Endoscopic full-thickness resection for polyps involving the appendiceal orifice: not yet ready for prime time

Ichkhanian et al. recently reported their multicenter international experience and outcomes following endoscopic full-thickness resection (EFTR) of polyps involving the appendiceal orifice using a full-thickness resection device (FTRD) [1]. Appendicitis occurred in one in every six cases.

EFTR involves extended dissection skills to remove polyps involving the appendiceal orifice. Use of the FTRD is a novel procedure with two potential risks/problems: first, it is not possible to exclude a polyp inside the lumen of the appendix which, if present, provides a residual risk of obstruction; second, blocking the orifice of the appendix may result in appendicitis or an appendiceal cyst. The authors report that one in six of their cases developed appendicitis, which makes the method less attractive. Appendicitis likely occurred because the mucous membrane of the appendiceal cavity has secretory function and the opening of the appendix was blocked. Obstruction in outflow results in a fluid collection within the cavity, which may result in either an appendiceal cyst or, if bacteria are present, appendicitis. Although the authors did not report any appendiceal cysts, cysts are typically a long-term complication. Surgery for cyst removal may be more difficult after use of the FTRD because it uses an over-the-scope clip system.

An alternative approach for polyps involving the appendiceal orifice is endoscopic transcecal appendectomy [2–5]. Endoscopic transcecal appendectomy eliminates lesions both around the orifice and inside the lumen of the appendix, whereas traditional appendectomy is limited to polyps within the lumen of the appendix. Kong et al. reported the endoscopic management of appendicitis using a single-operator cholangioscopy system, which allowed detailed examination of the entire appendiceal cavity during colonoscopy [6]. Use of a single-operator cholangioscope or ultrafine endoscope can detect the presence of polyps inside the appendiceal lumen and help to decide the best strategy for management to avoid complications, as well as any extra financial burden on the patients.

Publication History

Article published online:
25 May 2022

• References

• 1 Ichkhanian Y, Barawi M, Seoud T. et al. Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a multicenter international experience. Endoscopy 2022; 54: 16-24
• 2 Liu BR, Ullah S, Ye L. et al. Endoscopic transcecal appendectomy: a novel option for the treatment of appendiceal polyps. VideoGIE 2019; 4: 271-273
• 3 Yuan XL, Cheung O, Du J. et al. Endoscopic transcecal appendectomy. Endoscopy 2019; 51: 994-995
• 4 Liu BR, Song JT, Liu ZH. et al. Endoscopic transcecal appendectomy: the first human case report. Gastrointest Endosc 2018; 87: 311-312
• 5 Guo L, Ye L, Feng Y. et al. Endoscopic transcecal appendectomy: a new endotherapy for appendiceal orifice lesions. Endoscopy 2021; DOI: 10.1055/a-1675-2625.
• 6 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.