Endoscopic submucosal dissection (ESD) of cecal tumors extending into the appendiceal
orifice is technically challenging and associated with a high risk of perforation
and post-ESD appendicitis [1]
[2]. Here, we report a novel technique for preventing post-ESD appendicitis: the appendix
anchoring approach ([Video 1]).
Appendix anchoring approach: A novel technique for the prevention of appendicitis
post-appendiceal endoscopic submucosal dissection.Video 1
A 95-year-old man with no history of appendectomy presented with a 60-mm laterally
spreading tumor (LST) in the cecum that completely covered and extended into the appendiceal
orifice ([Fig. 1]). The LST was resected by ESD using the water pressure and countertraction method
[3]
[4]
[5]. After circumferential incision, submucosal dissection around the appendix was performed
to the extent possible, and the appendix was exposed beneath the lesion. Sufficient
traction was achieved in the appendix when a traction clip was applied. The dissected
appendiceal mucosa was inverted into the cecum by continuous traction, enabling the
submucosal dissection to continue toward the tip of the appendix ([Fig. 2]). However, a minor appendiceal mucosal tear occurred due to excessive tension. Through
the tear, the appendiceal lumen was lined with non-neoplastic mucosa, leading to the
decision to resect the appendix at that level. However, this raised concerns regarding
the burial of the residual appendiceal mucosa, potentially increasing the risk of
obstructive appendicitis ([Fig. 3]
a,b). Therefore, the distal appendix at the site of the mucosal tear was grasped with
a clip, and only the semi-circumference of the appendix was anchored to the cecal
wall to maintain luminal patency ([Fig. 3]
c,d). The lesion was resected en bloc by cutting immediately above the clip. The fixed
appendiceal lumen remained patent and was expected to be the drainage lumen. No adverse
events occurred intra- or postoperatively. The tumor was histologically diagnosed
as an intramucosal adenocarcinoma and curative resection was achieved.
Fig. 1 Endoscopic images of the tumor. a A 60-mm laterally spreading tumor in the inferior aspect of the cecum that completely
covered and extended into the appendiceal orifice. b Indigo carmine chromoendoscopy image. The distal margin of the laterally spreading
tumor within the appendix could not be visualized endoscopically.
Fig. 2 Process of submucosal dissection within the appendix. a–f Images showing the progression of submucosal dissection within the appendix. The
dissected appendiceal mucosa was inverted into the cecum by continuous traction.
Fig. 3 Schema of appendiceal resection at a level proximal to the tip. a Resection of the appendix at the level of the mucosal tear. b Resecting the appendix at the level of the mucosal tear could lead to the burial
of the residual appendiceal mucosa, potentially increasing the risk of obstructive
appendicitis. c The distal appendix at the site of the mucosal tear was grasped using a clip. To
preserve luminal patency, only a semi-circumference of the appendix was anchored to
the cecal wall. d En bloc resection by cutting just above the clip.
The appendix anchoring approach is a simple procedure that may prevent post-ESD appendicitis
when the appendix is resected proximal to the tip.
Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
