Advertisement

Prophylactic appendiceal retrograde intraluminal stent placement (PARIS)

Open AccessPublished:October 14, 2021DOI:https://doi.org/10.1016/j.vgie.2021.09.006

      Video

      Loading ...
      (mp4, 179.13 MB)
      Download video

      Video of the prophylactic appendiceal retrograde intraluminal stent placement technique.

      Abbreviations:

      EFTR (endoscopic full-thickness resection), ESD (endoscopic submucosal dissection), FTRD (full-thickness resection device), OTSC (over-the-scope clip)
      EMR or endoscopic submucosal dissection (ESD) are highly effective methods for resecting colonic polyps
      • Burgess N.G.
      • Bourke M.J.
      Endoscopic resection of colorectal lesions: the narrowing divide between east and west.
      • Moss A.
      • Williams S.J.
      • Hourigan L.F.
      • et al.
      Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study.
      • Oka S.
      • Tanaka S.
      • Saito Y.
      • et al.
      Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan.
      • Raju G.S.
      • Lum P.J.
      • Ross W.A.
      • et al.
      Outcome of EMR as an alternative to surgery in patients with complex colon 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 because it overcomes the potential risk of perforation or incomplete resection by deployment of an over-the-scope clip (OTSC) beneath the polyp before resection. However, appendicitis is a known adverse event seen in 0% to 50% of cases, with patients often requiring emergent appendectomy.
      • Brewer Gutierrez O.I.
      • Akshintala V.S.
      • Ichkhanian Y.
      • et al.
      Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis.
      • Ichkhanian Y.
      • Vosoughi K.
      • Diehl D.L.
      • et al.
      A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions.
      • Valli P.V.
      • Mertens J.
      • Bauerfeind P.
      Safe and successful resection of difficult GI lesions using a novel single-step full-thickness resection device (FTRD®).
      • Schmidt A.
      • Beyna T.
      • Schumacher B.
      • et al.
      Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications.
      • Boger P.
      • Rahman I.
      • Hu M.
      • et al.
      Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry.
      • Meier B.
      • Stritzke B.
      • Kuellmer A.
      • et al.
      Efficacy and safety of endoscopic full-thickness resection in the colorectum: results from the German colonic FTRD registry.
      • Krutzenbichler I.
      • Dollhopf M.
      • Diepolder H.
      • et al.
      Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels.
      • Bronzwaer M.E.S.
      • Bastiaansen B.A.J.
      • Koens L.
      • et al.
      Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study.
      • Al-Bawardy B.
      • Rajan E.
      • Wong Kee Song L.M.
      Over-the-scope clip-assisted endoscopic full-thickness resection of epithelial and subepithelial GI lesions.
      • Zwager L.W.
      • Bastiaansen B.A.J.
      • Bronzwaer M.E.S.
      • et al.
      Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry.
      Endoscopic retrograde appendiceal therapy is a minimally invasive technique for the treatment of uncomplicated acute appendicitis through internal drainage. Small studies have shown that it is associated with high rates of clinical efficacy (96%-100%).
      • Liu B.R.
      • Ma X.
      • Feng J.
      • et al.
      Endoscopic retrograde appendicitis therapy (ERAT): a multicenter retrospective study in China.
      • Li Y.
      • Mi C.
      • Li W.
      • et al.
      Diagnosis of acute appendicitis by endoscopic retrograde appendicitis therapy (ERAT): combination of colonoscopy and endoscopic retrograde appendicography.
      • Ye L.P.
      • Mao X.L.
      • Yang H.
      • et al.
      Endoscopic retrograde appendicitis techniques for the treatment of patients with acute appendicitis.

      Prophylactic Appendiceal Retrograde Intraluminal Stent Placement

      In our institution, a 52-year-old man was referred for management of a 1.5-cm semi-pedunculated (Paris Isp) polyp that was found during a routine screening colonoscopy (Fig. 1A; Video 1, available online at www.giejournal.org). A biopsy specimen of the polyp revealed tubular adenoma. Because of the position of the polyp, which extended into the appendiceal lumen, the decision was made to pursue EFTR rather than EMR. Recognizing the risk of postprocedural appendicitis, we elected to combine EFTR with prophylactic appendiceal retrograde intraluminal stent placement.
      Figure thumbnail gr1
      Figure 1Prophylactic appendiceal retrograde intraluminal stent placement. A, Subpedunculated polyp extending into appendiceal lumen. B, A 7F, 5-cm straight biliary stent exiting the appendix orifice. C, Polyp being withdrawn into the cap of the full-thickness resection device. D, After deployment of the over-the-scope clip (OTSC) and snare polypectomy. E, Endoscopic view of the stent adjacent to the OTSC after resection. F, Fluoroscopic view of the stent adjacent to the OTSC after resection. G, Pathology results showing fragments of tubular adenoma. H, Cecum view at colonoscopy 3 weeks after prophylactic appendiceal retrograde intraluminal stent placement. The appendiceal stent had migrated, but the OTSC remained in situ. I, Residual tissue above the OTSC, concerning for residual polyp, underwent biopsy and showed no remaining adenomatous tissue.
      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 (Fig. 1A). An ERCP sphincterorome preloaded with a 0.025-inch guidewire was introduced into the appendiceal orifice. The guidewire was advanced into the appendiceal lumen under fluoroscopic guidance. Contrast was injected and defined the appendix fluoroscopically.
      A 7F, 5-cm straight plastic biliary stent was then inserted over the guidewire, with the distal flange left at the appendiceal orifice (Fig. 1B). We then removed the colonoscope and loaded the FTRD. The colonoscope was once again advanced to the cecum. The polyp was then grasped with the forceps (Fig. 1C) and retracted into the cap of the colonoscope, and the OTSC was successfully deployed beneath the polyp (Fig. 1D). The polyp was then resected with a snare, retrieved, and sent to pathology. At the end of the procedure, the plastic stent remained in situ within the appendix lumen, adjacent to the OTSC (Fig. 1E and F).
      The patient was admitted overnight and was discharged home the next day. Pathology results showed fragments of tubular adenoma (Fig. 1G). The patient developed no signs of appendicitis and returned for a colonoscopy and appendiceal stent removal 3 weeks later. The OTSC remained in situ, but the stent had already spontaneously migrated. Because of concerns about incomplete resection of the polyp, the polyp site was carefully inspected and a biopsy was performed (Fig. 1H and I). This confirmed no residual adenomatous tissue (Video 1, available online at www.giejournal.org).
      Appendicitis after EFTR is probably due to the OTSC restricting outflow from the appendix.
      • Brewer Gutierrez O.I.
      • Akshintala V.S.
      • Ichkhanian Y.
      • et al.
      Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis.
      • Ichkhanian Y.
      • Vosoughi K.
      • Diehl D.L.
      • et al.
      A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions.
      • Valli P.V.
      • Mertens J.
      • Bauerfeind P.
      Safe and successful resection of difficult GI lesions using a novel single-step full-thickness resection device (FTRD®).
      • Schmidt A.
      • Beyna T.
      • Schumacher B.
      • et al.
      Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications.
      • Boger P.
      • Rahman I.
      • Hu M.
      • et al.
      Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry.
      • Meier B.
      • Stritzke B.
      • Kuellmer A.
      • et al.
      Efficacy and safety of endoscopic full-thickness resection in the colorectum: results from the German colonic FTRD registry.
      • Krutzenbichler I.
      • Dollhopf M.
      • Diepolder H.
      • et al.
      Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels.
      • Bronzwaer M.E.S.
      • Bastiaansen B.A.J.
      • Koens L.
      • et al.
      Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study.
      • Al-Bawardy B.
      • Rajan E.
      • Wong Kee Song L.M.
      Over-the-scope clip-assisted endoscopic full-thickness resection of epithelial and subepithelial GI lesions.
      • Zwager L.W.
      • Bastiaansen B.A.J.
      • Bronzwaer M.E.S.
      • et al.
      Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry.
      ,
      • Costamagna G.
      Acute appendicitis: will a novel endoscopic "organ-sparing" approach change the treatment paradigm?.
      The peak onset of appendicitis is within 1 to 2 weeks of the FTRD procedure, and prescribing periprocedural antibiotics does not affect the rate of appendicitis or need for appendectomy after FTRD.
      • Brewer Gutierrez O.I.
      • Akshintala V.S.
      • Ichkhanian Y.
      • et al.
      Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis.
      • Ichkhanian Y.
      • Vosoughi K.
      • Diehl D.L.
      • et al.
      A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions.
      • Valli P.V.
      • Mertens J.
      • Bauerfeind P.
      Safe and successful resection of difficult GI lesions using a novel single-step full-thickness resection device (FTRD®).
      • Schmidt A.
      • Beyna T.
      • Schumacher B.
      • et al.
      Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications.
      • Boger P.
      • Rahman I.
      • Hu M.
      • et al.
      Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry.
      • Meier B.
      • Stritzke B.
      • Kuellmer A.
      • et al.
      Efficacy and safety of endoscopic full-thickness resection in the colorectum: results from the German colonic FTRD registry.
      • Krutzenbichler I.
      • Dollhopf M.
      • Diepolder H.
      • et al.
      Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels.
      • Bronzwaer M.E.S.
      • Bastiaansen B.A.J.
      • Koens L.
      • et al.
      Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study.
      • Al-Bawardy B.
      • Rajan E.
      • Wong Kee Song L.M.
      Over-the-scope clip-assisted endoscopic full-thickness resection of epithelial and subepithelial GI lesions.
      • Zwager L.W.
      • Bastiaansen B.A.J.
      • Bronzwaer M.E.S.
      • et al.
      Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry.
      Temporary stent placement in the appendiceal lumen, as outlined in this case, has the potential to maintain drainage of the appendix during the periprocedural period and avoid 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.

      Disclosure

      Dr Khashab is a consultant for Boston Scientific, Olympus America, Medtronic, GI Supply, and Triton. Dr Kumbhari is a consultant for Medtronic, Pentax Medical, Boston Scientific, FujiFilm, and Apollo Endosurgery. All other authors disclosed no financial relationships.

      Supplementary data

      References

        • Burgess N.G.
        • Bourke M.J.
        Endoscopic resection of colorectal lesions: the narrowing divide between east and west.
        Dig Endosc. 2016; 28: 296-305
        • Moss A.
        • Williams S.J.
        • Hourigan L.F.
        • et al.
        Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study.
        Gut. 2015; 64: 57-65
        • Oka S.
        • Tanaka S.
        • Saito Y.
        • et al.
        Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan.
        Am J Gastroenterol. 2015; 110: 697-707
        • Raju G.S.
        • Lum P.J.
        • Ross W.A.
        • et al.
        Outcome of EMR as an alternative to surgery in patients with complex colon polyps.
        Gastrointest Endosc. 2016; 84: 315-325
        • Brewer Gutierrez O.I.
        • Akshintala V.S.
        • Ichkhanian Y.
        • et al.
        Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis.
        Endosc Int Open. 2020; 8: E313-E325
        • Ichkhanian Y.
        • Vosoughi K.
        • Diehl D.L.
        • et al.
        A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions.
        Surg Endosc. 2021; 35: 1296-1306
        • Valli P.V.
        • Mertens J.
        • Bauerfeind P.
        Safe and successful resection of difficult GI lesions using a novel single-step full-thickness resection device (FTRD®).
        Surg Endosc. 2018; 32: 289-299
        • Schmidt A.
        • Beyna T.
        • Schumacher B.
        • et al.
        Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications.
        Gut. 2018; 67: 1280-1289
        • Boger P.
        • Rahman I.
        • Hu M.
        • et al.
        Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry.
        Eur J Gastroenterol Hepatol. 2021; 33: 852-858
        • Meier B.
        • Stritzke B.
        • Kuellmer A.
        • et al.
        Efficacy and safety of endoscopic full-thickness resection in the colorectum: results from the German colonic FTRD registry.
        Am J Gastroenterol. 2020; 115: 1998-2006
        • Krutzenbichler I.
        • Dollhopf M.
        • Diepolder H.
        • et al.
        Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels.
        Surg Endosc. 2021; 35: 3339-3353
        • Bronzwaer M.E.S.
        • Bastiaansen B.A.J.
        • Koens L.
        • et al.
        Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study.
        Endosc Int Open. 2018; 6: E1112-E1119
        • Al-Bawardy B.
        • Rajan E.
        • Wong Kee Song L.M.
        Over-the-scope clip-assisted endoscopic full-thickness resection of epithelial and subepithelial GI lesions.
        Gastrointest Endosc. 2017; 85: 1087-1092
        • Zwager L.W.
        • Bastiaansen B.A.J.
        • Bronzwaer M.E.S.
        • et al.
        Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry.
        Endoscopy. 2020; 52: 1014-1023
        • Liu B.R.
        • Ma X.
        • Feng J.
        • et al.
        Endoscopic retrograde appendicitis therapy (ERAT): a multicenter retrospective study in China.
        Surg Endosc. 2015; 29: 905-909
        • Li Y.
        • Mi C.
        • Li W.
        • et al.
        Diagnosis of acute appendicitis by endoscopic retrograde appendicitis therapy (ERAT): combination of colonoscopy and endoscopic retrograde appendicography.
        Dig Dis Sci. 2016; 61: 3285-3291
        • Ye L.P.
        • Mao X.L.
        • Yang H.
        • et al.
        Endoscopic retrograde appendicitis techniques for the treatment of patients with acute appendicitis.
        Z Gastroenterol. 2018; 56: 899-904
        • Costamagna G.
        Acute appendicitis: will a novel endoscopic "organ-sparing" approach change the treatment paradigm?.
        Gastrointest Endosc. 2020; 92: 190-191