Acute appendicitis: Will a novel endoscopic “organ-sparing” approach change the treatment paradigm?

by Skeptical Scalpel, Physician’s Weekly Top Blogger

Will a novel endoscopic “organ-sparing” approach change the treatment paradigm?

I say a resounding “NO.” An opinion piece with the above title in the journal Gastrointestinal Endoscopy suggests that colonoscopy with extraction of a fecalith or stenting of an obstruction could replace laparoscopic appendectomy for uncomplicated acute appendicitis. This is based on a handful of observational studies done in China on fewer than 75 patients.

The procedure, endoscopic retrograde appendicitis therapy [ERAT], consists of the following: preparation of the colon with a 500 mL saline enema, colonoscopy, visualization of inflammation at the appendiceal orifice, insertion of a catheter over a guidewire into the lumen of the appendix under x-ray control, injection of dye to delineate the anatomy, saline lavage of the appendix, and either extraction of an obstructing fecalith using a basket or balloon catheter or insertion of a plastic stent to alleviate stenosis caused by lymphoid hyperplasia. See figure below.

As is true with nearly all new procedures, the success rate in these carefully selected patients is very high, and complications are few.

The original description of the technique calls for the administration of three “low pressure” 500 mL saline enemas as a prep. I can’t imagine being a patient with abdominal pain receiving three enemas, low pressure or not, in an emergency department.

The author attempts to make a case for preservation of the appendix and to his credit, cites a couple of studies with good outcomes after appendectomy in certain diseases.

He discusses some older meta-analyses comparing antibiotic treatment to appendectomy in uncomplicated appendicitis. However, he did not cite the February 2020 JAMA Surgery paper from Finland showing that the 7-year follow-up of patients treated with antibiotics in large randomized controlled trial showed that 39% of those initially treated with antibiotics eventually required appendectomy.

A 2016 paper touted the supposed benefit of ERAT for diagnosis of appendicitis stating, “Contrary to expectation, the frequency of misdiagnosis leading to unnecessary appendectomy has not changed with the introduction of CT, US, and laparoscopy, nor has the frequency of perforation decreased.” That statement was based on a paper from 2001 and is no longer true. The current negative appendectomy rate is 2-3%.

Which would you rather have for diagnosis—a 20 minute CT scan which has an accuracy of over 95% or the administration of three low pressure 500 mL saline enemas and a 45 minute colonoscopic procedure with anesthesia?

The few papers on ERAT downplay its risks, which include possible perforation caused by the enemas, insufflation of air into the colon, or instrumentation of the appendix, recurrence of appendicitis, and missed cancer in the appendix.

According to a review in BMJ Best Practice, fecaliths are found in 14-18% of patients with acute appendicitis. That means as many as 80% of patients undergoing ERAT might require a second colonoscopy to retrieve a stent.

Since the procedure was first described in 2012, subsequent papers all recommend a randomized prospective trial of ERAT vs. laparoscopic appendectomy for the treatment of uncomplicated acute appendicitis. To my knowledge, no such study is ongoing.

ERAT reminds me of a previous unsuccessful attempt to supersede laparoscopic appendectomy. The procedure was called NOTES or Natural Orifice Transluminal Endoscopic Surgery. I blogged negatively about transgastric appendectomy in 2013 and 2017.

What I said about NOTES goes for ERAT too—just because you can do something doesn’t mean you should.

Skeptical Scalpel is a retired surgeon and was a surgical department chair and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times.For the last 9 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,700,000 page views, and he has over 21,000 followers on Twitter.