Single-use cholangioscope-assisted diagnosis of a large sessile serrated lesion within the appendix

Appendiceal lesions are predominantly discovered incidentally during appendectomy for other indications. Single-use cholangioscopes, used in the management of appendicitis and diverticulitis, facilitate direct visualization of the appendix and diverticula [1] [2]. We present a case of a large appendiceal lesion, adeptly diagnosed via direct visualization with a 9-Fr single-use cholangioscope (EyeMax, Micro-Tech, Nanjing, China) ([Video 1]).

Large sessile serrated lesion within the appendix, diagnosed utilizing a single-use cholangioscope and removed by endoscopic transcecal appendectomy.Video 1

A 55-year-old female patient underwent colonoscopy for chronic constipation and was found to have a whitish lesion encircling the appendiceal orifice, categorized as 0-IIa in the Paris classification and as type 1 in the Japan Narrow-band imaging Expert Team (JNET) classification ([Fig. 1]). The lesion had a well-defined outer border, extending into the appendiceal lumen. To assess the intraluminal extent of the lesion, a single-use cholangioscope was successfully introduced into the appendiceal lumen ([Fig. 2]). With water immersion, the lesion manifested as a well-defined, whitish, villiform elevation, encircling the lumen, and proximal to the appendix base. The inner border of the lesion was distinctly demarcated ([Fig. 3]). Computed tomography revealed a normal appendix. Following consultation with the patient, endoscopic transcecal appendectomy was performed ([Fig. 4]). Postoperative pathological examination confirmed a sessile serrated lesion (SSL), characterized by distorted serrated crypts, deep crypt serration, and basal crypt dilation ([Fig. 5]). The patient experienced mild abdominal pain and low grade fever after surgery but recovered quickly with antibiotic treatment and was discharged on the 5th postoperative day.

Fig. 1 Colonoscopy revealed a whitish lesion encircling the appendiceal orifice, categorized as 0-IIa in the Paris classification and as type 1 in the Japan Narrow-band imaging Expert Team (JNET) classification.

Fig. 2 A cholangioscope was inserted into the appendiceal lumen to further assess the intraluminal extent of the lesion.

Fig. 3 The inner border of the lesion was distinctly demarcated.

Fig. 4 The removed appendix.

Fig. 5 Postoperative pathological examination confirmed a sessile serrated lesion.

SSLs are most commonly found in the right-sided colon and may extend into the appendix [3]. However, diagnosing lesions involving the appendiceal lumen is challenging, as colonoscopy cannot adequately visualize the full extent of these lesions. This case represents the first instance of utilization of a single-use cholangioscope to directly confirm SSL involvement of the appendix, followed by complete endoscopic resection, and offers a valuable reference for the clinical management of similar conditions.

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Publikationsverlauf

Artikel online veröffentlicht:
05. Februar 2025

• References

• 1 Ren JZ, Huang SL, Cai J. et al. Endoscopic direct therapy for appendicitis and diverticulitis in one patient with right-sided abdominal pain. Endoscopy 2024; 56: E687-E688
• 2 Cai J, Huang SL, Lu Y. et al. First report of the use of a digital single-operator cholangioscope for endoscopic direct diverticulitis therapy. Endoscopy 2024; 56: E466-E467
• 3 Penz D, Pammer D, Waldmann E. et al. Association between endoscopist adenoma detection rate and serrated polyp detection: Retrospective analysis of over 200,000 screening colonoscopies. Endosc Int Open 2024; 12: E488-E497