Visualization and biopsy of an appendiceal sessile serrated lesion during endoscopic retrograde appendicitis therapy

A 67-year-old man presented with pain and tenderness in the right lower quadrant. Abdominal computed tomography (CT) scan was performed, which revealed appendicitis and appendiceal fecaliths ([Fig. 1]). The patient was admitted to our hospital for endoscopic retrograde appendicitis therapy (ERAT). The procedure was performed using a 3.2-mm biopsy channel colonoscope (CF-H290I; Olympus) with successful intubation of a single-use subscope (9-Fr eyeMax; Micro-Tech) into the appendiceal cavity. The subscope demonstrated that the cavity wall of the appendix lumen was slightly hyperemia and edema, and appendiceal fecaliths were found within the appendiceal lumen ([Fig. 2] a). Plenty of normal salines was used to rinse out the fecaliths ([Fig. 2] b). Subsequently, a 1.2-cm laterally spreading tumor was identified within the appendiceal lumen, characterized by a rough, granular mucosal surface covered by a mucous cap ([Fig. 3] a, [Video 1]). Methylene blue staining revealed a clear boundary ([Fig. 3] b). A biopsy was performed. The pathological findings of the biopsy were sessile serrated lesions (SSLs) ([Fig. 4]).

Fig. 1 The abdominal CT revealed appendicitis and appendiceal fecalith (the red arrow).

Fig. 2 a The appendiceal fecaliths in the appendix lumen. b The appendiceal fecaliths were rinsed out.

Fig. 3 a The lesion was an area of rough, granular mucosa (the white arrow) in the appendix lumen. b Methylene blue staining showed a clear boundary.

The detection and biopsy of the lesion confined to the lumen of the appendix by the single-use subscope imaging system during endoscopic retrograde appendicitis therapy.Video 1

Fig. 4 Biopsy pathology of the lesion.

After obtaining informed consent, a laparoscopic appendectomy was performed. During the procedure, it was observed that the appendix was elongated and exhibited mild adhesions to the surrounding tissues. The rough area in the appendiceal lumen was obvious at postoperative specimen ([Fig. 5] a. The presence of SSL with low-grade dysplasia was confirmed by the postoperative histopathological analysis ([Fig. 5] b).

Fig. 5 a The rough area (the vascular clamp pointed) in the appendix lumen at the removed appendix. b Pathology of the lesion in the appendix lumen.

Postoperatively, the patient was given antibiotics therapy and fasted for 3 days. He recovered quickly from mild abdominal pain and was discharged 4 days later. The symptoms of right lower quadrant pain and tenderness were significantly relieved.

Appendiceal SSLs are lesions with malignant potential, they are rarely reported and mainly incidental findings in appendectomy specimens [1] [2]. This case demonstrates the utility of the single-use subscope imaging systems in managing appendicitis and detecting appendiceal lesions, providing clear visualization and enabling precise diagnosis and treatment. It provides a possible technique for the early detection and pathological diagnosis of lesions confined within the lumen of the appendix.

Endoscopy_UCTN_Code_CCL_1AD_2AB

 

MissingLinkText

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We are deeply grateful to Binzhou Medical University Hospital for providing the essential support that facilitated the conduct of this case. This study would not have been possible without the generous assistance and resources made available by this Hospital. Furthermore, we are thankful to the staff of the Digestive Endoscopy Center at Binzhou Medical University Hospital for their technical support, logistical assistance, and provision of necessary facilities, which enabled the smooth execution of our report. We would also like to express our gratitude to our colleagues and peers who provided constructive feedback and engaging discussions during the development of this report. Their insights were invaluable in refining our ideas and improving the overall quality of the manuscript. Lastly, we dedicate this work to our families and friends, who have provided unwavering support, understanding, and encouragement throughout our research endeavors. Their love and patience have been our greatest source of strength during this challenging journey.

• References

• 1 Chezar K, Minoo P. Appendiceal sessile serrated lesions are distinct from their rightsided colonic counterparts and may be precursors for appendiceal mucinous neoplasms. Hum Pathol 2022; 122: 40-49
• 2 Dincel O, Göksu M, Türk BA. et al. Incidental findings in routine histopathological examination of appendectomy specimens; retrospective analysis of 1970 patients. Indian J Surg 2018; 80: 48-53

Publication History

Article published online:
14 May 2025