With the continuous development of minimally invasive concepts and techniques, the surgery has become more and more minimally invasive, and many organs can be preserved without removing them. Current minimally invasive surgical procedures for appendicitis include laparoscopic appendectomy and natural orifice surgical appendectomy (NOTES surgery). However, all procedures involve the removal of the appendix.
Inspired by the endoscopic treatment of septic cholangitis, a new and innovative approach to the treatment of appendicitis was proposed and named – endoscopic retrograde appendicitis treatment (endoscopic
This method does not open the abdomen, does not cut the appendix, and achieves the treatment of appendicitis by addressing the etiology of acute appendicitis with complete preservation of the appendix and its function.
Surgical approach.
ERAT is currently indicated for the treatment of acute edematous, suppurative appendicitis.
1. Endoscopic appendiceal cannulation
The normal appendiceal opening is covered by a Gerlach’s flap.
The Gerlach’s flap is pushed open and the catheter is inserted through the important auxiliary role of the transparent cap at the front of the endoscope, as shown in the figure, the yellow arrow shows the Gerlach’s flap
When the catheter is successfully inserted into the appendiceal lumen, a milky white pus gushing out from the lumen is visible, as shown in Fig.
2.Endoscopic retrograde appendicography (ERA)
We believe that ERA is the best method to diagnose appendicitis and can effectively exclude negative appendicitis, including tumor appendicitis, etc.
After successful intubation, contrast is injected into the appendiceal cavity under X-ray, and the position, shape, length and intracavity of the appendix are shown, and appendiceal perforation can be determined if the contrast is spilled, as shown below
The arrow above shows the filling defect shadow in the appendiceal cavity, which is a fecal stone, and the whole appendix morphology in the oval shape.
3.Appendiceal lumen irrigation and appendiceal stent placement
After ERA examination, we can determine whether there is stenosis or obstruction in the appendiceal cavity; if there is no obvious stenosis or obstruction in the appendiceal cavity, appendiceal flushing is sufficient, and sterile saline and antibiotics are used as the flushing solution.
If appendiceal stenosis is found, then a stent should be placed and the appendiceal cavity should be fully flushed.
(Stent mockup)
4. Appendiceal fecal stone removal
If fecal stone is found in ERA, appendiceal balloon or mesh basket fecal stone removal is performed, the principle of which is like endoscopic retrograde cholangiopancreatography (ERCP).
(mockup)
The following diagram shows balloon lithotripsy, the small arrow shows the fecal stone removed.
The following figure shows mesh basket lithotripsy with arrows showing fecal stones.
Postoperative review: it is seen that the edema of the appendiceal opening has completely disappeared and there is no discharge, Figure A,B
Conclusion
The patient underwent ERAT with immediate relief of abdominal pain without hospitalization and was able to go home or return to work. During the follow-up period of 3 months-3 years, there was one case of recurrent appendicitis, and the patient underwent ERAT again (the patient volunteered for ERAT).
ERAT is an effective minimally invasive treatment procedure for acute appendicitis, which avoids surgical procedures and surgery-related complications, preserves the appendix and its function, and has a low recurrence rate. In particular, ERA can be an important test for the diagnosis of acute appendicitis (among others), and may even become the gold standard for screening in the future. Of course, this technology is currently in its infancy and requires long-term large sample studies and clinical multicenter randomized controlled trials, etc., to further validate its effectiveness and safety.