Endoscopic mucosal resection (EMR) of lesions involving the appendiceal orifice is
technically challenging because of poor endoscopic access due to the narrow lumen
of the appendix. This brings a high risk of perforation because of the thin colonic
wall at the base of the cecum.
In expert hands, EMR is a safe and effective treatment of laterally spreading tumors
(LST) surrounding the appendiceal orifice, but if more than 50 % of the circumference
of the orifice is involved, surgery should be considered [1].
Underwater EMR (UEMR), described by Binmoeller et al. in 2012 [2], has been shown to enable safe resection of appendiceal orifice lesions, especially
those limited to the rim. It allows endoscopic resection without previous submucosal
injection, as the colonic lesion “floats” in a lumen filled with water, making lesions
involving the appendiceal orifice more accessible to endoscopic resection [3].
Herein we present a case of a 73-year-old man referred to our unit for treatment of
a “donut”-shaped granular-type LST completely encircling the AO. No deep submucosal
invasion signs were observed ([Fig. 1]).
Fig. 1 “Donut”-shaped laterally spreading tumor under narrow-band imaging.
UEMR was performed using room-temperature sterile water to fill the lumen and a 15-mm
stiff, rounded snare (Captivator II; Boston Scientific, Voisins-le-Bretonneux, France)
through a single-channel colonoscope using AutoCut Mode (VIO 3; Erbe Elektromedizin,
Tübingen, Germany) ([Video 1]). During the procedure, deep extension into the appendiceal orifice was observed.
After a combination of air suction and more water infusion, the deep residual tissue
everted, making it accessible for snare resection.
Video 1 Underwater endoscopic mucosal resection of a “donut”-shaped laterally spreading tumor
involving the appendiceal orifice.
The procedure lasted 24 min and the patient was discharged after 2 h without complications.
The histological diagnosis was low-grade dysplasia adenoma.
Follow-up colonoscopy after 6 months showed no residual lesion ([Fig. 2]).
Fig. 2 Postresection scar after 6 months showing no residual tissue. Narrow-band imaging.
UEMR may allow safe complete endoscopic resection in cases of nonmalignant lesions
with deep extension into the appendiceal orifice.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
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