Cholangioscope-assisted endoscopic retrograde appendicitis therapy for the treatment of appendicitis complicated with fecal stones: a case report

Acute appendicitis typically occurs when the opening of the appendix is blocked, most commonly by an impacted fecalith [1]. Surgical interventions for acute appendicitis often come with the drawbacks of increased postoperative complications and a high rate of removing the healthy appendix [2]. In 2012, a minimally invasive technique known as endoscopic retrograde appendicitis therapy (ERAT) was proposed. This method involves flushing out fecal stones and eliminating the blockage through the natural passage [3]. However, ERAT relies on X-ray and involves a complex procedure [4]. Drawing inspiration from the successful application of ultraslim endoscopes in treating complex bile duct stones, we incorporated a 9-Fr cholangioscope to assist with ERAT in managing appendicitis complicated with fecal stones. In this report, we present a case wherein this innovative approach was used.

A 15-year-old girl presented with recurrent right lower abdominal pain, leading to a diagnosis of acute appendicitis with fecal stones as revealed by ultrasound. Considering the patient's young age and her expressed wish to preserve her appendix, a decision was made to proceed with cholangioscope-assisted ERAT for treatment ([Video 1]).

This video demonstrates the process of cholangioscope-assisted endoscopic retrograde appendicitis therapy for the treatment of appendicitis complicated with fecal stones.Video 1

A standard colonoscope with a 3.7-mm biopsy channel was used to reach the ileocecal region, where it was observed that the opening of the appendix appeared normal. Subsequently, a cholangioscope was inserted through the biopsy channel and successfully entered the appendix cavity ([Fig. 1]). This allowed for the visualization of a significant amount of yellow fecal stones. With direct visual guidance from the cholangioscope, the fecal stones were effectively flushed out of the appendix cavity ([Fig. 2]). After multiple flushing attempts ([Fig. 3]), it was observed that the mucosa of the appendix cavity had become smooth and the lumen was no longer obstructed ([Fig. 4]). The colonoscope and cholangioscope were then withdrawn. The pattern diagram of the treatment process for the appendicitis complicated with fecal stones in this case is shown below ([Fig. 5]). Following the surgery, the patient experienced significant relief from the symptoms and signs. During a follow-up phone call 1 month later, the patient reported no abdominal pain.

Fig. 1 Insertion of the cholangioscope into the opening of the appendix as observed during colonoscopy.

Fig. 2 With direct visual guidance from the cholangioscope, the fecal stones were effectively flushed out of the appendix cavity.

Fig. 3 After multiple flushing attempts, the fecal stones were flushed out of the appendix cavity under the colonoscope.

Fig. 4 It was observed that the mucosa of the appendix cavity had become smooth and the lumen was no longer obstructed under the cholangioscope.

Fig. 5 The pattern diagram of the treatment process for the appendicitis complicated with fecal stones in this case.

Compared to traditional ERAT, this operation does not rely on X-ray and provides a more comprehensive treatment for appendiceal fecal stones. The effectiveness and safety of ultraslim endoscope-assisted ERAT have been confirmed.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Khan S, Ali FS, Ullah S. Endoscopic retrograde appendicitis therapy: Is it really a need of the hour?. Ann Surg 2023; 277: e1-e4
• 2 Yang B, Kong L, Ullah S. et al. Endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy for uncomplicated acute appendicitis. Endoscopy 2022; 54: 747-754
• 3 Liu BR, Song JT, Han FY. et al. Endoscopic retrograde appendicitis therapy: a pilot minimally invasive technique (with videos). Gastrointest Endosc 2012; 76: 862-866
• 4 Ullah S, Ali FS, Shi M. et al. Is it time for global adoption of endoscopic retrograde appendicitis therapy of acute appendicitis?. Clin Res Hepatol Gastroenterol 2022; 46: 102049

Publikationsverlauf

Artikel online veröffentlicht:
05. Juni 2024