Introduction

Endoscopic retrograde appendicitis therapy (ERAT) offers an appendix-preserving approach, yet visual and specificity challenges persist. In contrast, endoscopic direct appendicitis therapy (EDAT) provides direct visual observation with diagnostic and therapeutic capabilities. This study aimed to assess the efficacy and feasibility of EDAT compared to ERAT in uncomplicated appendicitis.

Aims & Methods

We retrospectively reviewed of patients diagnosed with suspected uncomplicated appendicitis undergoing ERAT or EDAT from Jan 2021 to Mar 2024. The primary outcome was to evaluate the intervention success of two groups. The secondary outcomes included hospitalization, procedure time, stent placement, post-procedure hospitalization period, pain relief, recurrence, and endoscopic direct-view characteristics were compared.

Results

Sixty-nine patients were enrolled, among which 34 patients underwent ERAT and 35 patients underwent EDAT. EDAT showed significantly higher intervention success (100% and 85.3%, respectively, p = 0.018), and shorter hospitalization stay (p = 0.003), and post-procedure hospitalization stay (p < 0.001) compared to ERAT group. With comparable procedure time (p = 0.915) and recurrence (p = 0.164), significant fewer proportions of stent placements (p < 0.001), guidewire assists (p < 0.001), and post-procedure antibiotic administrations (p = 0.036) associated in EDAT group compared to ERAT group.

Conclusion

EDAT has demonstrated to be an effective and feasible approach, offering both diagnostic and therapeutic capabilities for uncomplicated appendicitis compared to ERAT.

References

1 Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C. & Staudenmayer, K. L. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surg 154, 141-149 (2019). https://doi.org:10.1001/jamasurg.2018.4282
2 Wu, T., Yang, Y., Wu, Y., Lu, L. & Dong, S. Complications after appendectomy in patients with treated appendicitis: results from a retrospective study. Ann Palliat Med 10, 12546-12553 (2021). https://doi.org:10.21037/apm-21-3295
3 Song, M. Y. et al. Long-term effects of appendectomy in humans: is it the optimal management of appendicitis? Expert Rev Gastroenterol Hepatol 15, 657-664 (2021). https://doi.org:10.1080/17474124.2021.1868298
4 Masahata, K. et al. Generation of colonic IgA-secreting cells in the caecal patch. Nature Communications 5, 3704 (2014).
5 Ambe, P. C. Negative Appendectomy. It is Really Preventable? Journal of Investigative Surgery 32, 474-475 (2019). https://doi.org:10.1080/08941939.2018.1453566
6 Jeon, B. G. Predictive factors and outcomes of negative appendectomy. Am J Surg 213, 731-738 (2017). https://doi.org:10.1016/j.amjsurg.2016.05.020
7 A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. New England Journal of Medicine 383, 1907-1919 (2020). https://doi.org:doi:10.1056/NEJMoa2014320
8 Salminen, P. et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA 313, 2340-2348 (2015). https://doi.org:10.1001/jama.2015.6154

Introduction

Over the past decade, endoscopic retrograde appendicitis therapy (ERAT) has emerged as a novel, minimally invasive treatment option for patients with acute uncomplicated appendicitis (AUA). However, it is not yet known whether ERAT is a feasible alternative to antibiotic therapy (ABT).

Aims & Methods

This study aims to evaluate the efficacy of ERAT versus ABT in patients with AUA. We performed a systematic review across PubMed, Embase, and Cochrane CENTRAL databases, searching for studies comparing ERAT to ABT in this population. Outcomes of interest included therapeutic success, — defined as the absence of reintervention up to 1 year of follow-up — recurrence rates, mean time to disease recurrence, and length of hospital stay (LOS). Risk ratios (RR) were used to evaluate binary outcomes with their corresponding 95% confidence intervals (CI), while the mean difference (MD) was calculated for continuous outcomes. All statistical analyses were performed using R software (version 4.4.1) with a random-effects model.

Results

This meta-analysis included 3 studies — 2 control-matched cohorts and 1 randomized trial — comparing 457 ERAT patients to 784 patients receiving ABT for AUA. Baseline clinical characteristics were equally distributed between the groups and the time of follow-up ranged from 3 to 12 months. There was no statistically significant difference between ERAT and ABT in treatment success (RR 1.06; 95% CI 1.00 to 1.12; p = 0.07) or recurrence rate (RR 0.36; 95% CI 0.11 to 1.22; p = 0.10). The difference in time to recurrence was also not significant (MD 116 days; 95% CI -49 to 282; p = 0.17). However, ERAT was associated with a significantly shorter LOS (MD -1.85 days; 95% CI -3.15 to -0.55; p = 0.005).

Conclusion

In patients with acute uncomplicated appendicitis, ERAT is non-inferior to antibiotic therapy, while considerably reducing the length of hospital stay. Further studies are warranted to better assess the efficacy of ERAT compared to ABT, and whether it decreases the risk of appendicitis recurrence.

References

1. Kang, J., et al. (2021). The modified endoscopic retrograde appendicitis therapy versus antibiotic therapy alone for acute uncomplicated appendicitis in children. Surgical Endoscopy, 35(11), pp.6291-6299. Available at: https://doi.org/10.1007/s00464-020-08129-8.
2. Li, D., et al. (2023). Endoscopic retrograde appendicitis therapy or antibiotics for uncomplicated appendicitis. British Journal of Surgery, 110(6), pp.635-637. Available at: https://doi.org/10.1093/bjs/znad023.
3. Zhan, K., et al. (2024). Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis. The American Journal of Gastroenterology. Available at: https://doi.org/10.14309/ajg.0000000000003118.
   

Introduction

Acute appendicitis is a widely encountered emergency across the globe, showcasing the resilience of modern medicine, as it is traditionally addressed through the transformative procedure of appendectomy. Endoscopic Retrograde Appendicitis Therapy (ERAT) has emerged as a minimally invasive alternative; however recurrence is a worry.

Aims & Methods

This multi-center retrospective study aimed to evaluate the long-term safety, efficacy, and recurrence-related risk factors of ERAT to guide clinical decision-making. A total of 435 patients who underwent ERAT for acute appendicitis between October 2017 and October 2024 at three Chinese medical centers were included. Appendicitis recurrence was defined as imaging-confirmed symptoms returning within one-month post-ERAT. Univariate and multivariate regression analysis identified independent recurrence risk variables.

Results

All ERAT procedures were technically successful and achieved a clinical success rate of 92.4%. Over a median follow-up period of 37 months, the overall recurrence rate was 16.1%, with the majority of recurrences (13%) observed within the first year. Independent risk factors for recurrence included recurrent appendicitis (HR=1.916), appendiceal lumen distortion (HR=7.996), absence of stent placement (HR=0.375, protective), and operator inexperience (HR=2.318). Stent implantation effectively minimizes recurrence risk, especially in complicated incidents. ERAT facilitated overseeing appendicolith elimination, which assisted in occurring appendicolith-associated appendicitis.

Conclusion

ERAT is deemed safe and effective for acute appendicitis, with the highest recurrence risk occurring within the first year. Effective stent placement and skilled operators are crucial for reducing recurrence in complex cases. The aforementioned findings put forward significant insights for enhancing ERAT and advancing therapeutic outcomes.

Introduction

Chronic appendicitis is a condition with chronic abdominal pain or mild attacks of appendicitis, seriously affecting the patient's quality of life. Endoscopic retrograde appendicitis therapy (ERAT) has emerged as a promising, non-invasive treatment for acute uncomplicated appendicitis.

Aims & Methods

We aim to assess the safety and efficacy of ERAT for chronic fecalith appendicitis.
We retrospectively reviewed the medical records of consecutive patients who underwent ERAT for chronic fecalith appendicitis at Zhongshan Hospital, Fudan University, Shanghai, China between December 2017 and June 2023. Clinicopathological characteristics, procedure-related parameters, AEs, and follow-up outcomes were analyzed.

Results

A total of 60 patients were included. ERAT intubation was successfully performed in all patients (100%). The median procedure time was 15 minutes (IQR, 12-25 minutes). The postoperative abdominal pain scores were significantly reduced (P<0.0001). Short-term adverse events included 5 cases of abdominal pain (8.3%) and 2 cases of fever (3.3%). Long-term adverse events included recurrent abdominal pain in 3 cases (5.0%) and recurrent appendicitis in 2 cases (3.3%). The median time to recurrence was 5 months (IQR, 2-12 months). Logistic regression analysis revealed appendiceal stenosis (OR=25.000, 95% CI, 1.114-561.281, P=0.043) and distorted appendix lumen (OR=12.500, 95% CI, 1.373-113.806, P=0.025) as significant risk factors for long-term adverse events.

Conclusion

ERAT may be a safe, effective and minimally invasive alternative approach for chronic fecalith appendicitis. Appendix lumen stenosis and distortion are risk factors of recurrence. Further large-scale prospective studies are necessary to assess the efficacy and safety of ERAT compared with antibiotic therapy and surgery.

Introduction

The technique of colorectal ESD has become increasingly standerdised, but challenges still remain for difficult cases. These include lesions occurring on the gravity side that become submerged in fluids, lesions at the colonic flexures that are difficult to approach, and lesions that face the endoscope perpendicularly. The advantages of “gel-immersion endoscopy”, include not only the easier identification of the bleeding point, but also enhancement of the visual field by clearing away the intestinal fluids and residues, aid traction of the lesion using buoyancy, and allowing to secure the visual field between the intestinal folds without needing to insufflate of the intestinal tract with gas. These advantages are favorable for colorectal ESD, and there are case reports of colorectal gel-immersion ESD (Gi-ESD), but there have been no studies of consecutive case series.

Aims & Methods

The present study aimed to clarify the indications and outcomes of Gi-ESD. This was a retrospective cohort study of consecutive patients with colorectal neoplasms who underwent ESD between July 2022 and May 2024. The inclusion criteria consisted of all colorectal ESD performed in our hospital. The exclusion criteria include (i) non-neoplastic lesion; (ii) carcinoma invading muscularis propria; (iii) underwater ESD method; and (iv) use of traction devices, (v)significant loss of clinical data. Gi-ESD was defined as mucosal incision and submucosal dissection performed partially or totally under clear gel (VISCOCLEAR, Otsuka pharmaceutical factory, Japan). Conventional ESD (c-ESD) was defined as all incisions and dissection performed without gel. The primary outcomes were en bloc resection rate and histologic R0 resection rate. Secondary outcomes were procedure time, dissection speed, intraoperative or postoperative perforation, postoperative hemorrhage, and gel-related adverse events.

Results

Among the 260 ESD, 29 were Gi-ESD group and 231 were c-ESD group. Gi-ESD group had significantly larger tumor diameters (25mm vs 18mm, p = 0.001), had a higher rate of lesions located in the cecum or ascending colon (55.2% vs 31.2%, P = 0.01), and had a higher rate of factors associated with difficult ESD (24.1% vs 9.5%, P< 0.05).
Gel was used to improve the visual field and aid traction during ESD, by lifting the lesion using buoyancy in 14 cases(48.3%) where the lesions occurred on the gravity side, to secure the visual field in cases where the lesion could not be approached without degassing such as behind the folds or colonic flexure in 9 cases(31%), and to allow ESD to be performed in a parallel direction with the muscularis propria in lesions that would otherwise have faced the endoscope perpendicularly under CO₂ insufflation in 6 cases(20.7%). Procedure time was significantly longer in the Gi-ESD group (50min vs 32min; P<0.001), but there was no significant difference in the dissection speed (14mm2/min vs 16.1mm2/min, p=0.45). There were no significant differences in the incidences of intraoperative perforation (0% vs 0.4%), delayed perforation (0% vs 0%), or post operative hemorrhage (3.4% vs 0.4%, p=0.21). There were no significant differences in both the en bloc resection rate (100% vs 99.1%) and the pathologic complete resection rate (96.6% vs 88.7%, p=0.33).

Conclusion

Using gel, en bloc resection was obtained without reducing the dissection speed, even for larger lesions associated with factors that make ESD difficult. Gi-ESD for colorectal lesions may be an alternative approach for lesions occurring on the gravity side and for lesions that are difficult to approach under CO₂ insufflation.

References

Yano T et al. Gel immersion endoscopy: A novel method to secure the visual field during endoscopy in bleeding patients. Gastrointestinal endoscopy 2016; 83: 809-11.
Nakano Y et al. Colorectal gel immersion endoscopic submucosal dissection using the tunneling method. Endoscopy 2023; 55: E864-e5.

Clinical Case Summary

Lesions involving the appendiceal orifice pose an endoscopic therapeutic challenge. The characteristics of the cecal wall and the complexity of exposing the appendiceal lumen make for demanding and often incomplete resections. While various techniques have been proposed, each has its limitations, including lesion size, technical difficulty, and increased risk of complications. We aim to introduce a new alternative: complete resection using a diathermic snare assisted by traction with rubber band and clip.

We present the case of a 62-year-old woman with a lesion in the cecum involving the appendiceal orifice. Previous histological examination revealed a tubular adenoma with low-grade dysplasia (LGD). Complete colonoscopy revealed a lesion with a Paris 0-IIa morphology, LST non-granular, measuring 18mm in diameter, located at the cecum and involving the appendiceal orifice. During examination with high-definition white light imaging and virtual chromoendoscopy using BLI, the lesion exhibited a Kudo IV crypt and JNET2A. Mucosectomy was performed piecemeal using the "underwater" technique. Residual lesion partially involved the appendiceal orifice, with the intra-appendicular lesion limits being indiscernible. Therefore, a novel approach involving traction and exteriorization of the appendicular mucosa was applied using a rubber band and TTS clip to achieve adequate exposure of the entire residual lesion. Subsequently, the lesion was completely resected using a diathermic snare. There were no complications. Histological examination confirmed the presence of a tubular adenoma with LGD.

Endoscopic resection of lesions involving the appendiceal orifice can be challenging. Traction methods have previously been described solely in the context of submucosal endoscopic dissection. We present an effective and safe alternative for adequately exposing the appendiceal lumen using a traction method, allowing for complete resection through endoscopic mucosal resection.

References

Justiniano CF, Ozgur I, Liska D, Valente MA, Steele SR, Gorgun E. The role of advanced endoscopy in appendiceal polyp management and outcomes. Surg Endosc. 2024 Apr;38(4):2267-2272. doi: 10.1007/s00464-024-10726-w.
Obri M, Ichkhanian Y, Brown P, Almajed MR, Nimri F, Taha A, Agha Y, Jesse M, Singla S, Piraka C, Zuchelli TE. Full-thickness resection device for management of lesions involving the appendiceal orifice: Systematic review and meta-analysis. Endosc Int Open. 2023 Oct 6;11(9):E899-E907. doi: 10.1055/a-2131-4891

Introduction

Endoscopic submucosal dissection (ESD) is an effective technique for treating large colorectal lesions but can result in strictures in 0.49-19.7% of cases. We developed a novel technique called Hybrid Endoscopic Stricturotomy (HES), which combines incision with endoscopic balloon dilation (EBD) to treat post-ESD colorectal strictures. This study aims to evaluate the efficacy and safety of HES.

Aims & Methods

This retrospective study analysed data from a prospectively maintained registry at San Raffaele Hospital, Milan, from November 2019 to October 2024.
HES was performed on patients who developed symptomatic post colorectal ESD strictures defined as a lumen calibre that does not allow the passage of the endoscope (9.2 mm diameter) after conventional EBD treatment.
The HES technique involved incision followed by EBD. An L-shaped knife was used to radially incise the stenotic tissue in four quadrants. After the incisions, a wire-guided balloon dilator was introduced and gradually inflated to a diameter larger than the stenosis. Follow-up endoscopies were scheduled every 2-4 weeks, and additional HES sessions were performed in in cases where lumen dilatation did not improve.
The primary outcome was clinical success, defined as lumen calibre ≥12 mm and symptom resolution; secondary outcomes included technical success, adverse events (AEs), and stricture recurrence.

Results

Of 265 patients treated with colorectal ESD, 7 patients (median age 71 years, 57.1% male) developed strictures; all in the rectum.
Lesions treated with ESD had a median length of 85mm on the major axis and 70mm on the minor axis. All lesions were classified as IIa+Is according to the Paris classification, except for one lesion arising on an anastomosis classified as IIa. The dentate line was involved in 5/7 cases (71.4%). Resection circumference was 100% in 2/7 patients (28.6%), 91-99% in 1/7 patient (14.3%), 76-90% in 1/7 patient (14.3%), 51-75% in 2/7 patients (28.6%), and 0-50% in 1/7 patient (14.3%). Median initial stricture diameter was 6mm (IQR 2). The median number of conventional EBD sessions before HES was 3 (range 2-5). Median stricture diameter after EBD treatment was 8mm (IQR 2).
Clinical and technical success was achieved in 100% of cases. During HES, the median maximum balloon diameter dilation was 20mm (range 15-20). The median number of HES treatment sessions was 2.3 (range 2-3). No AEs were reported. Over a median follow-up of 225 days (IQR 95 days), no symptomatic recurrences were observed.

Conclusion

HES, which combines incision and EBD, is a novel, safe and effective technique for treating post-colorectal ESD strictures to conventional EBD. Larger studies are needed to validate these preliminary results.