However, some endoscopists don't understand why they do this, because after all, surgical appendectomy is very mature.
I also have these questions if I have a little knowledge. Is this operation just to avoid leaving a scar on the stomach?
After reading the relevant literature these days, the endoscopist has done a lot of relevant research and really updated his cognition.
The appendix is a slender and curved blind tube between the cecum and ileum, which is located in the lower right of the abdomen. There are several theories about the pathogenesis of acute appendicitis: (1) nerve reflex theory, which holds that the disorder of nerve regulation leads to reflex spasm of muscles and blood vessels in the appendix wall, obstruction of the appendix cavity, blood supply disorder, and then bacterial infection.
(2) The theory of appendix cavity obstruction holds that the mechanical complete or incomplete obstruction of appendix cavity leads to the increase of pressure in the cavity, which affects the blood supply of appendix wall and then leads to bacterial infection.
(3) According to the theory of bacterial infection, the appendix itself is a polluted organ. When the mucosa is damaged locally, local bacteria can invade the appendix wall and cause infection. Bacteria infected outside the appendix reach the appendix through blood circulation, resulting in secondary infection.
The surgical resection of acute appendicitis is still controversial because the appendix is rich in lymphoid tissue and participates in the body's immunity. Studies have proved that the incidence of colon tumor in patients after appendectomy is higher than that in normal people 14%.
The appendix can also secrete a variety of digestive enzymes and hormones that promote intestinal peristalsis and regulate the balance of intestinal flora. Medical knowledge is constantly expanding. At present, although we can't clearly know the function of the appendix, no one wants to perform surgery easily.
Therefore, it is necessary to strictly grasp the indications of appendectomy and not to perform surgical resection easily.
Endoscopic retrograde appendicitis treatment (ERAT) was proposed inspired by ERCP technology. According to the theory of appendix cavity obstruction and bacterial infection, the core of acute appendicitis is appendix cavity obstruction and secondary bacterial infection, and the principle of ERAT treatment is to flush the appendix cavity with antibiotics and implant stents from the above two points to relieve obstruction and eliminate bacterial infection.
Through the guide wire/catheter technology (Seldinger technology), under the monitoring of radiation, with the help of colonoscopy, the obstructed appendix cavity was washed, drained, stones were removed and inflammatory secretions were removed, so as to relieve the obstruction, reduce the pressure in the appendix cavity, prevent the appendix from being ischemic and necrotic due to appendix hypertension, and achieve the therapeutic purpose.
1. Indications are acute and chronic appendicitis without necrosis and perforation caused by various reasons, including acute appendicitis caused by obstruction of appendix stones, recurrent appendicitis, high pressure in the cavity of appendix abscess, local stenosis of appendix cavity, local wrapping of appendix perforation abscess, etc. Surgical resection is still recommended for patients with suspected gangrene and perforated appendix.
These conditions need to be met: (1) onset time.
2. The steps of 2.ERAT include:
(1) Endoscopic appendectomy;
(2) decompression of the appendix cavity: after successful intubation of the appendix, the pus in the appendix cavity is quickly sucked out, so as to reduce the pressure in the appendix cavity and prevent the ischemic necrosis of the appendix caused by the increase of the pressure in the appendix cavity;
(3) Endoscopic retrograde appendography: After decompression of the appendix cavity, a proper amount of contrast agent is injected through the catheter to show the situation in the appendix cavity, such as stenosis and filling defect.
(4) Balloon or basket lithotomy: placing balloon catheter or basket to take out fecal stone under endoscope. (Black arrows indicate removed dung stones).
(5) Placing a plastic stent to drain pus: After the fecal stones are completely removed, placing a plastic stent to drain pus, and further washing the appendix cavity (normal saline+antibiotics). The stent was removed under colonoscopy about one week after operation.
4. Compared with appendectomy, advantages of ERAT technology:
(1) After decompression of the appendiceal cavity by endoscopic appendectomy, the patient's pain symptoms were quickly relieved, and the patient could immediately resume daily activities to avoid postoperative incision pain.
(2)ERAT technology has the advantages of less trauma, no scar on the body surface, and quick and convenient operation. The preliminary clinical results showed that there were no complications such as bleeding, perforation and abscess formation around the appendix. ERAT technology can be developed in outpatient clinics in the future, saving medical resources;
(3)ERAT technology retains the potential physiological function of the appendix.
Appendectomy and drug conservative treatment have always been the main methods to treat acute appendicitis.
It is easy to understand that some patients will give priority to conservative treatment in clinic. When the operation is mature, it is necessary to operate the knife, which is risky. Surgical resection will not be given priority unless absolutely necessary.
According to statistics, the common complications of appendectomy are incision infection (6%), abdominal infection (1.6%-3%), intestinal adhesion and obstruction (0.4%- 1.3%), incisional hernia (0.4%), interstitial pneumonia (2.5%) and urinary tract infection (2.5%).
At the same time, the conservative treatment of acute appendicitis is also facing unavoidable problems: (1) Patients with acute appendicitis complicated with appendiceal stones account for a considerable proportion, but such patients should not be treated conservatively; (2) Conservative treatment with broad-spectrum antibiotics undoubtedly increases the probability of antibiotic resistance and Clostridium difficile infection.
ERAT is a minimally invasive treatment under endoscope, which is the best indication for patients with acute appendicitis complicated with appendiceal stones.
A multicenter study collected the data of patients who received ERAT treatment in 8 hospitals from 2009 to 20 14 and met certain conditions. Results Among the 1 18 patients, 107 patients were successfully intubated, and the success rate of intubation was 9 1%. 100 patients were diagnosed with acute appendicitis and received endoscopic treatment. In 97 patients, the average time to relieve abdominal pain was 65438 02h (6-72h), and the average time to relieve abdominal tenderness was 24h (24-72h). The success rate of endoscopic treatment was 97%. The average hospitalization time is 3 days (2-4 days). Three cases failed in treatment, among which 2 cases found complications during operation, and the incidence of complications was 2%. After an average follow-up of 65438 02 months, 7 cases (7%) recurred.
Although this study has not been compared with other treatment methods, according to literature reports, the effective rate of treatment is similar to that of surgical treatment, the incidence of complications is lower than that of appendectomy, and the recurrence rate is lower than that of antibiotic treatment alone.
It is worth mentioning that in the above study, ERAT excluded 7 patients with acute appendicitis to avoid negative appendectomy. Negative excision means that some patients were not appendicitis originally, but were treated as appendicitis.
It is reported that for some atypical appendicitis, due to the difficulty in diagnosis, the negative surgical resection rate of acute appendicitis is as high as 20-30%. ERAT can not only directly observe the opening of the appendix through colonoscopy, but also confirm the diagnosis of appendicitis and exclude other diseases at the end of colon and ileum. It also has unique advantages in the diagnosis of appendicitis.
Diagnostic criteria of ERAT acute appendicitis: (1) Endoscopic manifestations: edema of appendix opening, presence or absence of pus outflow, and presence or absence of peripheral mucosal edema; (2) Endoscopic retrograde appendography: the appendiceal cavity becomes thicker >: 6mm, with localized stenosis, unsmooth inner wall, weakened peristalsis, filling defect and contrast agent overflowing the lumen (consider perforated appendicitis or abscess around the appendix).
ERAT has the advantage of diagnosis and treatment of appendicitis, which is worth recommending!
For some patients whose appendix function cannot be preserved, appendectomy is inevitable. Another method of digestive endoscopy for appendicitis: retrograde minimally invasive appendectomy through cecum endoscope.
The biggest advantage of cecal endoscopic retrograde appendectomy is that there is no abdominal incision, which avoids postoperative incision pain.
This technique is also an important reason why some endoscopists misunderstand the endoscopic treatment of appendicitis.
Because many doctors believe that it is impossible to choose more difficult techniques simply for leaving no scars on the body surface. After all, surgical appendectomy is very mature.
However, as an expert in digestive endoscopy, it is necessary to praise ERAT.