks pretty much similarly dilated.

0:35

There's not really any inflammation around it.

0:37

We don't have an acute appendicitis

0:38

component of this, but you do now have

0:40

this almost loculated fluid anterior to it.

0:44

And if you're looking closely at the

0:45

wall, we've lost the wall right here.

0:48

So in between those several months of when that

0:50

patient presented to the outside institution

0:52

and then came to our institution for surgery

0:56

and for purposes of planning their surgery.

0:57

Okay.

0:58

This mucous cyst ruptured.

0:59

You have loss of integrity

1:00

of the wall right here.

1:02

You can also tell this isn't an abscess.

1:03

This is the mucous cyst

1:04

itself by handful of units.

1:06

It's virtually identical.

1:07

If you put them on, there's no enhancing wall.

1:10

However, this does look loculated.

1:12

It's not like free fluid that

1:13

should flow into the pelvis.

1:15

You can see here, there really is no

1:16

free fluid layering in the pelvis.

1:18

And that's because this isn't free fluid.

1:20

This is mucus.

1:21

So it's going to kind of sit where it

1:23

ruptured from, but it's not an abscess.

1:25

There's no thick wall.

1:26

There's nothing enhancing right here.

1:28

So it's kind of this in

1:29

between sort of appearance.

1:31

In this case, the mucous cyst ruptured,

1:33

which is very important for the surgeon to

1:34

know, because it goes from a simple, uh,

1:37

Appendectomy, partial colectomy, take this out.

1:39

This hasn't spread anywhere, so this

1:41

is clearly spread into the peritoneum.

1:44

And now you might have to consider further

1:46

therapies such as beyond just cytoreductive

1:49

therapy, where you get out all the deposits

1:51

that you can, but you might need HIPEC, which

1:53

is hypothermic intraperitoneal chemotherapy.

1:56

This is still a little bit

1:57

tricky and controversial.

2:00

This therapy itself, but at our

2:02

institution, it's pretty, pretty standard

2:04

for what we'll do in cases like this.

2:06

So this person did end up going to get their

2:08

mucosal taken out and it had ruptured as

2:11

you know, it was very clear on the CT scan

2:13

itself and they did end up getting HIPEC

2:16

and this ended up being a low-grade

2:17

appendiceal mucinous neoplasm, but as you

2:20

can tell, given that this is here, this

2:22

kind of gelatinous mucinous material, it's

2:24

going to be much trickier, longer surgery,

2:27

with possible recurrence simply because you

2:29

cannot clear out all of that very easily

2:31

in a surgery, whereas you can just take

2:33

the appendix out if it hasn't ruptured yet.