Endoscopic full-thickness resection and post-procedural appendicitis: every advantage has its disadvantage

In the November issue of Endoscopy, the Dutch endoscopic full-thickness resection (eFTR) group shared the results of their 3-year colorectal eFTR registry [1]. In this large prospective study, 65 out of 367 patients (17.7 %) required additional surgery, in three cases because of iatrogenic appendicitis. Predicting who will develop appendicitis following eFTR of lesions involving the appendiceal orifice would be of great value in selecting patients for whom alternative therapeutic options might be preferable.

A retrospective analysis by Schmidbaur et al. evaluated eFTR in this specific context, showing an overall post-eFTR appendicitis incidence of 14 %, with a lower mean lesion size in such cases (9.6 mm versus 18.3 mm in the overall cohort) [2]. In 2018, the exploratory case series published by some of the current (co-)authors [3] showed an identical incidence of appendicitis (14.3 %; n = 1), with this event occurring in a patient with only 50 % involvement of the appendiceal orifice, while the majority of non-complicated resections had ≥ 75 % appendiceal orifice involvement.

As intraluminal obstruction is recognized as one of the potential causes of appendicitis, eFTR-induced acute appendicular obstruction in lesions with only partial involvement of the appendiceal orifice, and thereby previously maintained luminal patency, might be the driving force behind higher rates of post-procedural appendicitis. Conversely, in lesions that completely involve the appendiceal orifice, obstruction may perhaps have occurred during lesion progression well before the procedure, and eFTR-induced occlusion may therefore not lead to significant additional luminal obstruction, potentially explaining the lower rates of appendicitis.

In conclusion, these considerations make us wonder if perhaps extensive appendiceal orifice involvement ( ≥ 75 %) is associated with a lower risk of developing post-procedural appendicitis and whether a similar pattern was seen in the current study.

As a well-known Dutch soccer player once said: “Every advantage has its disadvantage.” However, instead of accepting these disadvantages, dissecting potential drawbacks and finding the ideal patient – procedure match should remain one of our joint priorities.

Publication History

Article published online:
22 April 2021

• References

• 1 Zwager LW, Bastiaansen BAJ, Bronzwaer MES. et al. Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry. Endoscopy 2020; 52: 1014-1023
• 2 Schmidbaur S, Wannhoff A, Walter B. et al. Risk of appendicitis after endoscopic full-thickness resection of lesions involving the appendiceal orifice: a retrospective analysis. Endoscopy 2020; DOI: 10.1055/a-1227-4555.
• 3 Bronzwaer MES, Bastiaansen BAJ, Koens L. et al. Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study. Endosc Int Open 2018; 6: E1112-E1119