Endoscopic management of multiple sessile serrated lesions in both the ileocecal region and the appendix cavity

A 54-year-old woman with no symptoms underwent a colonoscopy due to a family history of colon cancer. The procedure revealed a 2.0-cm laterally spreading tumor in the ileocecal region, adjacent to the appendiceal orifice ([Fig. 1]). Abdominal computed tomography (CT) demonstrated a normal appendix. To further examine the appendix, a cholangioscope was utilized ([Fig. 2]), which unveiled two areas of rough, granular mucosa within the appendix cavity, deemed abnormal ([Fig. 3]). After obtaining informed consent, endoscopic removal of both the ileocecal lesion and the appendix was performed ([Video 1]).

Fig. 1 The colonoscopy revealed a 20-mm laterally spreading tumor in the ileocecal region.

Fig. 2 A cholangioscope was utilized to further examine the appendix.

Fig. 3 The rough, granular mucosa was unveiled within the appendix cavity.

Endoscopic removal of the ileocecal lesion and the appendix.Video 1

Following submucosal injection, the ileocecal lesion was excised entirely using a GoldKnife (Micro-Tech, Nanjing, China), employing the endoscopic submucosal dissection technique. Subsequently, an endoscopic full-thickness resection of the cecum tissue surrounding the appendiceal orifice was executed. An IT knife and GoldKnife were used to dissect the mesoappendix, proceeding along the appendix from its base. During the dissection, an elastic band was used to secure the appendix to the intestinal wall, facilitating traction. Once fully detached, the appendix was extracted from the intestinal lumen using a snare device ([Fig. 4]). After thorough hemostasis, the wound was completely sealed using a StarClip (HCCD-0-195-M-C, Micro-Tech).

Fig. 4 The removed appendix.

Postoperative histopathological analysis confirmed the presence of sessile serrated lesions (SSLs) in the ileocecal lesion and the rough areas within the appendix cavity, characterized by distorted serrated crypts, deep crypt serrations, and basal crypt dilation ([Fig. 5]). The patient was kept fasting for 72 hours post-procedure and was administered antibiotic therapy. She experienced mild abdominal pain post-surgery but made a swift recovery and was discharged 5 days after the procedure

Fig. 5 Pathology of the lesion within the appendix cavity.

Sessile serrated lesions are predominantly located on the right side of the colon and may extend to the appendix [1]. When confined entirely within the appendiceal lumen, these lesions are nearly undetectable by conventional colonoscopy. This case highlights the importance of considering the presence of SSLs in the appendix cavity when such lesions are identified in the colon.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• Reference

• 1 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

Publication History

Article published online:
02 October 2024