Introduction:
Currently, the standard treatment for acute appendicitis is laparoscopic appendectomy. Recent studies suggest that antibiotics can also be used for the treatment of appendicitis instead of surgery. However, these studies proved that approximately 30 percent of patients treated with antibiotics had recurrent episodes of appendicitis within one year.
In 1885, when Abraham Groves performed the first appendectomy, surgical management became the treatment of choice for acute appendicitis. In 1983, with the development of laparoscopic appendectomy (LA), a new age of appendix surgery became popular as it minimized both surgical trauma and recovery time.
Currently, cases of negative appendectomies (appendectomy performed on a normal appendix where surgery is not required) have become common, ranging from 15 % to 30 %. This exposes the patients to an unncessary invasive interventions and also causes financial burdens on the patient and the hospital system.
What Is Acute Appendicitis?
Acute appendicitis is one of the most commonly occurring surgical emergencies, with a lifetime risk of 6.7 percent in females and 8.6 percent in males. It develops as a result of obstruction of the appendiceal orifice. The appendiceal orifice is usually seen in an impacted fecalith (mass of hardened fecal matter). In some cases, it might occur as a result of infections, tumors, or lymphoid hyperplasia.
Appendiceal obstruction leads to distension of the appendix, causing localized abdominal pain in the right lower quadrant. Other symptoms include fever, nausea, and vomiting.
What Is Endoscopic Retrograde Appendicitis Therapy (ERAT)?
Endoscopic retrograde appendicitis therapy (ERAT) is an endoscopic procedure used for the treatment of acute appendicitis. It can be used as an alternative to laparoscopic appendectomy. This procedure was first reported by Liu et al. in 2012.
The procedure involves the passing a colonoscope to the opening of the appendix for placing a stent or drain in the infected appendix through the appendiceal orifice, which removes the appendiceal obstruction.
Endoscopic retrograde appendicitis therapy (ERAT) includes cannulation (a technique that involves placement of the cannula inside a vein for providing venous access), an appendicogram (a simple diagnostic method for reviewing the position and anatomy of the appendix), appendiceal lumen irrigation, appendiceal stone extraction, and stent placement. The average time for performing the ERAT procedure is 40 minutes (35 to 45 minutes), which is only slightly more than a standard colonoscopic examination.
Liu et al performed ERAT on a human subject in December 2009, which was published in 2012. A subsequent multicenter cohort included 41 patients on whom ERAT was performed. The study reported a success rate of 97 percent, with only 6.2 percent of patients complaining of recurrent pain where subsequent appendectomy was required. In recent years, endoscopic retrograde appendicitis therapy (ERAT) has proved to be an organ-preserving intervention for acute uncomplicated appendicitis (AUA).
What Are the Indications of Endoscopic Retrograde Appendicitis Therapy (ERAT)?
With progress in technology and the expansion of endoscopic management of appendiceal diseases, the indications for ERAT have also expanded, and it is being used for the management of the following conditions:
-
Chronic appendicitis (the appendix is inflamed, filled with pus, and painful).
-
Perforated appendicitis (presence of a hole or perforation in the appendix).
-
Appendiceal cysts (appendiceal lumen leads to mucus accumulation and distended appendix).
-
Peri appendiceal abscesses (formation of an abscess around the appendix).
However, surgery is still recommended for complicated appendicitis cases until further studies are carried out to support the safety and effectiveness of ERAT.
What Is Better, Endoscopic Retrograde Appendicitis Therapy or Laparoscopic Appendectomy?
Recent studies comparing endoscopic retrograde appendicitis therapy (ERAT) to laparoscopic appendectomy (LA) have shown positive results in the safety and efficacy of endoscopic retrograde appendicitis therapy. If the current development and research are maintained, ERAT can be established as the standard of care for acute uncomplicated appendicitis (AUA).
A comparative study between ERAT and LA for the management of AUA revealed that successful appendiceal orifice intubation was seen in 97.4 percent of patients and appendiceal flushing with stent placement in 37 percent of patients. The clinical success rate of ERAT was 92 percent compared with surgery (100 percent).
The benefits of ERAT over laparoscopic appendectomy are:
-
Avoidance of surgical intervention.
-
Preservation of the appendix.
-
Direct visualization of the colon, along with management of other abnormalities.
-
Decreased rates of negative appendectomy.
Other benefits of endoscopic retrograde appendicitis therapy (ERAT):
-
Shorter operative time.
-
Reduced postoperative analgesia requirement.
-
A shorter time to the resumption of oral intake.
-
Less postoperative pain.
-
A shorter hospital stay.
Can Appendicitis Recur After Endoscopic Retrograde Appendicitis Therapy (ERAT)?
Appendicitis might recur after endoscopic retrograde appendicitis therapy (ERAT), although it is not common. Yang et al. documented recurrent appendicitis in eight percent of patients. Six out of 76 patients who experienced a recurrence were managed with appendiceal flushing without stent placement.
Currently, there are no indications for appendiceal stent placement during ERAT and the placement of stents can be done at the advice of the endoscopist. Patients usually undergo abdominal radiography two to four weeks after ERAT for examining whether the stent is placed properly or displaced. Retained appendiceal stents can be removed by endoscopy. A study by Shen et al, reported that the stent retention rate was 69 percent. Future studies must focus on the following to improve the outcomes of ERAT:
-
Indications for appendiceal stent placement.
-
Identifying factors associated with recurrent appendicitis.
-
Appendiceal stent retention.
What Are the Drawbacks of Endoscopic Retrograde Appendicitis Therapy (ERAT)?
The main drawback of endoscopic retrograde appendicitis therapy (ERAT) is that extensive data is not available. Most of the studies were undertaken at a single center or on a specific population, which questions the generalizability of the established safety and efficacy of this technique. Studies comparing ERAT to antibiotic therapy and ERAT to LA are also limited.
However, the future of this therapy is promising, as there are randomized clinical trials underway to bridge these knowledge gaps which will be helpful in the near future.
Conclusion:
Although endoscopic retrograde appendicitis therapy (ERAT) is a promising management and organ-preserving method, it needs further studies before it is recognized globally. Etiology-specific treatment strategies for ERAT are still to be investigated. It further demands multinational collaboration and a consensus on training and establishing pathways for its development. Extensive research is also needed in this area to encourage the global adoption of ERAT.
