Post written by Yang-Bor Lu, MD, from the Department of Digestive Diseases, Digestive Endoscopy Center, Xiamen Chang Gung Hospital, Xiamen, China.

We performed single-operator endoscopic direct appendiceal therapy (EDAT) by first using a slim endoscopic ultrasound (EUS) miniprobe (Olympus UM-2R, Tokyo, Japan) to map the appendiceal axis then steering a disposable cholangioscope (VedVision, TY-ISS-L31; Vedkang, Changzhou, China) coaxially into the lumen. Targeted lavage with 500 mL saline and 200 mL metronidazole solution cleared purulent debris. Pain and inflammatory markers normalized within 48 hours, and no relapse occurred at 3 months, confirming that miniprobe-guided EDAT offers a precise, radiation-free alternative for uncomplicated appendicitis.

Although EDAT/endoscopic retrograde appendiceal therapy (ERAT) is increasingly reported, novices still struggle to align the cholangioscope with the appendiceal lumen, a difficulty that prolongs procedures and raises failure rates, to our knowledge. To address this, we used a slim, through-the-scope miniprobe EUS as a near-real-time navigator to delineate the appendiceal axis before cannulation, obviating fluoroscopy.

In this patient, EUS guidance enabled single-pass, coaxial cannulation and effective lavage. To our best knowledge, this is the first reported case of miniprobe EUS-guided EDAT. These early findings suggest the approach could ease training and improve success, a hypothesis that warrants validation in larger series.

Our case shows that a slim, through-the-scope EUS miniprobe overcomes ERAT’s main drawback—the blind fluoroscopy-based search for the appendiceal lumen—by providing real-time “road-mapping” that enabled single-pass cannulation and lavage without radiation. This converts ERAT into a fully endoscopic, image-guided procedure that any center familiar with colorectal EUS or cholangioscopy can adopt. The technique may shorten the learning curve, improve success in difficult anatomies, and offer a safer option for patients unfit for surgery.

Next steps are a prospective series to measure cannulation time, success, and safety against standard ERAT, followed by multicenter and cost-effectiveness studies to support guideline inclusion.

Radial-scan EUS could potentially detect appendicoliths, an untested application that may explain some post-ERAT recurrences. Its wider field and deeper penetration might reveal shadowing stones, guide targeted lavage or lithotripsy, and verify clearance in real time. Prospective studies are required to confirm this value and refine when to re-treat or refer for surgery.

Endoscopic ultrasound image identifying the orientation of the appendiceal lumen relative to the appendiceal cavity (red arrow) and guiding the corresponding direction for appendicoscopic intubation (blue arrow).

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