Post written by Margaret G. Keane, MBBS, MSc, from the Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland.
In our video, we describe the case of a 52-year-old man who was referred to our institution for the management of a 1.5-cm semi-pedunculated polyp that was found during a routine screening colonoscopy. The polyp was biopsied and was found to be a tubular adenoma. Due to the position of the polyp, which extended in to the appendiceal lumen, we decided to pursue EFTR rather than EMR. Recognizing the risk of postprocedural appendicitis with EFTR of appendiceal lesions, we elected to combine the technique with prophylactic appendiceal retrograde intraluminal stenting or PARIS.
The procedure was performed with a pediatric colonoscope with a cap. After advancing the colonoscope to the cecum, the endoscope was positioned close to the appendix for stability during cannulation. The polyp could be seen on the edge of the valve of Gerlach and prolapsing into the appendiceal lumen. An ERCP sphincterorome preloaded with a 0.035-inch guidewire was introduced into the appendiceal orifice. The guidewire was advanced into the appendiceal lumen under fluoroscopic guidance. A 7F x 5-cm straight plastic biliary stent was then inserted over the guidewire. The colonoscope was then removed, loaded with the FTRD device, and once again advanced to the cecum. After deployment of the over-the-scope clip beneath the polyp, it was resected, retrieved, and sent to pathology. The patient was discharged home the next day, and pathology showed fragments of tubular adenoma. The patient developed no signs of appendicitis and returned for a colonoscopy and appendiceal stent removal 3 weeks later.
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are highly effective methods for resecting colonic polyps but are ineffective when removing polyps arising from the appendiceal orifice. Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD; Ovesco, Tuebingen, Germany) is a favorable approach for the management of such lesions, as it overcomes the potential risk of perforation or incomplete resection by deployment of an over-the-scope clip (OTSC) beneath the polyp prior to resection. However, appendicitis is a known adverse event seen in up to 50% of cases. Endoscopic stenting of the appendix has been described previously for the treatment of uncomplicated acute appendicitis.
Appendicitis after EFTR probably arises due to the OTSC restricting outflow from the appendix. The peak onset is within 1-2 weeks of the FTRD procedure and prescribing periprocedural antibiotics does not affect the rate of appendicitis or need for appendectomy. Prophylactically placing an appendical stent prior to EFTR is a straightforward endoscopic procedure that allows internal drainage of the appendix.
Temporary stenting of the appendiceal lumen as outlined in this case, has the potential to maintain drainage of the appendix during the periprocedural period and avoiding the risk of appendicitis associated with EFTR. The promising findings outlined in this case will need to be validated in prospective studies, but the technique is likely to be useful in high-risk surgical candidates and those with hostile abdomens.
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