We read with great interest the study by Uchima et al. on cap-suction underwater endoscopic mucosal resection (CAP-UEMR) of appendiceal lesions [1]. The authors concluded that CAP-UEMR is safe and effective for lesions involving the appendiceal orifice or ileocecal valve. Notably, seven patients had intraprocedural bleeding requiring endoscopic intervention, two had delayed bleeding, and one patient had recurrence within the short follow-up duration of the study (median 197 days).

CAP-UEMR at the appendiceal orifice is technically challenging and has two notable issues. First, incomplete resection may become a major deterrent if the extent of appendiceal involvement is not confirmed prior to the procedure. Second, the appendiceal mucosa has secretory function; appendiceal outflow obstruction, as can happen with CAP-UEMR of the appendiceal orifice, leads to the accumulation of secretions in the appendix, creating a nidus for infection, and may raise the risk of appendiceal cyst formation. The latter is typically a long-term complication and may not be captured in studies with a short follow-up duration.

The alternative technique of endoscopic transcecal appendectomy allows resection of lesions both around the appendiceal orifice and within the appendiceal lumen [2] [3]. Therefore, an understanding of the extent of appendiceal involvement by the lesion is critical for selection of the appropriate resection technique. Appendicoscopy allows for detailed visualization of the entire appendiceal cavity and can be performed with a single-operator cholangioscope system [4] [5]. For appendiceal lesions, pre-resection appendicoscopy can provide information on the extent of the pathology, allowing selection of the most appropriate resection technique, while decreasing the financial burden incurred by the need for additional interventions for definitive management of appendiceal lesions.

In conclusion, this study highlights the importance of training in endoscopic examination of the appendix to better understand appendiceal pathologies and to optimize the adoption of novel techniques such as endoscopic retrograde appendicitis therapy (ERAT), endoscopic transcecal appendectomy, and appendiceal CAP-UEMR.

Article published online:
30 January 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany