Multicentric study of long-term outcomes of the endoscopic resection of appendiceal lesions

Aims To determine the long-term efficacy and safety of endoscopic resection of appendiceal lesions. Primary endpoint was clinical success evaluated by recurrence rate during a clinical long-term follow-up of at least 12 months. Secondary endpoints were technical success rate (complete macroscopic resection at index procedure) and safety (including appendicitis rate with a clinical follow-up of at least 12 months) and the identification of factors associated with recurrence, incomplete and non en-bloc resection..

Methods Retrospective analysis of endoscopic resection of lesions with appendiceal involvement permorfed at eight centers in Spain (January 2016-July 2023). Intra-appendicular extension was described as superficial (visible appendiceal margin) or deep (if it was not possible to determine before resection). Additionally, circumferential extension was described according to the affected percentage. Data were analyzed using SPSS Statistics software (v.25.0).

Results 97 lesions with appendiceal involvement were treated (mean age 68 years, SD9.9; 57% men) with a median size of 18(IQR 10-29mm), 19 lesions(20%) were previously manipulated. 32 lesions with deep intra-appendicular involvement and 65 with superficial appendiceal involvement. 62 lesions (64%) had a circumferential involvement≥50%(p<0.001). Underwater endoscopic mucosal resection was performed in 54% lesions (42% of them by underwater cap-suction pseudopolyp formation). Technical success in the entire cohort was 93% (49% en-bloc, 85% with superficial involvement; p<0.001). There were 7 cases of incomplete endoscopic resection at first attempt (5 with deep appendiceal involvement;p=0.037), 4 derived directly to surgery, all of them with deep appendiceal involvement (pT2=1, HGD=2, tubular adenoma with LGD=1). The remaining 3 patients underwent second endoscopic attempt, eventually requiring surgery (serrated with dysplasia=2, tubular adenoma with LGD=1). There were 6 intraprocedural bleeding, 1 post-procedural bleeding and 1 case of intraprocedural perforation, all managed endoscopically. 84 patients completed at least 12 months of clinical follow-up(median 27, [IQR]16-34). 13 cases showed recurrence (7 with deep intra-apendicular extension), 12 treated endoscopically. The remaining case did not receive any additional treatment due to frailty and comorbidities. Surgery was needed during long-term follow-up in 3 additional cases (pT1a=1 and 2 cases of appendicitis, at 11 and 56 months after index procedure). Multivariate analysis showed depth of appendiceal lesion and size≥2cm were independent factors associated with non en-bloc resection at index procedure. No factors were found to be significantly associated with incomplete resection nor with the presence of recurrence [1] [2] [3] [4] [5] [6] [7] [8].

Conclusions The endoscopic management of lesions involving the appendix may indeed prove effective and safe after following a minimum follow-up of 12 months. Depth of appendiceal lesion and size≥2cm were linked to unsuccessful en-bloc resection. Further studies are needed to identify independent factors associated with incomplete resection and recurrence.

Publication History

Article published online:
27 March 2025

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