Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy

Is appendoscope a new option for the treatment of acute appendicitis?

Acute appendicitis is a common surgical emergency. It is commonly caused by obstruction of the appendiceal lumen due to fecaliths, tumors, or lymphoid hyperplasia. For over a century, appendectomy has been the primary treatment for acute appendicitis. Abraham Groves performed the first open appendectomy in 1883. In 1983, Kurt Semm completed the first laparoscopic appendectomy, heralding a new era in appendectomy. However, appendectomy is associated with certain complications and a rate of negative appendectomies. Studies have suggested controversy over the impact of appendectomy on the development of inflammatory bowel disease and Parkinson's disease, but an increasing number of studies indicate a possible positive correlation between appendectomy and colorectal cancer, gallstones, and cardiovascular disease. With the recognition that the appendix is not a vestigial organ and the advancement of endoscopic te-chnology, Liu proposed the endoscopic retrograde appendicitis therapy. It is an effective minimally invasive alternative for treating uncomplicated acute appendicitis. Our team has developed an appendoscope with a disposable digital imaging system operated through the biopsy channel of a colonoscope and successfully applied it in the treatment of appendicitis. This article provides an overview of the progress in endoscopic treatment for acute appendicitis and offers a new perspective on the future direction of appendiceal disease treatment.

Contrast-Enhanced Ultrasound-Guided Endoscopic Retrograde Appendicitis Treatment-A Pilot Study on the Diagnostic and Therapeutic Efficacy in Uncomplicated Appendicitis

OBJECTIVE

To determine the diagnostic and therapeutic value of contrast-enhanced ultrasound-guided endoscopic retrograde appendicitis treatment (ERAT) in patients with uncomplicated appendicitis.

METHODS

A retrospective analysis was performed on clinical and ultrasound data collected from 105 pediatric patients with uncomplicated appendicitis between January 2020 and December 2023. The ultrasound findings before and after treatment, as well as postoperative follow-up and recurrence rates, were summarized and analyzed.

RESULTS

Successful intubation was achieved in 96 patients (91.4%). The conventional ultrasound appendix visualization rate was 39.6% (38/105), while the appendix visualization rate after contrast-enhanced ultrasound-guidance was 75% (72/105). Contrast-enhanced ultrasound revealed various appendiceal morphologic changes in 89 patients, such as twisting, tortuosity, stiffness, rough inner wall, dilated diameter, and narrowing of the lumen. Additionally, local filling defects, which indicated the presence of fecal stones or debris deposition, were noted in 68 patients. No leakage of the contrast agent occurred. Post-treatment evaluation showed improvement in appendiceal diameter, lumen, and filling defects (P < .01). The follow-up rate was 82 of 89 patients (92.1%), all of whom recovered well without a recurrence. The recurrence rate was 7.9% (7/89). Among the patients with recurrences, five patients resolved after medical treatment and two patients recovered after surgical treatment.

CONCLUSION

Contrast-enhanced ultrasound-guided ERAT for uncomplicated appendicitis is safe and effective. Specifically, the appendix is increased, which facilitates an evaluation of therapeutic effectiveness. ERAT serves as a valuable supplementary modality to determine the need for surgical treatment of acute appendicitis, which is of significant clinical value.

Endoscopic retrograde appendicitis therapy: current and the future

This article presents an overview of endoscopic retrograde appendicitis therapy (ERAT), an innovative and minimally invasive treatment for appendicitis with an appendix-preserving manner. Since its initial application in 2009, ERAT has gained significant popularity in China, due to its rapid recovery and minimal risk of complications. The ERAT procedures comprise several steps, including appendiceal orifice access and intubation, appendiceal lumen imaging, decompression and irrigation, fecalith removal, and stenting. ERAT has been used in various forms of complicated appendicitis, such as in pregnant women and children, with continuous improvements in both technique and safety. It has the potential to become the preferred diagnostic and treatment method for appendicitis. Until 2023, over 10,000 ERAT procedures have been successfully conducted in China, and the technique has gained more attention worldwide. However, challenges remain, including training, standardization of ERAT practice, research and technology improvement, enhancing public awareness, and fostering international collaboration. In summary, ERAT can be the standard treatment for appendicitis treatment, which represents a paradigm shift in the conventional clinical practice.

Appendicoscopy using single-operator cholangioscope in the management of acute obstructive appendicitis: a novel alternative (with video)

BACKGROUND AND AIMS

The aim of this study was to investigate the safety and efficacy of appendicoscopy using a single-operator cholangioscope (SOC) for the management of acute obstructive appendicitis.

METHODS

This study describes 110 cases of acute obstructive appendicitis managed with the use of appendicoscopy between January 2021 and June 2023. The success rate (technical + clinical), procedure time, time to abdominal pain relief according to a visual analog scale score, postoperative length of hospital stay, and adverse event rates were recorded and analyzed.

RESULTS

The technical success rate of appendicoscopy was 96.4%, and the clinical success rate was 91.8%. The mean ± standard deviation procedure time was 20.9 ± 10 minutes. The abdominal pain score at 6 hours after the procedure was ≤3 (visual analog scale method) in 99.1% of patients. The average length of postoperative hospital stay was 3.5 ± 1.5 days. No adverse events occurred.

CONCLUSIONS

Appendicoscopy seems to be a feasible and effective alternative therapy for the accurate diagnosis and treatment of acute obstructive appendicitis.

Use of a cholangioscope for appendixoscopy and detecting a residual appendiceal adenoma

Video 1Use of a cholangioscope for appendixoscopy and detecting a residual appendiceal adenoma.

Single-operator cholangioscopy system for management of acute cholecystitis secondary to choledocholithiasis

This study aimed to investigate the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) + EyeMax (single-operator cholangioscopy system; SOC) (i.e., ERCP+SOC) for the treatment of choledocholithasis-associated acute cholecystitis. Twenty-five patients were evaluated between January 2022 and June 2023. The success rate (technical + clinical), procedure time, postoperative recovery, postoperative length of hospital stay, and complications rates were recorded. The procedure and clinical success rates were 92% (23/25) and 96% (24/25), respectively. The mean procedure time was 36.6±10 minutes (standard deviation [SD]). The average postoperative hospitalization was 2±0.8 days. No adverse events such as bleeding, perforation, or bile leakage occurred. Cholecystitis did not recur during the 2 to 18 months of follow-up. ERCP+SOC may be a feasible, safe, and effective alternative treatment for acute cholecystitis secondary to choledocholithiasis. ERCP+SOC was able to simultaneously resolve both biliary tract and gallbladder problems via natural orifice endoscopy. Its advantages included no skin wound, reduced postoperative pain, quick recovery, limited to no exposure to x-rays, and a short hospital stay.

Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis

INTRODUCTION

Endoscopic retrograde appendicitis therapy has been proposed as an alternative strategy for treating appendicitis, but debate exists on its role compared with conventional treatment.

METHODS

This systematic review was performed on MEDLINE, Cochrane Central Register of Controlled Trials, and EMBASE. The last search was in April of 2023. The risk ratio with a 95% confidence interval was calculated for dichotomous variables, and the mean difference with a 95% confidence interval for continuous variables. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool (randomized controlled trials) and the Risk of Bias in Non-Randomized Studies of Intervention tool (non-randomized controlled trials).

RESULTS

Six studies met the eligibility criteria. Four studies compared endoscopic retrograde appendicitis therapy (n = 236 patients) and appendectomy (n = 339) and found no differences in technical success during index admission (risk ratio 0.97, 95% confidence interval [0.92,1.02]). Appendectomy showed superior outcomes for recurrence at 1-year follow-up (risk ratio 11.28, 95% confidence interval [2.61,48.73]). Endoscopic retrograde appendicitis therapy required shorter procedural time (mean difference -14.38, 95% confidence interval [-20.17, -8.59]) and length of hospital stay (mean difference -1.19, 95% confidence interval [-2.37, -0.01]), with lower post-intervention abdominal pain (risk ratio 0.21, 95% confidence interval [0.14,0.32]). Two studies compared endoscopic retrograde appendicitis therapy (n = 269) and antibiotic treatment (n = 280). Technical success during admission (risk ratio 1.11, 95% confidence interval [0.91,1.35]) and appendicitis recurrence (risk ratio 1.07, 95% confidence interval [0.08,14.87]) did not differ, but endoscopic retrograde appendicitis therapy decreased the length of hospitalization (mean difference -1.91, 95% confidence interval [-3.18, -0.64]).

CONCLUSION

This meta-analysis did not identify significant differences between endoscopic retrograde appendicitis therapy and appendectomy or antibiotics regarding technical success during index admission and treatment efficacy at 1-year follow-up. However, a high risk of imprecision limits these results. The advantages of endoscopic retrograde appendicitis therapy in terms of reduced procedural times and shorter lengths of stay must be balanced against the increased risk of having an appendicitis recurrence at one year.

Appendixoscopy to evaluate a suspected mucinous appendiceal lesion

Video 1Colonoscopy with "appendixoscopy" using a single-operator digital cholangioscope to exclude a mucinous lesion of the appendix.

Endoscopic Retrograde Appendicitis Therapy: Is it Really a Need of the Hour?

ABSTRACT

Endoscopic retrograde appendicitis therapy (ERAT) has emerged as a promising, non-invasive treatment for acute uncomplicated appendicitis (AUA). ERAT involves cannulation, appendicography, appendiceal stone extraction, appendiceal lumen irrigation, and stent deployment. Recent randomized trials comparing ERAT to laparoscopic appendectomy (LA) have provided promising results in terms of safety and efficacy of ERAT. If the current trajectory of research and development is maintained, ERAT will likely become a strong contender for the standard of care for AUA. Standardized training and credentialing for ERAT, akin to procedures established for endoscopic retrograde cholangiopancreatography, will be pivotal to global adoption of this modality.

Endoscopic retrograde appendicitis therapy for acute appendicitis: a systematic review and meta-analysis

Background and study aims Endoscopic retrograde appendicitis therapy (ERAT) is an endoscopic procedure for management of patients with acute appendicitis (AA). In addition to being minimally invasive, it has the added advantages of preservation of appendix and simultaneous inspection of colon. We performed a systematic review and meta-analysis on ERAT in patients with AA.

Methods We conducted a comprehensive search of multiple electronic databases (from inception through January 2022) to identify studies reporting ERAT in AA. The primary outcome was to evaluate the overall clinical and technical success of ERAT. The secondary outcome was to study the total and individual adverse events (AEs). The meta-analysis was performed using Der Simonian and Laird random effect model.

Results Seven studies reporting on 298 patients were included. The majority of the patient population was male (55.3 %), with mean age of 31 ± 12.39 years. The pooled technical success rate was 99.36 % (95 % CI 97.61–100, I2 = 0) and the pooled clinical success rate was 99.29 % (95 % CI 97.48–100, I2 = 0). The pooled AE rate was 0.19 % (95 % CI 0–1.55, I2 = 0). The most common AE was perforation with 0.19 % (95 % CI 0–1.55, I2 = 0). The recurrence rate was 6.01 % (95 % CI 2.9–9.93, I2 = 20.10). Average length of procedure was 41.1 ± 7.16 min. Low heterogeneity was noted in in our meta-analysis.

Conclusions ERAT is a safe procedure with high rates of clinical and technical success in patients with AA. Further randomized controlled trials should be performed to assess the utility of ERAT in AA as compared to laparoscopic appendectomy.

Endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy for uncomplicated acute appendicitis

BACKGROUND

Endoscopic retrograde appendicitis therapy (ERAT) is a new and minimally invasive technique for the treatment of acute appendicitis. This study aimed to assess the efficacy and clinical outcomes of ERAT versus laparoscopic appendectomy for patients with uncomplicated acute appendicitis.

METHODS

We adopted propensity score matching (1:1) to compare ERAT and laparoscopic appendectomy in patients with uncomplicated acute appendicitis between April 2017 and March 2020. We reviewed 2880 patients with suspected acute appendicitis, of whom 422 patients with uncomplicated acute appendicitis met the matching criteria (ERAT 79; laparoscopic appendectomy 343), yielding 78 pairs of patients.

RESULTS

The rate of curative treatment within 1 year after ERAT was 92.1 % (95 % confidence interval [CI] 83.8 % to 96.3 %). The percentage of patients recording visual analog scale values of  ≤ 3 for pain at 6 hours after treatment was 94.7 % (95 %CI 87.2 % to 97.9 %) in the ERAT group, which was significantly higher than that in the laparoscopic appendectomy group (83.3 %; 95 %CI 73.5 % to 90.0 %). Median procedure time and median hospital length of stay were significantly lower in the ERAT group compared with the laparoscopic appendectomy group. At 1 year, the median recurrence time was 50 days (interquartile range 25-127) in the ERAT group. The overall adverse event rate was 24.4 % (95 %CI 14.8 % to 33.9 %) in the laparoscopic appendectomy group and 18.4 % (95 %CI 9.7 % to 27.1 %) in the ERAT group, with no significant difference between the two groups.

CONCLUSION

ERAT was a technically feasible method of treating uncomplicated acute appendicitis compared with laparoscopic appendectomy.