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

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

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

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

Endoscopic submucosal dissection (ESD) for the anal canal lesions (ACLs) is technically challenging because of the specific anatomical features of the anal canal. We aimed to evaluate the efficacy and safety of ESD for ACLs.

Aims & Methods

We retrospectively investigated 102 patients with ACLs who underwent ESD from August 2010 to August 2023. We collected and analyzed clinicopathological characteristics, procedure‑related parameters, outcomes, and follow‑up data.

Results

Of the 102 patients with ACLs (mean age 63 years, 46 men), ACLs were located above the dentate line (ADL) in 55 patients, and lesions involved the dentate line (IDL) in 47. The mean procedure duration was 37.0 min. The en bloc resection and en bloc with R0 resection rates were 94.1% and 88.2%, respectively. Adverse events (AEs) included two intraoperative bleeding, two delayed bleeding, and one febrile episode. Anal pain occurred in 5 patients. During a median follow-up of 37 months, local recurrence was revealed in 3 patients, and one had metastases. Compared with the ADL group, the IDL group had significantly longer procedure duration, larger specimens, lower rates of En bloc with R0 resection, higher anal pain rate, and more AEs. When only adenomas/adenocarcinomas were included in the analysis, the two groups had no significant differences regarding recurrence-free, overall, and disease-specific survival.

Conclusion

The favorable short‑ and long-term outcomes indicate ESD is a safe, effective, and attractive therapeutic modality for ACLs. A multicenter and prospective study should be conducted to validate this technology.

Introduction

Incidence of squamous cell carcinoma (SCC) of the anal canal is increasing. SCC arises from anal intraepithelial neoplasia (AIN) and condylomas. However, destruction of these anal lesions with standard techniques carries a high risk of recurrence and potential functional impairment. Endoscopy can be used to detect and treat colorectal lesions by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), but its value in the management of anal lesions has been poorly studied. The aim of this study was to assess the feasibility, efficacy and safety of endoscopic management of AIN and condylomas.

Aims & Methods

We conducted a retrospective study including all patients who had undergone endoscopic resection either by EMR or DSM of anal lesion (AIN or condylomas). The following criteria were evaluated: the rate of residual lesion at the end of endoscopic treatment, the rate of monobloc resection, the rate of complication per procedure and within 30 days after the procedure, the rate of new anal lesion and the rate of SCC during follow-up.

Results

From May 2015 to November 2024, 33 patients were included. Twenty-six (78.8%) were women. Mean age was 62.8 (±11.1) years. Two (6.1%) patients were HIV-positive. Eleven (33.3%) patients had a history of anal lesions, including one (3.0%) case of SCC. The median number of lesions per patient was 1 (IQR 1 - 2), with multifocal involvement in 15 (45.5%) patients. Thirteen (39.4%) patients had anal involvement reaching more than one hemi-circumference. Seven patients (21.2%) underwent ESD, and 26 (78.2%) underwent EMR. At the end of endoscopic treatment, no residual lesions were visible in 31 (93.9%) patients. Lesions were intentionally left in the remaining two patients. Resections were monobloc and macroscopically complete in 19 (57.6%) patients. Intra-procedural hemorrhage was visualized in 18 (54.5%) patients and was treated endoscopically during the same anesthesia without recurrence or clinical impact. One case of anal stenosis occurred 27 days after circumferential ESD treated with 4 sessions of digital dilatations and one corticosteroid injection. No other complications occurred within 30 days after the procedures. Mean length of hospital stay was 1.12 (+/- 0.33) days. Pathological findings were: condyloma in 6 (18.2%) patients, AIN1 in 8 (24.2%) patients, AIN2 in 5 (15.2%) patients, AIN3 in 10 (30.3%) patients, and SCC in 4 (12.1%) patients (two SCC T1 R0, one of which required additional radiotherapy, and two in situ SCC). Follow-up data were available for 29 patients. Mean follow-up time was 34.4 (+/- 35.7) months. Of these 29 patients, 8 (27.6%) cases of a new AIN or condyloma (outside the resection scar) were detected during follow-up after an average duration of 4 (+/- 2.1) months, 7 of which were treated by endoscopy. Two (6.9%) cases of scar recurrence were detected 4 and 13 months after treatment. During follow-up, three (10.3%) cases of SCC ≥ T1 were diagnosed, including one case of recurrence at one year of a SCC pre-existing endoscopic treatment. The other two cases were diagnosed at one and 6 years.

Conclusion

Endoscopic management (EMR or DSM) of AIN and condylomas is a safe and effective. It should be part of the therapeutic arsenal in the management of these lesions. Increased surveillance is essential, given the high risk of new lesions.

References

Deshmukh AA, Suk R, Shiels MS, et al. Recent Trends in Squamous Cell Carcinoma of the Anus Incidence and Mortality in the United States, 2001-2015. J Natl Cancer Inst 2020; 112: 829–838.
Palefsky JM, Lee JY, Jay N, et al. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. N Engl J Med 2022; 386: 2273–2282.
Borch-Johnsen P, Nygren J, Schmidt PT. Endoscopic underwater detection and resection of anal squamous intraepithelial lesions in non-anesthetized patients - a feasibility study and comparison with standard surgical treatment. Scand J Gastroenterol 2024; 59: 232–238.