Diagnostic and therapeutic value of appendoscope-assisted endoscopic retrograde appendicitis therapy

Abstract

Background and study aims

The appendoscope, derived from the peroral digital single-operator cholangioscope, is an endoscopic device enabling direct visualization of the appendix lumen for diagnostic or therapeutic purposes. This study aimed to investigate diagnostic and therapeutic efficacy of appendoscope-assisted endoscopic retrograde appendicitis therapy (ERAT) in patients with appendicitis.

Patents and methods

A total of 131 patients were enrolled in the study, with 125 included in the final analysis. Patient demographics, procedure success, abdominal pain resolution, appendoscope manifestations, treatment strategies, procedure time, duration of antibiotic use, postoperative hospital stay, and comorbidities were recorded. Complications and recurrences were followed up. These variables were subsequently analyzed to evaluate efficacy of appendoscope-assisted ERAT.

Results

The technical success rate of appendoscope-assisted ERAT was 98.5%, and the clinical success rate was 100%. Appendoscope visual manifestations included appendicolith (76.8%, n = 96), stenosis (16.8%, n = 21), foreign body (6.4%, n = 8), mucosal inflammation (13.6%, n = 17), and perforation (3.2%, n = 4), with these findings occurring individually or in combination. Abdominal pain disappeared within 12 hours post-procedure in 79% of patients (n = 99). Average procedure time was 50.3 ± 18.9 minutes. Antibiotic therapy duration was less than 2 days in 39% of patients (n = 49), whereas 19% (n = 24) received no antibiotics. Average postoperative hospital stay was 1.9 ± 1.4 days. Concomitant intestinal lesions were identified in 16 patients (12.8%). Recurrence occurred in 4.8% of patients (n = 6) during a 4- to 16-month follow-up. No complications were recorded.

Conclusions

Appendoscope-assisted ERAT is a feasible, accurate, safe, and effective alternative for diagnosis and treatment of appendicitis.

Keywords

Endoscopy Lower GI Tract - Diagnosis and imaging (inc chromoendoscopy, NBI, iSCAN, FICE, CLE...) - Endoscopy Upper GI Tract - Dilation, injection, stenting - GI surgery

Publikationsverlauf

Eingereicht: 14. März 2025

Angenommen nach Revision: 23. Juni 2025

Accepted Manuscript online:
07. Juli 2025

Artikel online veröffentlicht:
29. Juli 2025

• References

• 1 Krzyzak M, Mulrooney SM. Acute appendicitis review: Background, epidemiology, diagnosis, and treatment. Cureus 2020; 12: e8562
• 2 Zhang A, Fan N, Zhang X. et al. Endoscopic retrograde appendicitis therapy. Therap Adv Gastroenterol 2024; 17: 17562848241275314
• 3 Flum DR, Davidson GH, Monsell SE. et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med 2020; 383: 1907-1919
• 4 Talan DA, Saltzman DJ, Mower WR. et al. Antibiotics-first versus surgery for appendicitis: a US pilot randomized controlled trial allowing outpatient antibiotic management. Ann Emerg Med 2017; 70: 1-11
• 5 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
• 6 Herrod PJJ, Kwok AT, Lobo DN. Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis. BJS Open 2022; 6: zrac 100
• 7 Di Saverio S, Birindelli A, Kelly MD. et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016; 11: 34
• 8 Flum DR. Clinical practice. Acute appendicitis--appendectomy or the "antibiotics first" strategy. N Engl J Med 2015; 372: 1937-1943
• 9 Collard MK, Bardin J, Laurin M. et al. The cecal appendix is correlated with greater maximal longevity in mammals. J Anat 2021; 239: 1157-1169
• 10 Vitetta L, Chen J, Clarke S. The vermiform appendix: an immunological organ sustaining a microbiome inoculum. Clin Sci (Lond) 2019; 133: 1-8
• 11 Randal Bollinger R, Barbas AS, Bush EL. et al. Biofilms in the large bowel suggest an apparent function of the human vermiform appendix. J Theor Biol 2007; 249: 826-831
• 12 Liu Z, Ma X, Zhu C. et al. Risk of colorectal cancer after appendectomy: A systematic review and meta-analysis. J Gastroenterol Hepatol 2023; 38: 350-358
• 13 Kim SY, Lim H, Park B. et al. Increased risk of gallstones after appendectomy: A longitudinal follow-up study using a national sample cohort. Medicine (Baltimore) 2020; 99: e20269
• 14 Zhang L, Hu C, Zhang Z. et al. Association between prior appendectomy and the risk and course of Crohn's disease: A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2023; 47: 102090
• 15 Flum DR, Morris A, Koepsell T. et al. Has misdiagnosis of appendicitis decreased over time? A population-based analysis. JAMA 2001; 286: 1748-1753
• 16 Chaochankit W, Boocha A, Samphao S. Negative appendectomy rate in patients diagnosed with acute appendicitis. BMC Surg 2022; 22: 404
• 17 Ma KW, Chia NH, Yeung HW. et al. If not appendicitis, then what else can it be? A retrospective review of 1492 appendectomies. Hong Kong Med J 2010; 16: 12-17
• 18 Tao L, Wang H, Guo Q. et al. Appendicoscopy using single-operator cholangioscope in the management of acute obstructive appendicitis: a novel alternative (with video). Gastrointest Endosc 2024; 100: 532-536
• 19 Kong LJ, Liu D, Zhang JY. et al. Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy. Endoscopy 2022; 54: 396-400
• 20 Jeffrey Jr RB, Laing FC, Townsend RR. Acute appendicitis: Sonographic criteria based on 250 cases. Radiology 1988; 167: 327-329
• 21 Memon ZA, Irfan S, Fatima K. et al. Acute appendicitis: diagnostic accuracy of Alvarado scoring system. Asian J Surg 2013; 36: 144-149
• 22 Liu BR, Kong LJ, Ullah S. et al. Endoscopic retrograde appendicitis therapy (ERAT) vs appendectomy for acute uncomplicated appendicitis: A prospective multicenter randomized clinical trial. J Dig Dis 2022; 23: 636-641
• 23 Feng S, Ling K, Zhang T. et al. Application of an appendoscope in chronic appendicitis. Endoscopy 2022; 54: E296-E297
• 24 Song M, Ullah S, Liu B. Endoscopic retrograde appendicitis therapy for treating periappendiceal abscess: first human case report. Am J Gastroenterol 2021; 116: 1119
• 25 Kanat BH, Solmaz ÖA, Bozdağ P. et al. Chronic appendicitis: the process from pre-diagnosis to pathology. Eur Rev Med Pharmacol Sci 2021; 25: 7898-7902
• 26 Mahida JB, Lodwick DL, Nacion KM. et al. High failure rate of nonoperative management of acute appendicitis with an appendicolith in children. J Pediatr Surg 2016; 51: 908-911
• 27 Shen Z, Sun P, Jiang M. et al. Endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy versus open appendectomy for acute appendicitis: a pilot study. BMC Gastroenterol 2022; 22: 63
• 28 Yang B, Kong L, Ullah S. et al. Endoscopic retrograde appendicitis therapy versus. laparoscopic appendectomy for uncomplicated acute appendicitis. Endoscopy 2022; 54: 747-754