Randomized Trial of Endoscopic Retrograde Appendicitis Therapy Versus Appendectomy for Acute Uncomplicated Appendicitis
Douglas K. Rex, MD, MASGE, reviewing Liu BR, et al. J Dig Dis 2022 Dec 13.
Increasingly, antibiotics are used to treat acute uncomplicated appendicitis. Successful antibiotic treatment can be followed by recurrence. An alternative nonoperative approach is endoscopic retrograde appendicitis therapy (ERAT). This is the first randomized trial to compare ERAT to appendectomy for uncomplicated appendicitis.
Patients were excluded from the study if a CT scan showed extra luminal air, periappendiceal pus, or disseminated intraperitoneal fluid.
Patients undergoing ERAT underwent colonoscopy to the cecum with a distal cap, then fluoroscopy-guided catheter placement into the appendix over a 0.035-inch guidewire. Water soluble contrast was injected to look for leakage, fecalith, and strictures. Filling defects were removed by basket or balloon, followed by repeated flushing of the lumen and 7 to 8.5 Fr stent placement for strictures. Patients were followed for 36 months.
Among 110 randomized patients, technical success was achieved in 95% of ERAT cases and 100% of appendectomy cases. All 3 ERAT failures underwent appendectomy. Among the ERAT patients, 8 (15%) had an appendicitis recurrence. Of these, 4 chose repeat ERAT, and all 4 were successfully treated by stent placement. In all, 42% of ERAT patients had stent placement.
The median duration of procedure time was 55 minutes with ERAT and 60 minutes with appendectomy. Postoperative analgesic therapy was required in 9% of ERAT recipients versus 49% of appendectomy recipients. The median postoperative fasting time was 6 hours with ERAT and 48 hours with appendectomy, and the median hospital stay was 3 days with ERAT and 5 days with appendectomy.
COMMENTThese data suggest ERAT could be a viable first-line therapy for acute uncomplicated appendicitis. The advantages would appear to be no scar, faster recovery, and whatever biological advantages are maintained from preserving the appendix. The recurrence rate remains a disadvantage but might be reduced by stent placement in all cases of stricture.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Liu BR, Kong LJ, Ullah S, et al. Endoscopic retrograde appendicitis therapy (ERAT) vs. appendectomy for acute uncomplicated appendicitis: a prospective multicentre randomized clinical trial. J Dig Dis 2022 Dec 13. (Epub ahead of print) (https://doi.org/10.1111/1751-2980.13148)
