Saif Ullah

INTRODUCTION: Endoscopic retrograde appendicitis therapy (ERAT) is a new and noninvasive endoscopic technique originally developed by Liu in China for the management of acute appendicitis. Although its safety and efficacy have been extensively validated in adult populations, evidence regarding its use in pediatric patients remains scarce. The aim of this study was to evaluate the clinical outcomes of ERAT in pediatric appendicitis. METHODS: This retrospective study analyzed pediatric patients who underwent ERAT in our hospital between January 2019 and August 2022. Data collected included patient demographics, the success rate of ERAT, and the duration of hospital stay. In addition, recurrence rates were assessed during the follow-up to evaluate the safety and long-term efficacy of the procedure. RESULTS: A total of 73 patients were included in this study. Appendiceal intubation was successfully performed in 72 of 73 patients (98.63%). Among these patients, 72.22% of patients had appendiceal fecal stones or food residue, and the success rate of stone removal was 94.23%. Overall, the clinical success rate of the procedure was 91.78%. The median procedure time was 22 minutes (interquartile range 15–36.5), and the median postoperative hospital stay was 2 days (interquartile range 1–4). During the 1-year follow-up, 14.92% of the patients had recurrent appendicitis. DISCUSSION: ERAT seems to be a safe and effective alternative approach to treat appendicitis in pediatric patients, especially for obstructive appendicitis with appendicolith.

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Acute appendicitis is a common abdominal surgical emergency. Although appendectomy is effective treatment of acute appendicitis, it is associated with a range of complications and carries the risk of negative appendectomy. Anders et al reported the association between appendectomy and advanced colorectal neoplasia (aCRN) in patients with inflammatory bowel disease (IBD).¹ They concluded that patients with ulcerative colitis (UC) who underwent appendectomy after their UC diagnosis experienced a higher rate of aCRN compared with patients with UC and no appendectomy. The rate of aCRN was not higher for patients undergoing appendectomy prior to a UC diagnosis or for patients with Crohn’s disease (CD), regardless of the timing of appendectomy. Although the current management (open or laparoscopic appendectomy) bodes well for a majority of patients with acute appendicitis (AA), 15% to 30% of patients are subjected to negative appendectomies which are an unneeded, invasive intervention with its associated risks.^2,3 Negative appendectomies also contribute to the financial burden on the patient, hospital system, and society.⁴ In addition, appendectomy has been associated with an increased risk of colorectal cancer, gallstones, and cardiovascular diseases resulting in increasing advocacy for organ preserving management of AA.⁵ Whether inflammatory bowel disease and Parkinson’s disease are increased among those with appendectomy is debated.^6,7 The potential role of the appendix prevention of a myriad of disease processes has fostered interest in nonoperative management of AA and paved the way for evolution of new management modalities.

Objectives: To compare the effectiveness and safety of transgastric and transrectal pure natural orifice transluminal endoscopic surgery (NOTES) for cholecystolithotomy.Methods: This was a single‐center retrospective comparative study of consecutive patients who underwent pure NOTES for either transrectal or transgastric gallbladder‐preserving cholecystolithotomy between September 2017 and April 2020. Patients with symptomatic cholelithiasis were assigned for transrectal or transgastric NOTES based on the patients’ choice. Treatment success, postoperative pain, peritonitis, time to resume normal diet, and duration of hospitalization were compared.Results: The technical success rate was 100%. Forty‐eight patients underwent successful NOTES cholecystolithotomy via the transrectal (n = 26) or transgastric route (n = 22). One (3.8%) patient in the transrectal NOTES group experienced postoperative abdominal pain compared to 6 (27.3%) in the transgastric NOTES group (P = 0.04). Fever and bile peritonitis developed in one (3.8%) patient in the transrectal NOTES group versus 8 (36.4%) in the transgastric NOTES group (P = 0.005). A postoperative fluid diet was commenced at 6 h with the transrectal approach versus on day 3 for the transgastric NOTES group. The mean postoperative hospitalization for transrectal and transgastric NOTES groups was 4.5 days versus 7 days (P = 0.001). Three patients in the transgastric NOTES group developed postoperative gastric fistula.Conclusions: Transrectal NOTES has advantages over transgastric NOTES, including preserved spatial orientation, relatively easier removal of specimens, early food intake, shorter hospitalization, fewer postoperative complications and less pain. Multicenter clinical trials with long‐term follow‐up are needed to confirm the safety and efficacy of both approaches.

Dear Editor

Dear Editor

Although laparoscopic appendectomy is the common intervention for uncomplicated acute appendicitis, there are risks¹. Guidelines from the World Society of Emergency Surgery suggest that antibiotic therapy is an option², but recurrence is 15 to 39 percent at 5 years³. A mini-invasive technique called endoscopic retrograde appendicitis treatment (ERAT) was developed for uncomplicated appendicitis instead of antibiotics or surgery⁴. ERAT aims to relieve the obstruction or stenosis of the appendiceal lumen, to prevent recurrent episodes of the disease (92 to 95 percent have not had a recurrence to date)^5–7. This multicentre study assessed ERAT versus antibiotics for the treatment of uncomplicated appendicitis. Data on adult patients treated with ERAT or antibiotics for imaging-confirmed uncomplicated appendicitis from five centres in China (May 2018 to June 2020) was assessed retrospectively. The ERAT procedure was performed as described⁴ (Appendix S1). The antibiotic group received intravenous metronidazole 500 mg q8h combined with ceftriaxone 2 g q12h, cefoperazone/sulbactam 2 g q12h, or piperacillin–tazobactam 4.5 g q8h. Oral antibiotics (metronidazole 500 mg q8h with levofloxacin 500 mg q24h, ciprofloxacin 500 mg q8h, or amoxicillin–clavulanic acid 625 mg q8h) were taken after a minimum 72 hours of intravenous antibiotics. Patients could take analgesics as needed. Appendicectomy was recommended if there was worsening pain or white cell count.

A 61-year-old man was admitted for management of gallbladder polyps. The patient refused cholecystectomy as he wished to retain his gallbladder, but consented to undergo pure flexible endoscopic gallbladder-preserving polypectomy. With the patient under general anesthesia, a colonoscope was advanced into the colon for colonic cleansing, following which a detachable colonic exclusion balloon was placed in the transverse colon and inflated to 3.0–3.5 cm in diameter to occlude the transverse colonic lumen. Disinfection of the distal colon was then completed with a 0.1 % povidone–iodine solution ([Fig. 1]). A disinfected colonoscope with a transparent cap attached on its tip was inserted and an incision was made on the right anterior wall of the rectum using a HookKnife and IT Knife. The endoscope was passed through the incision and advanced upward until the gallbladder was identified. A 1.5-cm full-thickness longitudinal incision was created in the gallbladder wall, and the tip of the endoscope was inserted into the gallbladder cavity. Several small superficial polyps were seen and resected using an electrocoagulation snare ([Fig. 2 a, b]). This left one invasive, deep, and large (1 × 0.8 × 0.3 cm) pedunculated polyp, which was removed by endoscopic submucosal dissection ([Video 1]). The technique used included a circular incision ([Fig. 2 c]) around the lesion using the HookKnife and then resection using a snare ([Fig. 2 d]). After the resection had been completed ([Fig. 2 e]), the gallbladder and rectal incisions were closed with endoclips ([Fig. 2 f]). Video 1 Pure flexible endoscopic gallbladder-preserving polypectomy, including endoscopic submucosal dissection of the largest polyp, is performed to manage gallbladder polyps. The tissue specimen was sent for histopathology and showed cholesterol polyps with chronic hyperplasic fibrous connective tissue inflammation. The patient received levofloxacin (0.5 g four times daily) and cefoperazone–sulbactam (2 g four times daily) intravenously for 3 days after the procedure. He was discharged on day 4 and has remained well during 15 months of follow-up. This case illustrates that gallbladder-preserving polypectomy may be a feasible and minimally invasive technique for the management of patients with large gallbladder polyps. Although this procedure is unlikely to replace cholecystectomy, it could prove useful for patients wanting to avoid surgical resection. Endoscopy_UCTN_Code_TTT_1AT_2AB Article published online: 21 April 2023 © 2023. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Objective: To compare the efficacy and feasibility of endoscopic retrograde appendicitis therapy (ERAT) with appendectomy for treating acute uncomplicated appendicitis.Methods: This was a prospective multicenter randomized trial in which consecutive patients were randomized at a ratio of 1:1 to receive either ERAT or appendectomy. The outcomes included technical success rate, procedure time, postoperative pain relief, postoperative analgesic use, time to soft diet intake, length of postoperative hospital stay, postoperative complications, and recurrence rate.Results: From August 2013 to December 2015, 110 patients with acute uncomplicated appendicitis were randomized to ERAT or appendectomy. The technical success rate was 94.55% for ERAT compared with 100% for appendectomy. Recurrence of appendicitis within 3‐year follow‐up occurred in 8 patients following ERAT. Postoperative abdominal pain was less frequent with ERAT than with appendectomy (21.15% [11/52] vs 87.27% [48/55], P < 0.001). Soft diet intake begun earlier after ERAT than appendectomy (6 h vs 48 h, P < 0.001), and post‐procedure hospital stay was shorter (3 days vs 5 days, P < 0.001), as was the use of analgesics postoperatively (9.09% vs 49.09%, P < 0.001).Conclusions: ERAT is a feasible, safe, and effective alternative approach for the management of acute uncomplicated appendicitis. Compared with appendectomy, advantages of ERAT include no skin wound, organ preservation, reduced postoperative pain, early food intake, quick recovery, fewer postoperative complications, and shorter post‐procedure hospitalization. The unsolved problem related to ERAT is the recurrence of appendicitis.