Unexpected Findings in Gastrointestinal Tract Surgery

r Complications in General Surgery

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Unexpected Findings in Gastrointestinal Tract Surgery

Marinos C. Soteriou, MD, * and Lester F. Williams, Jr, MDt

That patients who require emergency operations for acute conditions can have unanticipated problems as the cause of the acute circumstances or as coincidental findings is a well-accepted surgical dictum. Moreover, considerable discussion has centered on patients with an abdominal aortic aneurysm who have concomitant problems. Emphasis on elective nonvascular abdominal surgical procedures with unexpected findings in organs other than those of the planned procedure is scarce, however. Numerous congenital or acquired disorders remain clinically silent, and, given the increasing emphasis on same-day surgery, minimally symptomatic problems may go unnoticed before operation. Operative injuries will not be discussed, and because we are dealing with problems that are asymptomatic or minimally symptomatic, we will not cover lesions that are the source of serious bleeding, obstruction, or perforation. The special emphasis on the interrelationship of gastrointestinal tract problems and abdominal aortic aneurysm relates to infection of a prosthetic graft and concern about rupture of the aneurysm in the early postoperative period. 19, 138 As attention moves away from vascular procedures, infection of a prosthetic graft is no longer paramount. Although the dramatic circumstances of postoperative rupture of an aneurysm may not be encountered, other postoperative complications related to the unexpected finding remain potentially serious and thus require evaluation. When an unexpected finding is encountered, the surgeon is confronted with a series of questions. Is this unexpected process so significant for the health of the patient that it takes precedence over the planned procedure? Does the unexpected finding require surgical attention during this operation? This cannot be ascertained without additional information: what is the exact nature of the new process? Is the macroscopic description sufficient, or are tissue biopsy and staging necessary for precise diagnosis? If the new *Surgical Resident, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee tProfessor of Surgery, Vanderbilt University; and Chief of Surgery, St. Thomas Hospital, Nashville, Tennessee

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finding is truly incidental, should it be treated by operative means during this procedure (i. e., as a concomitant operation)? Can the secondary procedure be performed safely? Should it be performed to prevent expected postoperative problems or only to prevent long-term problems? Clearly, understanding the importance of the new finding requires specific information about diagnosis, natural history, and operative therapy. As we have defined the conditions to be discussed in this article, commonly, this means evaluating an unexpected mass. In the circumstance in which treatment of the unexpected condition has important implications for either intraoperative or postoperative management, especially when the new procedure is more involved than the planned operation, a complex medical, moral, ethical, or legal problem may exist. Given the constraints of article size, we will not be able to address these issues. Some might believe that these are the most significant features for determining the pros and cons of performing the unplanned procedure. In fact, the more critical factors relate to the nature of the new process and the details of surgical evaluation and therapy because these features correlate with the planned operative intervention.

GALLSTONES In the United States, 20 million patients have gallstones, with 1 million new cases being discovered each year. Thus, this significant medical problem that affects 20% of adults will be a common incidental finding in patients undergoing an abdominal procedure. In fact, 50% or perhaps even 85% of patients are asymptomatic, and few patients who have symptomatic gallstones seek medical attention for the first time with a serious, potentially lethal complication. 24. 83 From these data, one might conclude that the discovery of incidental gallstones should not lead to cholecystectomy. Incidental cholecystectomy as opposed to cholecystectomy as a planned coprimary procedure is usually recommended, however.ll, 46, 72, 97, 135, 138, 150 Gallstones are so common that some authors 37 suggest that any patient undergoing major elective abdominal or pelvic surgery should have preoperative screening. Because abdominal ultrasonography is being used so commonly for abdominal complaints, looking for gallstones as a routine should be easy. When the intraoperative diagnosis is insecure, this study might be necessary,135 but most authors l l believe that palpation of the gallbladder will provide the diagnosis regularly. Authors who champion screening believe that knowing beforehand permits better diagnosis and, therefore, better informed consent and incision selection. To decide about an incidental or concomitant cholecystectomy, several options must be considered, as noted earlier. For gallstones, the diagnosis is secure on the basis of intraoperative palpation, and such asymptomatic gallstones do not represent a great threat to the patient's health. 24, 83 Thus, the primary concern is whether cholecystectomy would complicate the primary operative procedure. Most authors 7, ll, 37, 46, 72, 85, 135 but not all authors50 believe incidental cholecystectomy is safe. Thus, the likelihood and danger of early postoperative acute cholecystitis or obstructive jaundice

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becomes primary. If neither of these phenomena is likely, the decision can be based on the long-term development of symptoms or complications related to the gallstones. Some confusion exists because 30 postoperative days is the early period to some surgeons, whereas long term is the first postoperative 6 months, but to other surgeons long term is 6 months to 5 years. If the latter definition of long term is the basis for a decision, the question remains: is the operation absolutely safe and insignificant to the results of the planned primary operation? Unfortunately, secure data to answer these questions are not available. Factors that are known to influence the course of gallstones, such as feminine gender, obesity, diabetes,42, 65 or' cirrhosis, 64 are not stratified in reports. Moreover, differences between cholesterol and pigment gallstones are seldom evaluated despite the fact that recent evidence l23 has shown that patients with pigment gallstones more commonly have postoperative infection. For most, the question "can an incidental cholecystectomy be performed safely during elective abdominal operations?" is answered affirmatively for the general population II, 37, 46, 135 and the elderly, II6 for colonic operations, 7, 9, 26, II9 hysterectomy,73 and arterial operations. 19, 138 More complicated gallstone surgery, such as common duct exploration, should not be performed as an incidental procedure. 50 Problems with available data are apparent, however. Comparing complications when the cholecystectomy was added to another operation with complications seen when cholecystectomy was the primary and only procedure is as unacceptable as is the use of historic controls. Data from a large population-based surveySO showed that 69 patients with concomitant cholecystectomy compared with 4114 patients without secondary cholecystectomy had a significant (3.3 times) increase in wound infection and in the other postoperative complications (1. 7 times). Other authors 20 , 72 have voiced similar concerns but have used historic controls, namely, coprimary cholecystectomy or cholecystectomy alone. Secondary cholecystectomy was more dangerous when the primary operation involved the upper gastrointestinal tract than when a pelvic or colonic operation was performed. Despite these observations, conventional wisdom appears to be that coincidental cholecystectomy carried out in healthy patients with ideal operative circumstances is safe. 9, II, 20, 28, 46, 72, 73, 97, 135, 138, 150 Whether or not incidental cholecystectomy should be performed should depend on the occurrence and danger of postoperative acute cholecystitis or obstructive jaundice. Early reports stressed the need for incidental cholecystectomy because postoperative complications relative to the gallstones were dangerous45,97, 150 rather than common. II, 135 It is critical to note, however, that the dangerous feature is derived from series with many patients with acalculous disease: 35% of 40 patients,97 62% of 28 patients, 45 and 50% of 8 patients. l50 Such acalculous cholecystitis could not be prevented by incidental cholecystectomy because no gallstones would have been found, and thus no cholecystectomy was performed. When 53% of 394 patients about to undergo aortic surgery were screened for gallstones using oral cholecystography, 73 patients (18%) had gallbladder disease;37 13 patients had incidental cholecystectomy, but 60 patients did not, In follow-

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up study, only 3 patients (0.8%) had postoperative acute cholecystitis. One of the three patients came from the 60 patients with gallstones but without cholecystectomy, whereas 2 patients came from the 321 other patients who did not have known gallbladder disease. These authors 37 concluded that although cholecystectomy was a safe procedure, the risk of postoperative cholecystitis was so negligible that it was not necessary. Other authors 19 have similar observations. Early postoperative acute cholecystitis is rare, and with a proper intraoperative diagnosis of gallstones, postoperative complications should be diagnosed without undue delay and therefore treated without undue risk. Epidemiologic assessments of patients with asymptomatic gallstones reveal an ever decreasing incidence of serious complication even when patients are observed over years. 24. 46, 84. 104 Whether or not such data are changed when an abdominal operation intervenes is unknown. Although it may be true that increasing symptoms will develop in some patients with gallstones over the long term and although these symptoms may justify subsequent elective cholecystectomy, such data are suspect and are difficult to use as the basis to justify routine incidental cholecystectomy24. 46, so, 84, 104 unless the operative conditions are especially ideal. 45, 19

MECKEL'S DIVERTICULUM

Meckel's diverticulum, the most common congenital abnormality of the small bowel, IS, 30 represents a remnant of the omphalomesenteric duct, which connects the intestinal tract to the yolk sac during the fetal period. The duct usually obliterates within 5 to 7 weeks postpartum, but 1% to 3% of the population have persistence of the duct that can give rise to Meckel's diverticulum, an omphalomesenteric fistula, an enterocyst, or a fibrous band between the small bowel and the umbilicus. Meckel's diverticulum, a true diverticulum on the antimesenteric border of the small bowel, has been reported 76. 80, 145 to be the incidental finding in 46% to 80% of the diagnosed cases. Meckels6 reported the risk of complications associated with the diverticulum to be 25%, a figure so high that it established the resection of an incidentally found asymptomatic Meckel's diverticulum as the gold standard. With the 25% theory and a 2% incidence of diverticulum, 1 person per 200 of the general population should have some complications associated with Meckel's diverticulum, which, of course, is not the case.94, 126 Now, almost all surgeons accept that an incidental small-bowel procedure can be performed safely so that the Significant issue is the natural history rather than the surgical procedure. 19 Obstruction of small bowel secondary to intussusception, hernia around the band to the umbilicus, or inflammation of Meckel's diverticulum are the most common complications requiring treatment. It is unclear whether we can predict which diverticulum is at high risk for complications. In more than 90% of patients, Meckel's diverticula are found within 100 cm proximal to the ileocecal valve, IS, so but they have been reported as proximal as within 10 cm from the ligament ofTreitz. The location of the diverticulum

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does not seem to be predictive of complications, however. Symptomatic diverticula may be both longer (>4 em) and broader (>2 cm)16 or just longer than 2 cm81 than asymptomatic ones. The presence of ectopic tissue, especially gastric mucosa and pancreatic tissue, is more common in symptomatic diverticula, 76. 80, 81, 121 but palpation is not an accurate method to detect its presence. 76, 140 These data show inconsistency and disagreement, however, so that the management of the incidentally found Meckel's diverticulum is still controversial because prediction of later complications based on the character of the Meckel's diverticulum is not possible. Supporters l8. 88, 100 of prophylactic diverticulectomy base their opinion on the significant morbidity and mortality rates associated with surgery for a symptomatic diverticulum and not on the likelihood of postoperative complications or the risk of complications from an elective operation. Early reports of many years of experience noted mortality rates of 20%142 and 11 %.124 More recent reviews 80. 121. 140 reported a mortality rate of O. The risk of complications associated with resection of asymptomatic diverticula is in the range of 1.2% to 8.9%,25,76,81,88,140 which is higher then anticipated for incidental small-bowel resection. 19 On the other side are authors 76, 126 who believe that incidental diverticulectomy should not be performed because of the low risk of the development of complications. In a study126 of 202 patients, the total complication rate was 4%, with a diminishing risk with age (4.2% at 1 year of age, 2% at 30 years, and almost 0 at 70 years). Other authors 76 noted that the 3.7% chance of complications developing at age 16 years decreases to 0.5% at age 76 years. Thus, to save one life from the complications of Meckel's diverticulum, it would be necessary to remove 800 asymptomatic diverticula, all procedures being performed without serious complications. Finally, the postoperative history for unresected Meckel's diverticulum seems benign because no early or late complications occurred related to the diverticulum in 32 patients 81 (28 patients 76 or 44 patients l21 ) even when followed up for 7.8 years after laparotomy. Given these data, three approaches 31 are reasonable: (1) when an abnormal attachment or an adhesive band to the umbilicus is identified, this should be divided. Occasionally, such a mesodiverticular band contains the arterial supply to the diverticulum, and, therefore, such ligation will necessitate concomitant resection of the diverticulum; (2) in a child or young adult, an incidentally found diverticulum can be removed if the patient's general condition is good, and the primary operation is not extensive; and (3) in patients more than 40 years of age, the incidentally found nonadherent Meckel's diverticulum should be left alone.

SMALL-BOWEL MASSES Although Meckel's diverticulum, the most common incidental smallbowel lesion found, can present as a mass, most such masses will be smaUbowel tumors,20, 28 especially in patients more than 50 years of age, Rarely are they inflammatory masses. Except when obvious spread to lymph nodes or liver is present, the intraoperative diagnosis is most difficult on inspec-

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tion, with few clues that differentiate benign from malignant lesions. Benign lesions are more commonly asymptomatic and, therefore, may be more common as incidental findings. One must be certain that these lesions are not metastatic from other common carcinomas, such as from the colon, ovary, or breast. The prognosis is excellent for patients with benign lesions and can be good for patients with malignant lesions found before bleeding, obstruction, or spread has occurred. The specific problems of lymphoma and carcinoid require special attention because adequate classification or staging is so vital for each of the lesions. 98 Recently, staging for adenocarcinoma has also proved to be of value. 82 The details are established, however, by careful assessment of the mesentery for nodal spread and the liver for metastatic deposits. Frozen-section analysis of a metastatic lesion or of the removed small bowel will establish two specific lesions, lymphoma and carcinoid, that require special attention. Fortunately, therapeutic decisions are relatively easy even without a secure diagnosis because limited resection is appropriate for all such lesions, and, as noted earlier, small bowel resections in this context are safe. Radical en bloc resection is seldom necessary. Moreover, when required to remove all tumor, resection is seldom useful except for carcinoid tumors. Rarely, mesenteric or even retroperitoneal cysts will be discovered as incidental problems noted as possible small-bowel masses. 49. 114 These smooth, round, compressible lesions, which can be unilocular or multilocular, are almost all benign, although low-grade malignancy can occur, as suggested by changes in the wall. Enucleation is the preferred therapy, but internal drainage is acceptable if resection would compromise the blood supply to vital structures. COLONIC MASSES It is conceivable that a previous episode of acute colonic diverticulitis could result in a colonic mass that would be found incidentally during an abdominal operation. Such circumstances are not discussed, however, in material on the surgical treatment of colonic diverticulitis. Thus, the discovery of an unexpected colonic mass will almost always raise the issue of large-bowel carcinoma, and when surgical therapy is to be undertaken, it should follow the principles of cancer therapy. We present colonic masses in that context because both diagnostic approach and therapy would be the same. The treatment of patients with carcinoma of the colon, as is well known to most surgeons, includes numerous options from segmental resection to radical hemicolectomy. The issue is less clear, however, when the surgeon is confronted with unexpected carcinoma of the colon in unprepared bowel. This could be common because carcinoma of the large bowel is one of the most common of adult neoplasms, and it is often (34%)9.87 localized when found. Data for patients who, in elective laparotomy for another reason, are incidentally found to have asymptomatic carcinoma of the colon are scarce. From a tumor biology standpoint, these patients probably are

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comparable to patients found to have asymptomatic carcinoma of the colon on screening colonoscopy or on work-up for blood in the stool. From the standpoint of surgical procedures, however, these patients are different from patients with elective colonic preparations because they will not have had bowel preparation or preoperative staging. Moreover, unlike unexpected gallstones or Meckel's diverticulum, colonic carcinoma may be a more important factor than the planned operation. When found incidentally in asymptomatic patients, these lesions are likely to be favorable early carcinomas. 131 Patients with asymptomatic carcinoma of the colon found on routine proctosigmoidoscopy were node negative (Dukes' A or B) 64% to 81 % of the time and had high (64% to 88%) 5-year survival rates. 47, 56, 113 The aforementioned data suggest that asymptomatic carcinoma of the colon is likely to be limited, and, when treated properly, is associated with a good chance for cure so that intraoperative diagnosis and staging are critical. Staging cannot be based solely on intraoperatively found enlargement of lymph nodes because metastatic disease was present in only 39% of 337 enlarged lymph nodes in one study.43 On the other hand, only 2% of normal-size nodes contained lymphatic metastasis, and only 5% of patients with carcinoma of the colon will present with metastasis to distant lymph nodes without involvement of local nodes. 148 Other authors 43 report even fewer patients (1.6%) who presented with this type of distant lymph node metastasis. When adjacent organs such as small bowel are involved, en bloc resection of all involved structures is indicated, 132, 147 but metastases may make the magnitude of surgery too great for an incidental procedure. Adhesions between the colonic lesion and surrounding structures should be resected, not lysed, because they may contain malignant cells. 68, 137, 147 The surgeon must be concerned about other large-bowel lesions because in asymptomatic patients with incidentally intraoperatively found carcinoma of the colon, the status of the rest of the colon is unknown. Careful intraoperative examination must search for coexistent lesions to avoid unpleasant postoperative surprises. Fortunately, the presence of distant synchronous polyps can be verified postoperatively with colonoscopy and treated without another operation as part of the scheme to reduce the risk of metachronous carcinoma of the colon, a fact that agrees with the 1.5% to 7.6% range reported74 in the literature. Second carcinomas require additional operations, however. In a prospective study74 of 166 patients, synchronous lesions occurred in 1.5% to 7.6% of patients with carcinoma of the colon. Benign polyps were reported in 12% to 62% of patients with a single carcinoma but in 57% to 86% of patients with synchronous carcinomas. In this study,74 only 12.5% of the synchronous lesions were located close to each other so that standard resection would remove both tumors. Other authors 75, 91, 109, 133 reported synchronous lesions in the same surgical segment in 43% to 69% of the patients. Review of the literature 132 comparing segmental colon resection with radical procedures found that although several studies showed an increase in the 5-year survival rates after radical hemicolectomy compared with segmental resection, with no increase in morbidity and mortality rates, none of these differences was statistically significant. Although theoretically, radical lymphadenectomy for carcinoma of the colon was the proper

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procedure from an anatomic and pathologic point of view, it did not prove to be so in clinical trials. Another argument against radical hemicolectomy is that this procedure increases the chance for perioperative need of blood transfusions that may decrease the recurrence-free 5-year survival rates. 14 Sugarbaker and Corlew,132 therefore, concluded that limited resection is an adequate cancer procedure for many patients, reserving radical resection of the colon only for young patients with low perioperative risk. Given these data, colonic resection for an unexpectedly found carcinoma becomes an issue of operating on unprepared large bowel. One way to avoid this problem would be to perform some form of preoperative colonic cleansing, even when the planned procedure is not related to the colon, for all patients who undergo laparotomy, but such an approach is not likely to be followed regularly. The significance of the colonic fecal load after poor mechanical colon preparation in anastomotic dehiscence is well described. 66, 107 Recently, some novel ways to deal with this problem have been suggested, including on-table lavage lO3 and intracolonic bypass tube, 105 The intraoperative irrigation of the colon is designed to decrease the fecal load of the unprepared bowel and its effect on an anastomosis, The technique (Fig. 1) involves the insertion of a No. 14 Foley catheter into the cecum through a small enterotomy 5 em proximal to the ileocecal valve. An exit tube is inserted proximal to the malignant lesion so that this colonic lumen can be irrigated with 3 L of Hartmann's solution. Further details about this procedure are described in the original publication l03 that reported on 50 patients with obstructing carcinoma of the colon who

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Figure 1. With the help of antegrade colon irrigation, the fecal load of unprepared bowel is reduced, thereby diminishing the risk for anastomotic leakage. (Reprinted by permission of the Lahey Clinic, Burlington, MA.)

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underwent on-table irrigation, with only two anastomotic leakages and one operative death. Another method of protecting an anastomosis after colon resection is by using an intracolonic tube. 105 The tubes bypass the fecal contents of the proximal colon beyond the suture line so that they have no contact with the anastomosis (Fig. 2). The technique is considered to be simple. The reinforced proximal end of the latex tube is sutured about 6 cm proximal to the planned colocolonic anastomosis by a submucosal interlocking continuous suture using absorbable material. After the posterior part of the colocolonic anastomosis has been performed, the tube is pulled through the distal colon all the way down to the rectum, with the help of a previously inserted rectal tube. The anterior part of the colocolonic anastomosis is completed. The tube serves as a bypass, usually for 14 to 30 days, after which it is expelled. With the help of this device, Ravo et aP07 confirmed the findings of Irvin and Goligher66 about the deleterious effects of colonic fecal load on the colo colonic anastomosis. In 29 patients with perforated diverticulitis, obstructing left-colon carcinoma, persistent colocutaneous fistula, and low rectal carcinoma or sigmoid volvulus, resection and primary anastomosis were performed on unprepared bowel without a protective colostomy.lo6 No operative deaths or anastomotic leakages occurred. Of 29 patients (10%), 3 had postoperative complications unrelated to the bypass (upper gastrointestinal tract bleeding, prolonged ileus, or myocardial infarct). These data suggest that this method is another way to perform colocolonic anastomosis safely in unprepared bowel. Thus, it is possible to perform an appropriate resection for colon

Figure 2. The intracolonic latex tube is used to bypass fecal contents of the colon; thus, their contact with the colonic anastomosis is avoided. (Reprinted by permission of the Lahey Clinic, Burlington, MA.)

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Tube expelled 14-30 days post-op

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carcinoma even with unprepared bowel when it is found as an unexpected lesion.

MASSES OF APPENDIX The safety of incidental appendectomy for a normal appendix has been accepted for many years. 8. 79, 130 Although this practice seems to be decreasing in recent years, surgeons agree that the appendix that contains a mass should be removed as a secondary operation in almost all elective abdominal procedures. Although such a mass could be inflammation or a rare benign tumor, for practical purposes, only three significant lesions-mucocele, carcinoid, and adenocarcinoma-are of importance. Mucocele M ucoceles of the appendix are a variable group of lesions characterized by cystic dilation of the appendix that contains mucoid material. Mucoceles can be one of three categories58 : mucosal hyperplasia-dilated appendix lined by normal appendiceal mucosa with focal or diffuse mucosal hyperplasia; cystadenoma-mucus-filled cystic tumors, partially lined by neoplastic epithelium (epithelial atypia); and cystadenocarcinoma-cystic tumors completely lined by malignant neoplastic epithelium with stromal invasion or the presence of epithelial cells in peritoneal implants. The pathogenesis of the mucocele is not clear. It is believed the mucus accumulates in the appendix secondary to obstruction of the proximal appendiceal lumen from any cause, such as fecalith, inflammation, scarring, or even such tumors as villous adenoma. 16, 35, 99, 141, 149 It is still unknown why obstruction of the appendiceal lumen would lead to an asymptomatic mucocele and not to appendicitis. Some authors 58, 102, 149 believe that cystadenomas and cystadenocarcinomas are the result of malignant degeneration in the wall of a benign mucocele. The histologic classification of the mucocele is associated with such problems as nonuniform terminology and distortion of local anatomy caused by a large intraluminal collection of mucin. Confusion also occurs in the diagnosis of benign and malignant pseudomyxoma peritonei. For the aforementioned reasons, considerable inconsistency exists in the literature concerning the classification and treatment of patients with this disorder. When found incidentally, these lesions will be a mass in the appendix, with the precise diagnosis occurring only after removal unless evidence of malignant spread is detected. The appendiceal mucocele is a rare disorder found in only 0.07% to 0.3% of appendectomies, 17, 69, 144, 149 with only 23% found incidentally. 3 Because appendectomy as an incidental procedure during other operations has for many years been accepted as safe, little doubt exists that a mucocele needs to be removed whenever encountered. Because an association with synchronous tumors in other organs, such as colon carcinoma or ovarian cystadenoma, has been reported,58, 99, 102 careful inspection during laparotomy is essential. Postoperative colonoscopy would be advisable for these patients. Simple appendectomy with special care not to perforate the appendix

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so as to avoid any mucus spillage is curative for mucosal hyperplasia and the cystadenoma type of mucocele. 3.58.99 The suggestion59 that the majority of malignant mucoceles can be handled satisfactorily by appendectomy depends on data from 18 patients treated at the Mayo Clinic from 1910 to 1941. Because the criteria used to characterize malignancy in this series58 do not include stromal invasion as now required, patients who were alive and well 29 years after appendectomy may have had cystadenoma rather than cystadenocarcinoma. Because the differential diagnosis between benign and malignant mucocele can only be established after histologic examination, any macroscopically diagnosed mucocele should usually be treated with simple appendectomy, with right hemicolectomy being indicated only when appendectomy is not possible for technical reasons. When examination of frozen sections reveals a cystadenocarcinoma, right hemicolectomy should be performed. When later examination reveals cystadenocarcinoma, interval right hemicolectomy is the treatment of choice. When pseudomyxoma peritonei is found with the benign form of mucocele, evacuation of mucus and thorough lavage of the peritoneal cavity are sufficient. Pseudomyxoma secondary to cystadenocarcinoma with visceral invasion by mucus-producing epithelial cells should be treated by thorough debridement and lavage of the peritoneal cavity. The value of removal of large areas of visceral and parietal peritoneum to remove small peritoneal implants is not yet established, 53 but aggressive surgical management with several laparotomies and repeated paracentesis may keep these patients alive for several years. 69. 77. 99 Treatment modalities, such as implantation of intracavitary radioisotopes 6 and instillation of intraperitoneal alkylating agents,22. 77 need further evaluation. Carcinoid Carcinoid tumors of the appendix, a member of the family of APUDomas (amino precursor uptake and decarboxylation), are more common than mucoceles, with a prevalence of 0.3% of all appendectomies. 90 Concerns have been expressed 143 about the high incidence of synchronous noncarcinoid malignancies, such as colon, breast, and prostatic carcinoma, in patients with carcinoid, and, therefore, careful intraoperative and postoperative examination is indicated. Most carcinoids are asymptomatic and are discovered incidentally,89. 143 predominantly in young adults. Paradoxically, decreasing tumor size and incidence of metastasis occur with advancing age. Appendiceal carcinoids are usually at the appendiceal tip, with 70% to 90% being less than 1 cm in size. 89. 92 Simple appendectomy is adequate for tumors up to 2 cm in size without evidence of metastasis. 92 More aggressive appendiceal carcinoids are rare,90 but carcinoids more than 2 cm and tumors at the base of the appendix or with invasion of the serosa, the mesoappendix, or lymph nodes require right hemicolectomy, especially in young patients. Adenocarcinoma Primary appendiceal adenocarcinoma is a rare entity that is unlikely to be encountered more than once. 38. 48 Of these tumors, 6% to 30% will be discovered unexpectedly with incidental appendectomy.21. 27. 57. 60. 115. 128

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The tumor is reportedly4, 29, 48, 60, 93 more common at the base of the appendix, The malignant potential resembles that of colonic adenocarcinoma; thus, it is more aggressive than appendiceal carcinoids and mucoceles of the appendix, It spreads in lymphatics, hematogenously, and by continuity. Some authors 4, 57 showed dramatic improvement in 5-year survival rates with right hemicolectomy instead of appendectomy (63% versus 20%57 and 60% versus 40%4), whereas other authors 44 , 48 reported disappointingly high recurrence rates even after right hemicolectomy. Because of the mode of spread and the usually basal location of the tumor, we believe that right hemicolectomy, provided the procedure will not appreciably increase the operative risk, should be the treatment of choice for both invasive and noninvasive tumors when no metastatic disease is present. Interval hemicolectomy should also be considered for patients who were initially treated with appendectomy.

GASTRIC MASSES Benign peptic ulcers of the stomach found incidentally as a gastric lesion are now uncommon. Better medications available since the H2 blockers were introduced have decreased the incidence of gastric ulcers, but more important for incidental secondary operative decisions, these medications have made operative correction of peptic problems to prevent postoperative complications unnecessary. Thus, gastric masses found incidentally require surgical therapy only when they are likely to be tumors. Unfortunately, most gastric carcinomas will be obvious because metastatic spread will be present, and histologic diagnosis is all that is required. As with colonic carcinoma, staging is essential because with early lesions, subtotal gastrectomy can be both curative and reasonable as an incidental secondary procedure. 12, 120

MASSES IN SOLID ORGANS Of the solid-organ masses that might be found unexpectedly during operations on the gastrointestinal tract, liver masses are the most common. Ovarian masses are the most important for the general surgeon to handle correctly. Pancreatic masses are' the most difficult to assess and to treat, especially when they are not clearly separate from other retroperitoneal lesions. Ovarian Tumors The general surgeon should be acquainted with the general guidelines of gynecologic surgery because ovarian masses are not uncommon incidental findings, and precise staging during the first operation is critical for proper management. Ovarian carcinoma of epithelial origin accounts for 80% to 90% of the ovarian tumors, with stroma and germ-cell tumors comprising the remain-

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der. Epithelial ovarian carcinoma, usually found in postmenopausal women between 50 and 60 years of age, is fifth in incidence and fourth in cause of death among malignancies in women. The overall 5-year survival rate is 37%, but it ranges from 85% when the disease is localized to the ova.ries to 15% for advanced stages. Of the patients with epithelial ovarian carcinoma, 75% initially present with spread beyond the ovary, and 60% present with spread beyond the pelvis. 39, 101 Although epithelial ovarian carcinoma begins in the ovary, cell exfoliation occurs early, with the cells transported with the clockwise flow of the peritoneal fluid to the right upper quadrant through the right paracolic gutter. For this reason, this malignant process commonly shows metastatic involvement to the right paracolic gutter, the right hemidiaphragm, the liver capsule, the omentum, and para-aortic lymph nodes and the cul-desac. The International Federation of Gynecology and Obstetrics (FIGO)101 classification of ovarian neoplasms (Table 1) is based on the disease found at the initial surgical exploration. This makes the role of the first surgeon important. The diagnostic part of the laparotomy must establish the precise histologic type and grade of the carcinoma and must provide complete surgical staging. Thus, thorough evaluation with documentation of all locations and organs involved must be performed. Moreover, the amount and location of the disease left after a.ggressive cytoreduction are critical for prognosis as well as for subsequent therapy. Whether this operation provides the primary therapeutic procedure or palliative reduction of tumor bulk depends on local surgical practice. Because the most important prognostic factor in patients with advanced epithelial ovarian carcinoma is the residual tumor at the end of cytoreductive surgery, a definitive plan is essential. When the general surgeon who incidentally discovers an ovarian carcinoma is to be the primary surgeon for this problem, the following principles must be understood. An aggressive tumor de bulking, including bowel resection whenever indicated, and me-

Table 1. Ovarian Carcinoma Staging According to the International Federation of Gynecology and Obstetrics (Based on Findings at Clinical Examination and Surgical Exploration) Stage I Growth limited to the ovaries Stage IA Growth limited to one ovary; no ascites Stage IB Growth limited to both ovaries; no ascites Stage IC Growth limited to one or both ovaries; ascites present with malignant cells in fluid Stage II Growth involving one or both ovaries with pelvic extension Stage IIA Extension or metastasis to the uterus or tubes only Stage lIB Extension to other pelvic tissues Stage III Growth involving one or both ovaries with widespread intraperitoneal metastases to the abdomen (omentum, small intestine and its mesentery) Stage IV Growth involving one or both ovaries with distant metastases outside the peritoneal cavity

Modified from Perez CA, Bradfield JS: Radiation therapy in the treatment of carcinoma of the ovary. Cancer 29:1030, 1972; with permission.

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ticulous staging of the tumor with cytologic evaluation of peritoneal fluid and biopsies of common locations of metastatic disease (right paracolic gutter, liver capsule, omentum, para-aortic lymph nodes, and right hemidiaphragm) or any other location that looks suspicious should be performed. The role of surgery in the management of epithelial ovarian carcinoma is of major importance, with cytoreduction being stressed by several authors. Griffiths et aP2 first reported that the median survival time of patients with epithelial ovarian carcinoma improved with decreasing size of residual disease after initial surgical reduction. A literature review by Hoskins et a1 62 revealed that the study by Griffiths et a152 was followed by several other reports 23, 26, 54, 55, 78 confirming the importance of primary cytoreductive surgery, The ways that cytoreductive surgery is believed61 to influence the prognosis in. the patients are by reducing the tumor size, so that a larger percentage of the tumor cells will be in active growth phase and, therefore, increasingly sensitive to chemotherapy; by reducing the number of cells capable of undergoing mutation to resistant cell lines; and by reducing poorly vascularized tumor parts not accessible to chemotherapy. A literature revie~2 showed that if the residual tumor at the end of the initial cytoreductive surgery was less than 2 cm, an improved response rate to multidrug chemotherapy and an increased progression-free interval were observed, Additionally, an increased number of patients had a negative second-look laparotomy, When fertility is an issue and the patient has disease limited to one ovary, unilateral salpingo-oophorectomy, wedge biopsy of the other ovary, omentectomy, para-aortic lymph node biopsy, and peritoneal washings are acceptable. After recovery from operation, the patient may need secondlook laparotomy, and further follow-up study with cisplatin combination chemotherapy being indicated for patients with stages Ie to IV disease. Liver Masses Most liver masses can be palpated easily even when they are not superficial, Therefore, gentle and careful liver palpation should always be performed. The number and location of the masses in relation to major vascular structures are critical for making the right decision on whether, how, and when to resect. Thus, intraoperative ultrasonography is recommended after a liver mass is discovered. The incidentally found liver mass will fall into one of two categories: lesions in which biopsy is not needed or is contraindicated, or lesions that need to be biopsied. The first group includes lesions that have been diagnosed previously as benign and did not show any recent changes, as well as vascular lesions, especially the cavernous hemangioma that should not be biopsied. The second group contains primary benign liver tumors (hepatocellular adenoma and focal nodular hyperplasia), primary malignant liver lesions (hepatocellular carcinoma), and disease metastatic to the liver. Smaller lesions, especially when superficial, can undergo excisional biopsy that becomes both diagnostic and therapeutic. Incisional biopsy should be used for larger superficial masses to ensure an adequate tissue sample. For lesions deep in the liver, parenchymal needle aspiration biopsy is appropriate but may not always differentiate benign from low-grade malignant lesions, especially on frozen-section study.

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Vascular Liver Tumors. Cavernous hemangioma is the most common benign tumor and the second most common hepatic mass, after metastasis to the liver, seen in the United States. With a 0.4% to 7.3% autopsy incidence,67 these lesions will often be discovered incidentally. The natural history of the tumor is benign. Although reports of spontaneous rupture and intra-abdominal hemorrhage exist, a literature review by Sewell and Weiss 1l8 in 1961 revealed only 11 such cases, 7 of which were fatal. In a more recent review by Trastek et al 136 in 1983, only 21 patients were reported in the world literature with spontaneous lifethreatening hemorrhage. The often quoted threat of spontaneous fatal hemorrhage of a cavernous hemangioma is rare. Tumors smaller than 4 cm in diameter should be left alone because they rarely increase in size or rupture. 13 Trastek et aP36 reported on 36 patients with hemangiomas larger than 4 cm in diameter (by definition, giant hemangiomas) who were observed for up to 15 years. None of these patients experienced rupture with intra-abdominal hemorrhage, not even deterioration of symptoms attributable to the hemangiomas. Although the size of four lesions increased, no patient required operation. Although the mortality rate associated with resection of large liver hemangiomas is close to 0 in experienced hands, 117, 127,136 the blood loss associated with these procedures can be significant (up to 5 L,117 average 1750 mL). This blood loss is not an acceptable risk unless removal is clearly indicated. It is usually accepted that the hemangioma should be considered for resection when it presents as a palpable preoperative mass, especially in patients prone to trauma or when the patient complains of fever, epigastric pain, and discomfort attributable to the hemangioma. Diagnostic uncertainty, rupture with intra-abdominal bleeding, and the rare Kasabach-Merritt syndrome 71 (thrombocytopenia caused by platelet trapping and consumption in the hemangioma) are more clearcut indications for surgery. Rapidly growing tumors because of dilation rather than new growth should also be excised even though they are benign. 1, 51, 96 Review of the literature by Schwartz and Husser ll7 in 1987 revealed that rapid growth of the lesion during pregnancy was observed in only one patient and that the effects of pregnancy or contraceptive drugs on growth are inconsistent; therefore, current or future pregnancy is not an indication for resection. Because the indications noted earlier will not exist in patients being discussed here, we conclude that an incidentally found hemangioma of the liver should neither be resected nor biopsied. Thus, if the incidentally found tumor has the characteristic macroscopic appearance of a soft red mass with gray-white streaks, no further diagnostic measures are indicated intraoperatively. Some authors127, 136 reported bleeding complications after fine-needle or excisional biopsy of the lesion. Data125, 134 suggest that fine-needle aspiration is safe, especially with proper technique (use of aspiration through a layer of normal liver parenchyma and stopping when the initial attempt at aspiration is followed by a spurt of blood). The value of fine-needle biopsy for confirming the diagnosis of a hemangioma is not high (definite diagnosis was possible in 3 of 11,136 7 of 21,134 and 4 of 31 125 patients). Excisional biopsy should not be performed unless carcinoma is suspected. Fine-needle aspiration biopsy may be safe, but considering the benign

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natural history of this tumor, even a low risk for complications during biopsy is not acceptable. Therefore, needle or excisional biopsy should be performed only when diagnostic doubt exists and then judiciously. Hepatic Cysts. Hepatic cysts are common and are usually small obvious cysts that do not require therapy. Rarely, a larger hepatic cyst may be an incidental finding. The critical features are biliary communication and carcinoma, both of which can be determined by careful inspection of the opened cyst. 33. 73 Because unroofing to permit drainage into the peritoneal cavity is proper therapy, with fenestration being used to connect multiple cysts to one drainage port, opening the cyst for diagnosis is reasonable. Although total cystectomy with hepatectomy is possible, major resection should be reserved for therapy of malignant lesions of the cyst wall determined by biopsy of the opened cyst. Metastatic Liver Tumors. In a series of 19,208 autopsies on patients with extrahepatic malignant tumors, Edmondson and Peters32 reported that 38% of these patients had hepatic metastasis; 48% of the patients with metastatic disease were asymptomatic. Therapy and prognosis demand a precise diagnosis, and tissue diagnosis is essential in the asymptomatic patient with an incidentally found liver nodule. Although the macroscopic appearance of metastatic lesions may provide some indication about the location of the primary tumor,32 expanding, modular, or infiltration processes overlap significantly. Indeed, only histologic study will provide definitive information. Intraoperative ultrasonography can provide useful information about the number and localization of liver nodules as well as involvement of the inferior vena cava or portal vessels. When the patient does not have a known primary tumor site, an extensive search of the abdomen and retroperitoneum should be performed because colon, rectum, pancreas, and stomach are the most common primary tumor sites. When no evidence of a primary tumor is found by thorough inspection and palpation, some authors believe more aggressive measures should be employed. On-table endoscopy, possibly with endoscopic ultrasonography for detection of intramural lesions, is easily performed for the stomach, but colonic examination is more difficult. In the event of pancreatic masses, intraoperative ultrasonography is of great value for assessing the resectability of a malignant lesion because it can detect minimal portal vein involvementlO or involvement of adjacent structures. Resection for carcinoma of the liver from a pancreatic or gastric source and resection for carcinoma of extra-abdominal origin is not commonly associated with long-term survival, and, therefore, curative procedures should not be attempted. In contrast, hepatic carcinoma of colonic origin can often be resected with good long-term results. Patients with metastatic hepatic carcinoid tumor may also benefit from resection of the liver, even if it is only for cytoreduction as a form of palliation of symptoms caused by excessive production of hormones causing the carcinoid syndrome. From more than 140,000 patients found to have colorectal carcinoma9 . 87 in 1986, 60,000 died as a result of metastatic disease. Involvement of the liver is found in 8% to 25% of patients undergoing laparotomy for carcinoma of the colon, with liver involved in almost 80% of the patients who died. More than 50% of patients presented with disease limited to the liver.

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Obviously, metastasis to the liver is a regulating factor in the prognosis in patients with colorectal carcinoma. Although only a few hundred liver resections are performed each year for metastatic colorectal disease, it is estimated that 5000 to 6000 patients could benefit from such resectional regimens. 122 Moreover, liver resection for metastatic disease can be associated with a low (3% to 5%) operative mortality rate. 2, 34, 112 Thus, the issue of whether patients with metastatic carcinoma of the colon limited to the liver and confined within removable locations should undergo resection should no longer be debated, The 5year survival rates after resection (20% to 45%) are higher than without resection. 112 When colonic resection for carcinoma has been performed, some surgeons would consider major hepatic resection for the incidentally found metastatic lesion, but other surgeons would complete the planned procedure and return for the liver resection in the early postoperative period. When primary colonic carcinoma is detected during this operation, colon resection should be performed, but most surgeons would not add major hepatic resection. A decision to perform hepatectomy should follow the generally accepted principles for this approach when it is the planned procedure. No patient should undergo major resection unless all tumor can be removed, at least within the abdomen, Resection of the liver associated with removal of extrahepatic metastasis (lungs, adrenals) showed a 20% 5-year survival rate,63 Hepatic or celiac lymph node involvement associated with metastasis to the liver is a relative contraindication. From 24 patients with involvement of the liver and regional lymph nodes who underwent hepatic resection combined with removal of the lymph node groups draining the liver, no 5year survivors were reported.108 A later report63 from the same registry showed one 5-year survivor from 25 patients. The importance of a tumor-free margin of resection is stressed by Hughes and coworkers63 because a positive margin of resection is associated with an 18% 5-year survival rate. Although a negative margin of 1 cm or less was associated with a 5-year survival rate of 26%, a clear margin greater than 1 cm showed the far superior survival rate of 44%. Incision into tumor tissue at the time of resection also decreased mean survival even when resection resulted in a tumor-free margin. A margin of less than 1 cm was associated with a 26- to 28-month survivaL A clear margin of 1 cm or greater was associated with a median survival of 44 months. Although age, sex, tumor size, and site (left versus right, unilobar versus bilobar) as well as the site of colonic primary do not have prognostic significance, the role of the number of hepatic lesions is not yet clarified. 63 The status of the nonmalignant lobe is important, however. The presence or absence of cirrhosis should also be evaluated because cirrhotic patients are at higher risk for perioperative complications (liver failure, ascitic fistula, and bleeding). Additionally, the limited functional reserve of the liver in cirrhosis does not permit extensive resection. Resection that left 60% of the liver containing normal parenchyma was better tolerated than removal of 15% to 20% of functioning tissue from a cirrhotic liver.129 For this reason, liver tissue biopsy should be obtained

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and combined with clinical data and tests (Child's classification or indocyanine green maximal disappearance rate) to assess the functional reserve of the liver and thereby select patients who would tolerate major hepatic resection. After taking into consideration the aforementioned information, the surgeon who has found incidental carcinoma of the liver should decide what treatment to offer and at what time. Wedge resection or left lateral segmentectomy for solitary liver metastasis can be performed at the time of resection of the colon without causing a higher perioperative mortality rate. 139 In the event the patient has nonresectable metastatic disease, placement of a catheter in the hepatic or, preferably, gastroduodenal artery should be considered for later application of chemotherapeutic agents. Primary Hepatic Tumor. Focal Nodular Hyperplasia. It is not yet clear whether focal nodular hyperplasia represents localized cirrhosis or hamartomatous malformation or is the result of focal injury to liver tissue. 67. 70. 95 This lesion is usually asymptomatic and, therefore, incidentally found in 44% to 90% of patients. 41.67.70 In most patients, focal nodular hyperplasia, a solitary lesion,67 is less than 5 cm in size and is sharply demarcated from liver tissue with a characteristic central stellate scar; occasionally, it is surrounded by a fibrous capsule. 41 . 67. 146 The natural history of this disorder is benign, as reported by Kerlin et al,71 who observed no complications in 16 patients with biopsy-confirmed focal nodular hyperplasia who were observed for 2 to 15 years. The lesion should undergo biopsy study and be left in situ unless the diagnosis is a concern. An excisional biopsy technique is justifiable if it can easily be achieved by wedge resection. Hepatocellular Adenoma. The hepatocellular adenoma is a rare disorder, occurring mainly in women during their reproductive years. 40. 1Jl In 1973, Baum et al 5 first reported the possible association between hepatocellular adenoma and oral contraceptives. Other authors 70. llO confirmed the relationship and observed a rising risk of hepatocellular adenoma with increasing duration of oral contraceptive use. Although regression of hepatocellular adenoma after discontinuation of oral contraceptives has been reported,95 it is not clear whether all of these tumors regress or whether the potential for complications decreases as the size decreases. The tumor is usually larger than 5 cm in diameter and symptomatic, and, therefore, it will rarely be encountered as an incidental finding. 40. 67 Hepatocellular adenomas are hypervascular tumors with sharp margins, mainly located in the right lobe of the liver, with two or more nodules being present in 29% of patients. 67 Because of their potential for complications, such as bleeding or malignant transformation, these benign tumors should be resected when the risk is low. In high-risk patients or in patients with bilobar involvement (8%67), in which removal of the tumor would indicate major hepatic resection, conservative treatment with observation is an acceptable alternative. Hepatocellular Carcinoma. Hepatocellular carcinoma is primanly a disease of the cirrhotic liver, and, therefore, its treatment is complicated. Hepatocellular carcinoma appears as a soft mass without central umbilication with areas of bleeding and necrosis, eventually with satellite nodules around

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the primary lesion. 40 These tumors occasionally remain asymptomatic, although they have reached an enormous size. Primary hepatocellular carcinoma in a noncirrhotic patient and hepatocellular carcinoma in a peripheral location in a cirrhotic liver should be resected with a 2-cm tumor-free margin provided the patient's condition is stable. 15 Unfortunately, resection is rarely possible, and wedge biopsy of the lesion should be obtained to provide valuable information for further treatment. In one study,15 18 patients were found to have incidental liver carcinoma after liver transplantation for hepatic failure secondary to cirrhosis; 70% had a 3year disease-free interval. Therefore, for the asymptomatic incidentally found hepatocellular carcinoma, and when underlying cirrhosis prohibits extensive curative resection, liver transplantation in the postoperative period would be an appropriate decision. Pancreatic Masses Incidentally found pancreatic masses represent the most difficult lesions. Because of space constraints and a recent revieWl6 of this specific problem, they will not be discussed.

SUMMARY We discussed the proper management of patients with asymptomatic lesions incidentally found during laparotomy for other problems. For common or important lesions, information about the natural history, significance, treatment guidelines, and possible risks or complications related to operations on such incidentalomas were given. Thus, we discussed gallstones, masses of the upper and lower gastrointestinal tract, and masses in solid organs, such as liver, ovaries, and pancreas.

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