But there were some fellow endoscopists who didn't understand why it was necessary to go through with it, because after all, surgical appendectomy is well established.
In a moment of half-knowledge, I too would have these questions. Is it possible to carry out surgery in this area just so that there will be no scarring on the stomach?
Over the past few days, reading the literature on the subject, the endoscopist gurus have done a lot of research on the subject, and it has indeed renewed my knowledge.
The appendix is a thin, curved, blind tube located between the cecum and the ileum, in the lower right part of the abdomen. There are several theories about the pathogenesis of acute appendicitis: (1) the theory of neural reflexes, which suggests that dysregulation of the nerves leads to reflex spasms of the muscles and blood vessels of the appendiceal wall, resulting in obstruction of the appendiceal lumen and obstruction of the blood supply, with subsequent bacterial infection.
(2) Appendiceal obstruction theory, that the appendiceal cavity mechanical complete or incomplete obstruction, resulting in increased intracavitary pressure, affecting the appendiceal wall of the blood flow obstruction, followed by bacterial infection.
(3) Bacterial infection theory, that the appendix itself is a contaminated organ, when the mucosa is locally damaged, the local bacteria can invade the appendix wall infection; appendix outside the infection of bacteria through the blood circulation to the appendix and secondary infection.
The treatment of acute appendicitis by surgical resection is still controversial, because the appendix is rich in lymphoid tissue, which is involved in the body's immune system, and some studies have proved that the incidence of colon tumors in patients after appendectomy is increased by 14% compared with that of normal people.
The appendix also secretes a variety of digestive enzymes as well as hormones that promote intestinal motility and regulate the balance of intestinal flora. Medical knowledge is constantly expanding, and at the moment, although we don't have a clear idea of what the appendix does, no one wants to take a surgical procedure lightly.
Therefore, we should strictly grasp the indications for appendectomy, and not easily perform surgical removal.
Endoscopic retrograde appendicitis therapy (ERAT) is inspired by the ERCP technique. According to the doctrine of appendiceal obstruction and bacterial infection, the core of the pathogenesis of acute appendicitis lies in the obstruction of the appendiceal lumen and secondary bacterial infection. The principle of ERAT treatment is based on the above two points, through antibiotic irrigation and stenting of the appendiceal lumen, in order to relieve the obstruction and eliminate the bacterial infection.
Through the guidewire/catheter technique (Seldinger technique), under the supervision of radiation, with the help of colonoscopic guidance, the obstructed appendiceal lumen is flushed with inflammatory secretions, drained, lithotripsy, and electrocautery, so as to relieve the obstruction, reduce the pressure in the appendiceal lumen, and prevent the appendiceal high pressure from causing appendiceal ischemia and necrosis, so as to achieve the therapeutic purpose.
1.Indications Acute and chronic appendicitis caused by various reasons without necrosis and perforation, including appendiceal fecal stone obstruction of acute appendicitis, recurrent appendicitis, appendiceal septic cavity, high pressure, appendiceal cavity, appendiceal cavity local narrowing, appendiceal perforation and abscess local parcels, and so on. Surgical resection is still recommended for patients suspected of having gangrenous perforated appendix.
These conditions need to be met: (1) onset time <48h; (2) clinical manifestations of metastatic right lower abdominal pain or acute episodes of right lower abdominal pain; (3) right lower abdominal McNeil's point of fixed tenderness, which may be accompanied by rebound pain; (4) temperature <39 degrees Celsius; (5) white blood cell count <20×109/L; (6) vital signs are stable; (7) exclusion of Acute cholecystitis, pancreatitis, urinary stones, gynecologic emergencies and other acute abdominal conditions.
2. The steps of ERAT include:
(1) endoscopic appendiceal intubation;
(2) appendiceal decompression: after successful appendiceal intubation, the pus in the appendiceal cavity is rapidly suctioned to lower the pressure in the appendiceal cavity and to prevent appendiceal ischemia and necrosis resulting from the elevated pressure in the appendiceal cavity;
(3) endoscopic retrograde appendicography: after appendiceal decompression, the appendiceal cavity is decompressed. After decompression of the appendiceal cavity, an appropriate amount of contrast medium is injected through the catheter to show the condition of the appendiceal cavity, such as stenosis, filling defect, etc.;
(4) Balloon or mesh basket lithotripsy: fecaliths are removed by endoscopic insertion of a balloon catheter or a mesh basket for removal of fecaliths. (The black arrow shows the removed fecal stone).
(5) Plastic stent placement and pus drainage: after adequate removal of the fecal stone, a plastic stent was placed for pus drainage and further appendiceal cavity flushing (saline + antibiotics). The stent was removed under enteroscopy about one week after surgery.
4. Advantages of ERAT technique over appendectomy:
(1)After endoscopic appendice insertion for appendiceal lumen decompression, the patient's pain symptoms are rapidly relieved, and the patient can immediately return to daily activities, avoiding post-surgical incisional pain;
(2)ERAT technique is minimally invasive, without scarring on the surface of the body, and is quick and easy to operate, and preliminary clinical The preliminary clinical results showed that the patients had no complications such as bleeding, perforation and periappendiceal abscess formation.ERAT technique can be carried out in outpatient clinics in the future, which saves medical resources;
(3) ERAT technique preserves the potential physiological function of the appendix.
Appendectomy as well as pharmacologic conservative treatment has been the mainstay of treatment for acute appendicitis.
There are some patients in the clinic who prefer conservative treatment, which is very understandable. Surgery, even if it is mature, requires a knife, and there are risks associated with the knife, so surgical resection will not be preferred as a last resort.
Statistics, appendectomy common complications include incisional infection (6%), abdominal infection (1.6% - 3%), small bowel adhesion obstruction (0.4% a 1.3%), incisional hernia (0.4%), etc., and other complications, such as interstitial pneumonia (2.5%), urinary tract infections (1.1%), cardiovascular accident (1.1%).
At the same time, the conservative treatment of acute appendicitis is also faced with unavoidable problems: (1) with appendiceal fecaliths acute appendicitis patients accounted for a large proportion of patients, but this category of patients should not be as a conservative treatment of the drug (2) conservative treatment of broad-spectrum antibiotics, undoubtedly increase the antibiotic resistance and the chance of Clostridium difficile infection.
ERAT, on the other hand, is a minimally invasive endoscopic treatment for patients with acute appendicitis accompanied by appendiceal fecaliths, which is precisely the best indication for ERAT.
A multicenter study was conducted to collect data on patients who underwent ERAT and met certain criteria in eight hospitals between 2009 and 2014. Results Of the 118 patients included in the analysis, 107 were successfully intubated, with an intubation success rate of 91%. 100 patients were diagnosed with acute appendicitis and given endoscopic treatment, and in 97 cases, the mean time to relief of conscious abdominal pain was 12h (6-72h), and the mean time to disappearance of abdominal pressure was 24h (24-72h), with a 97% success rate of endoscopic treatment. The success rate of treatment was 97%. The average hospitalization time of the patients was 3d(2-4d).3 patients had treatment failure, of which 2 cases were found perforation classified as complication during the operation, and the complication rate was 2%. At a mean follow-up of 12 months, there were 7 (7%) recurrences.
Although this study was not compared with other treatments, according to the literature, the treatment efficacy was similar to that of surgical treatment, the complication rate was lower than that of appendectomy, and the recurrence rate was lower than that of antibiotic treatment alone.
It is worth mentioning that in the above study, 7 patients were excluded from acute appendicitis by ERAT to avoid negative appendectomy. Negative resection also means that some of the patients were not appendicitis but were removed as appendicitis.
It has been reported that for some atypical appendicitis, the rate of negative surgical resection for acute appendicitis is as high as 20-30% due to diagnostic difficulties. ERAT can further clarify the diagnosis of appendicitis by both direct observation of the appendiceal opening through colonoscopy and exclude other diseases of the colon and ileocecal end, and also has unique advantages in the diagnosis of appendicitis.
ERAT diagnosis of acute appendicitis criteria: (1) endoscopic manifestations: appendiceal opening edema, with or without pus outflow, with or without surrounding mucosal edema; (2) endoscopic retrograde appendicography manifestations: appendiceal lumen thickening >6mm, limited stenosis, the inner wall is not smooth, peristalsis is weakened, filling defects, and the contrast agent overflows the lumen (consider perforated appendicitis or periappendiceal abscess). .
The diagnostic and therapeutic advantages of ERAT for appendicitis make it worthy of recommendation!
Appendectomy is inevitable in some patients in whom appendiceal function cannot be preserved. Another transgastrointestinal endoscopic treatment for appendicitis: endoscopic retrograde minimally invasive appendectomy via the cecum.
The greatest advantage of endoscopic retrograde appendectomy is that there is no abdominal incision, which avoids postoperative incision pain.
And this technique is a major reason why some endoscopists misunderstand endoscopic treatment of appendicitis.
Because many physicians believe in their hearts that they cannot choose a difficult technique simply for the sake of a scarless body surface; after all, surgical removal of the appendix is very well established.
But as a gastrointestinal endoscopist, it is still necessary to push ERAT.