Pioneering minimally invasive solutions for chronic appendicitis: EUS-assisted endoscopic appendicitis therapy (with video)

Chronic appendicitis (CA) is a rare scenario, with just an estimated 1.5% of all appendicitis.[1] Nevertheless not considered a surgical emergency, this rare clinical entity poses a diagnostic and therapeutic dilemma for clinicians with delay in diagnosis leading to a risk of complications such as perforation or abscess.[2] CA should be included in the differential diagnosis of patients presenting with chronic lower abdominal pain, as early diagnosis and timely intervention can reduce the risk of complications. Although cholangioscopy is traditionally used of biliary tract lesions, its extended application through the colonoscope therapeutic channel for managing appendicitis is emerging.[3,4] However, the variable anatomical orientation of the appendix[5] poses successful intubation challenges. Here, we utilized the EUS-assisted intubation as a crucial part of endoscopic appendicitis therapy (EAT) to achieve accurate CA diagnosis and guide appropriate management. Patient was a 54-year-old woman presenting with episodic lower abdominal pain for over 2 months, accompanied by malaise. Abdominal computed tomography revealed an enlarged appendix [Figure 1A]. Colonoscopy identified an edematous and inflammatory appendiceal orifice [Figure 1B]. Subsequent EUS was performed with a 12-MHz ultrasonic miniprobe (UM-2R; Olympus, Tokyo, Japan) to determine the orientation between the appendiceal orifice and the appendix lumen before appendicoscope intubation [Figure 2A, Video 1]. Subsequent EAT was performed using a single-use video cholangioscope (TY-ISS-L31, VedVision; Vedkang, Changzhou, China) through the colonoscope’s therapeutic channel. Assisted by EUS, the appendicoscope was smoothly intubated to investigate the appendiceal lumen, revealing yellowish fibrous obliteration of the lumen [Figure 2B]. Repeated irrigation with saline and metronidazole exposed smooth lining mucosa without foreign objects or fecal deposits, confirming the diagnosis of CA [Figure 2C]. The patient reported significant resolution of abdominal pain 12 hours post-procedure and was discharged 2 days later without complications. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Supplementary Video","caption":"Video 1. EUS-assisted intubation orientation for endoscopic appendicitis therapy. Videos are available only at the official website of the journal (www.eusjournal.com).","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_57sbpsxm"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Figure 1: A, Coronal Abdominal computed tomography imagine indicated enlargement of the appendix (green arrow). B, Colonoscopic view of a edematous appendiceal orifice (green arrow).Figure 2: A, EUS-assisted with the appendicoscopy intubation orientation (orifice: green triangle; intubation orientation: red arrow). B, Appendicoscopic view shows yellowish fibrous obliteration of the lumen. C, Appendicoscopic view exposed smooth lining mucosa after repeated irrigation.EUS-assisted EAT is beneficial for reliable assessment of lower abdominal pain suspected to be due to CA or unresponsive to medical treatments, also aiding in differential diagnoses of an enlarged appendix. By facilitating successful intubation, accurate diagnosis, and minimal invasive immediate treatment, EUS-assisted EAT effectively resolved symptoms, providing a novel and organ-preserving alternative to conventional surgery.