Endoscopic transcecal appendectomy: a new endotherapy for appendiceal orifice lesions

Breaking boundaries: laparoscopic and endoscopic collaboration in appendectomy

BACKGROUND

The combination of endoscopy and laparoscopic assistance is gaining attention due to its minimally invasive approach and the potential to improve the safety of surgical treatment for potential malignant tumors at the base of the appendix.

METHODS

Initially, we attempted an endoscopic resection for a patient with a large adenoma in the ileocecal region, with involvement of the appendiceal orifice. However, due to intraabdominal adhesions, a smooth resection was not possible. Therefore, in collaboration with the surgical team, we proceeded with the laparoscopic release of adhesions followed by endoscopic appendectomy. The surgical site was closed using endoscopic purse-string sutures, and intestinal and intraperitoneal dual drainage tubes were placed.

RESULTS

The patient had a favorable recovery following the appendectomy, with no adverse complications. One year later, the follow-up endoscopy revealed excellent closure of the surgical site.

CONCLUSIONS

The integration of internal medicine and surgery has become an inevitable trend in the advancement of medical disciplines. The laparoscopic and endoscopic combined surgery enhances the cooperation between internal medicine and surgery, ultimately benefiting the patients. This significant attempt holds the promise of further supplementation and support from additional clinical data.

Feasibility of a novel unassisted single-channel transcolonic endoscopic appendectomy for the treatment of appendiceal lesions (with video)

BACKGROUND

Transcolonic endoscopic appendectomy (TEA) is rapidly evolving and has been reported as a minimally invasive alternative to appendectomy. We aimed to characterize the feasibility and safety of a novel unassisted single-channel TEA.

METHOD

We retrospectively investigated 23 patients with appendicitis or appendiceal lesions who underwent TEA from February 2016 to December 2022. We collected clinicopathological characteristics, procedure‑related parameters, and follow‑up data and analyzed the impact of previous abdominal surgery and traction technique.

RESULTS

The mean age was 56.0 years. Of the 23 patients with appendiceal lesions, fourteen patients underwent TEA and nine underwent traction-assisted TEA (T-TEA). Eight patients (34.8%) had previous abdominal surgery. The En bloc resection rate was 95.7%. The mean procedure duration was 91.1 ± 45.5 min, and the mean wound closure time was 29.4 ± 18.6 min. The wounds after endoscopic appendectomy were closed with clips (21.7%) or a combination of clip closure and endoloop reinforcement (78.3%), and the median number of clips was 7 (range, 3-15). Three patients (13.0%) experienced major adverse events, including two delayed perforations (laparoscopic surgery) and one infection (salvage endoscopic suture). During a median follow-up of 23 months, no residual or recurrent lesions were observed, and no recurrence of abdominal pain occurred. There were no significant differences between TEA and T-TEA groups and between patients with and without abdominal surgery groups in each factor.

CONCLUSION

Unassisted single-channel TEA for patients with appendiceal lesions has favorable short- and long-term outcomes. TEA can safely and effectively treat appendiceal disease in appropriately selected cases.

Transcecal endoscopic appendectomy for management of complex appendiceal polyps extending into the appendiceal orifice

Background and study aims Endoscopic resection of appendiceal orifice (AO) polyps extending inside the appendiceal lumen is challenging given the inability to determine polyp lateral margins and risk of appendicitis. Transcecal endoscopic appendectomy (TEA) ensures en bloc resection of these complex polyps. Patients and methods This case series includes patients who underwent TEA by a single endoscopist in the United States. Technical success was defined as achieving complete removal of the appendix along with AO polyp in an en bloc fashion. Results In total, nine patients were included (mean age 69.7 ± 9.6 years). The average appendix size was 4.07 ± 2.02 cm. Technical success was achieved in 100% of the patients. The average procedure length was 118.1 ± 44.21 minutes. The en bloc resection rate, R0 resection rate, and curative resection rates were 100%. Patients were observed for an average of 3.1 ± 1.6 days. One patient developed loculated fluid collection 9 days post procedure, which resolved on its own with oral antibiotic therapy. No other adverse events were recorded. Conclusions This was an early study of the feasibility of TEA in the United States. This novel technique, in early-stage development, is potentially safe and associated with a minimal risk profile in expert hands. Further prospective studies are needed to standardize the technique.

Resection of polyps involving the appendiceal orifice by combined endo-laparoscopic surgery: Two case reports

BACKGROUND

The management of polyps involving the appendiceal orifice (AO) presents notable challenges. Endoscopic resection is frequently hindered by operational complexities, a heightened risk of incomplete removal, and an elevated risk of procedural complications, including appendicitis. Conversely, surgical resection may entail unnecessary excision of intestinal segments, leading to potential morbidity.

CASE SUMMARY

Here, we reported two patients who presented with polyps deeply situated within the AO, with indistinct boundaries making it challenging to ensure completeness using traditional endoscopic resection. To overcome these challenges, we employed combined endo-laparoscopic surgery (CELS), achieving curative resection without postoperative complications.

CONCLUSION

The application of CELS in managing polyps involving the AO is emerging as a safe and effective treatment modality.

Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review

Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.

Small bowel obstruction - A rare complication after endoscopic transcecal appendectomy

Endoscopic transcecal appendectomy has become an alternative treatment for laparoscopic appendectomy due to its less invasive nature. Here we report a rare complication of small intestinal obstruction after endoscopic transcecal appendectomy.

Endoscopic Transcecal Appendectomy (ETA): A Literature Review on Risks and Benefits

Different colorectal lesions have attracted different procedures in their management. One of the novel approaches that have been documented in recent times is endoscopic transcecal appendectomy (ETA). ETA is an endoscopic and less invasive approach to the excision of lesions within the appendix. The appendix is also completely resected in the process. The main aim of this paper is to establish some of the benefits and risks that come with ETA. The study was conducted from a systematic review perspective using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, which governs the implementation of systematic reviews. Key considerations in the PRISMA framework used in this article include identifying the articles, screening them, and determining their eligibility and their final inclusion or exclusion based on the specified criteria. To arrive at relevant articles, some keywords were used in the various search engines of the databases that were consulted. Some of the keywords that were used included ETA, endoscopic mucosal resection (EMR), endoscopic full-thickness resection (EFTR), endoscopic submucosal dissection (ESD), adverse events, risks, safety, efficacy, and the appendiceal orifice. It was established that the key benefits of the ETA include the ability to avoid postoperative appendicitis and residual lesions in tissue. On the other hand, some risks that could come with ETA were found to include potential tumor seeding and postoperative bleeding. However, the key study limitation is that most of the referenced studies in this literature review are retrospective case series and case reports that are prone to selection bias. Furthermore, most ETA procedures in this literature review were performed by a few experienced and highly skilled endoscopists, making the ability to make such results generalizable to all endoscopists and patient populations a debatable issue. In the future, there is a need for more multicenter and large studies to be conducted with longer follow-up periods to ascertain the results obtained in this review. This will ensure a more informed decision-making process for or against ETA implementation in real-world clinical environments.