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Endoscopic retrograde appendicitis therapy: a starting point for a change of perspective in treating acute appendicitis (and beyond)Referring to Yang B et al. p.747–754
As a surgeon who grew up with the dogma that every acute appendicitis demands a surgical treatment with appendectomy, I could never have imagined myself re-evaluating the role of nonoperative treatment with antibiotics and other preserving strategies for acute appendicitis. However, as the great philosopher Arthur Schopenhauer said “There are three steps in the revelation of any truth: in the first, it is ridiculed; in the second, resisted; in the third, it is considered self-evident.” After passionately investigating the role of antibiotics as the sole treatment for uncomplicated acute appendicitis, I confess I am currently in the second step in the revelation of the truth, but very close to the third.
Randomized controlled trials and subsequent meta-analyses  have demonstrated that antibiotic therapy as a primary nonoperative management strategy for uncomplicated appendicitis in adults and children may fail within 24–48 hours in about 10 % of cases, and it is associated with a 27.7 % recurrence rate within 1 year. Lack of long-term follow-up was considered one of the main limitations to the widespread adoption of an antibiotic-first strategy until Salminen et al. published the 5-year follow-up results of the Appendicitis Acuta (APPAC) trial in 2018, reporting a 39.1 % recurrence rate within 5 years among patients who were initially treated with antibiotics . Recently, the CODA Collaborative demonstrated that in patients with uncomplicated appendicitis who received initial treatment with antibiotics, 40 % required appendectomy within 1 year and 46 % within 2 years . These long-term follow-up studies supported the feasibility of nonoperative management with antibiotics as an alternative to surgery for uncomplicated appendicitis.
“Endoscopic retrograde appendicitis therapy can also be used to manage appendiceal abscess, with good outcomes and without the need for surgery. This option might be of utmost importance in patients not suitable for surgery because of poor clinical condition or when laparoscopic expertise is unavailable.”
What role can there be, therefore, for endoscopic retrograde appendicitis therapy (ERAT), which is undoubtedly more challenging than laparoscopic appendectomy and requires preliminary bowel preparation with 2 L of polyethene glycol electrolyte solution in patients already suffering from abdominal pain caused by appendiceal inflammation and accompanied, in many, by fever and nausea? Apparently, none, especially considering that, when patients with endoluminal appendicolith on computed tomography scan are excluded from the group receiving antibiotic therapy, the immediate success rate of nonoperative treatment rises to 94 % .
However, the study by Yang et al., published in this issue of Endoscopy, demonstrates that ERAT can have a prominent space among the different treatments available for acute appendicitis . The most relevant strength of this study is the comparison of a new experimental treatment (ERAT) with what is now universally recognized as the gold standard of therapy (laparoscopic appendectomy). This allows valid conclusions to be drawn, which can be the starting point for future research. In this study, the rate of curative treatment within 1 year follow-up after ERAT was 92.1 %, which, to the best of my knowledge, is among the highest rates achieved by a nonsurgical treatment to date. In keeping with the results reported by Yang et al., a previous study by Liu et al. showed that up to 94 % of patients treated with ERAT did not have a recurrence during follow-up .
Yang et al. reported visual analog scale values of ≤ 3 for pain at 6 hours after treatment in 94.7 % of patients in the ERAT group, significantly higher than the rate in the laparoscopic appendectomy group. Median operative time and length of hospital stay were significantly lower in the ERAT group compared with the surgical group. However, this study did not consider patients with appendicoliths. This represents a relevant limitation, as when appendicoliths are present, the failure rate of conservative antibiotic treatment will increase significantly, and this scenario can represent the primary indication for ERAT .
This raises the question: is it worth opting for ERAT (also from a sustainability and generalizability perspective), when current evidence suggests laparoscopic appendectomy remains the gold standard for treatment? Emerging evidence shows that more and more parents prefer conservative management of uncomplicated appendicitis over surgical management for their children owing to fears of surgical risks and complications. Furthermore, in children, ERAT treatment could produce the most excellent benefits, in my opinion. Considering that the appendix plays an essential role in regulating immunity and the composition of the intestinal microbiome, all efforts should be made to preserve the organ in children during their period of development until we have accumulated strong evidence on the long-term consequences of appendectomy on the potentially increased risk of colorectal cancer and cardiovascular diseases.
Moreover, appendicitis is a common and serious situation during pregnancy because of the increased risk of fetal loss and perforation in the third trimester. Although laparoscopic appendectomy seems a relatively safe therapeutic option in pregnancy, it poses a specific risk of fetal loss and preterm delivery. In this regard, ERAT performed with contrast-enhanced ultrasound instead of endoscopic retrograde appendiceal radiography, or using an intraductal cholangioscope , is a promising alternative. Use of the cholangioscope allows the endoscopist to detect feces, pus moss adhesion, or other causes of luminal obstruction in the appendiceal cavity, obviating the need for X-rays and the use of contrast media. This method can also allow lithotripsy of appendicoliths, which are considered causal factors of the disease in up to 70 % of cases.
Another scenario where ERAT can play a primary role is complicated appendicitis with phlegmon or abscess. Laparoscopic appendectomy can be particularly challenging in these patients due to the perivisceral adhesions. In the past, initial nonoperative management was suggested for these patients, as conservative treatment with antibiotics was associated with significantly fewer overall complications compared with immediate appendectomy. Conversely, current evidence shows that surgical treatment of patients presenting with appendiceal phlegmon or abscess is more effective than simple antibiotics in reducing the length of hospital stay and the need for readmissions, provided that laparoscopic expertise is available . As reported by Cui , ERAT can be attempted for management of appendiceal abscess, with good outcomes and without the need for surgery. This option might be of utmost importance among patients not suitable for surgery because of poor clinical condition or when laparoscopic expertise is unavailable.
According to the great pioneers of minimal access surgery, such as Professor Sir Alfred Cuschieri, the role of surgery as we currently know it is anticipated to contract in the future, with more and more emphasis on advanced technology, new materials, flexible endoscopy, and interventional radiology. In addition, multidisciplinary disease-related treatment groups will allow the treatment of many diseases, including acute appendicitis, to be pursued optimally by endoscopy, interventional radiology, or surgery, depending on the stage of the disease.
Article published online:
07 March 2022
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- 1 Podda M, Gerardi C, Cillara N. et al. Antibiotic treatment and appendectomy for uncomplicated acute appendicitis in adults and children: a systematic review and meta-analysis. Ann Surg 2019; 270: 1028-1040
- 2 Salminen P, Tuominen R, Paajanen H. et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA 2018; 320: 1259-1265
- 3 Davidson GH, Flum DR. CODA Collaborative. et al. Antibiotics versus appendectomy for acute appendicitis – longer-term outcomes. N Engl J Med 2021; 385: 2395-2397
- 4 Salminen P, Paajanen H, Rautio T. et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA 2015; 313: 2340-2348
- 5 Yang B, Kong L, Ullah S. et al. Endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy for uncomplicated acute appendicitis. Endoscopy 2022; 54: 747-754
- 6 Liu BR, Ma X, Feng J. et al. Endoscopic retrograde appendicitis therapy (ERAT): a multicenter retrospective study in China. Surg Endosc 2015; 29: 905-909
- 7 Di Saverio S, Podda M, De Simone B. et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15: 27
- 8 Kong LJ, Liu D, Zhang JY. et al. Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy. Endoscopy 2021; DOI: 10.1055/a-1490-0434.
- 9 Cui G, Lv W, Wang J. et al. Endoscopic retrograde appendicitis therapy: a novel approach for peri-appendiceal abscess. Endoscopy 2021; DOI: 10.1055/a-1471-2871.