Endoscopic transcecal appendectomy: a novel option for the treatment of appendiceal polyps

Although most polyps involving the appendiceal orifice can be removed endoscopically,¹ removal of polyps originating inside the appendix is currently feasible only by surgical appendectomy.² We have previously reported endoscopic transcecal appendectomy for appendiceal cysts.³ In this case, we investigated the feasibility and safety of endoscopic transcecal appendectomy for the treatment of appendiceal polyps originating inside the appendix.

A 52-year-old woman with polyps originating within the appendix and involving the appendiceal orifice (Fig. 1A) declined standard surgical management but consented to endoscopic transcecal appendectomy after hearing an explanation of standard-of-care alternatives and the novel nature of the procedure. Institutional review board approval was obtained from the institution to submit this manuscript for publication.

Figure 1.

A, B, Polyps originating from the appendix and involving the appendiceal orifice. C, The cecum and affected appendix. D, The incision viewed from inside the cecum after appendix excision. E, Closure of the incision with endoclips and an endoloop. F, 2-month follow-up colonoscopy showing the recovery of the incision site.

Saline solution was used to cleanse the areas of the procedure (colon and cecum). After routine bowel preparation, an endoscope (GIT-H260; Olympus, Tokyo, Japan) was advanced, and a large polyp was seen extending from the appendiceal lumen into the appendiceal orifice (Fig. 1B; Video 1, available online at www.VideoGIE.org). After submucosal injections, a circumferential full-thickness incision was made around the appendiceal orifice with Hook (KD-620LRL; Olympus) and IT2 (KD-611L; Olympus) knives. The endoscope was advanced into the peritoneal cavity, where the cecum and an enlarged appendix were clearly seen (Fig. 1C). Endoscopic dissection of the appendix was then performed along the outer surface of the appendix, which was separated from the mesoappendix with snare traction to allow the appendix to be resected en bloc (Fig. 1D) and be pulled into the colonic lumen and removed through the anus. Homeostasis was obtained with endoscopic electric coagulation. The kissing suturing method was used to close the opening as follows: A standard single-channel endoscope was used to perform the procedures. A transparent cap was attached to the end of the endoscope to provide a constant view. A nylon loop was fixed on the tip of the transparent cap attached to the endoscope. The endoscope, with attachable nylon loop, was passed to the area of the defect, and the loop was placed into the incision. A clip was used to fix one side of the nylon loop to the edge of the full-thickness incision of the defect. A second clip was then used to anchor the same nylon loop to the opposite edge of the full-thickness incision. The nylon loop was then ligated to bring both edges together. Clips were then used to ensure complete closure of the incision (Fig. 1E).

The procedure was done by a gastroenterologist in the endoscopy room, and the procedure time was 2 hours and 20 minutes. No significant bleeding or any other adverse events occurred either during or after the procedure. The patient received a liquid diet and prophylactic antibiotics for 3 days after the procedure was completed. She was discharged 4 days after the procedure. Follow-up at 2 months confirmed complete recovery, and endoscopy showed complete healing at the incision site (Fig. 1F). No adverse events have been noted during the 10 months of follow-up. Figure 2A shows the gross specimen of the enlarged appendix, and Figure 2B shows the opened appendix with the polyp inside the appendiceal lumen. A papillary protrusion is seen near the base of the appendix and extending 1.5 cm from the head of the appendix (size: 35 mm × 20 mm). Histopathologic examination of the polyp revealed an appendiceal villous tubular adenoma with low-grade intraepithelial neoplasia (Fig. 2C and 2D).

Figure 2.

A, Gross specimen of the enlarged appendix. B, Opened appendix with a polyp inside the appendiceal lumen. C, D, Histologic view of the resected polyp revealing an appendiceal villous tubular adenoma with low-grade intraepithelial neoplasia.

Endoscopic transcecal appendectomy is a novel approach for the management of appendiceal polyps unsuitable for polypectomy and provides an option to surgical appendectomy. Laparoscopic procedures are preferred to open surgery because they are minimally invasive and cause less damage. Natural orifice transluminal endoscopic surgery (NOTES) seeks to improve on the advantages of laparoscopic surgery by totally avoiding an external incision and its associated adverse events, such as wound infection, pain, herniation, and adhesions. NOTES appendectomy seems feasible with available instruments, but it currently requires a longer operative time than laparoscopic surgery. With experience and improved techniques, the operative time for NOTES appendectomy is expected to decrease. Further validations are needed to confirm the safety and efficacy of this approach.

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Technical description of endoscopic transcecal appendectomy.