Over-the-scope clips versus standard treatment

We read with interest the paper published by Dr Chen and colleagues and congratulate them for their excellent skills displayed in the accompanying video describing the transcolonic endoscopic appendicectomy (TEA). We feel, however, that their comments about the safety, efficacy and potential for wider use of TEA demand a critical analysis of its place in the management of lesions involving the appendix orifice. Based on our expertise in laparoscopic colorectal surgery and advanced endoscopic mucosal resection, we have concerns about the potential for significant complications this novel procedure may cause compared with established techniques referred to in the paper and literature. First, we are concerned about the peritoneal contamination occurring after opening of the caecal pole. We noted the intestinal cleansing described, but as any experienced colonoscopist would acknowledge, it is impossible to sterilise the colonic fluid by washout and to stop the leakage of small bowel content into the caecum during a procedure lasting well over 1 hour. While the alternative procedures respect the integrity of the caecal wall and, therefore, avoid exposure of peritoneal cavity to colonic flora, the intentional opening of the colonic wall in TEA results undoubtedly in peritoneal contamination and cannot be sanctioned as a sound concept. The authors implicitly acknowledge this by administering intravenous antibiotics for 6 days postoperatively. We would like to suggest to the authors to obtain fluid samples during the procedure for microbiology analysis and to consider combined mechanical and oral antibiotic bowel preparation. Second, the average duration for this procedure in their expert hands was 110 min, whereas an extended laparoscopic appendicectomy (ELA) with caecal pole resection in expert hands would take half that time, especially given the noninflammatory nature of the lesions. The longer duration of TEA increases the cost and the risks of general anaesthesia and offers no advantages. Third, we strongly disagree with the comment that ‘the resection range is more accurate’ as it does not consider the variation in the position of the appendix. Although the TEA would be satisfactory for pelvic, subcaecal, preileal and postileal appendices, it would be technically more challenging and riskier for retrocaecal and subserous appendices, which are the more common positions of the appendix. The superiority of ELA comes from the ability to directly visualise the appendix and any surrounding adhesions and to safely protect the surrounding viscera from diathermy damage during dissection as opposed to the limited views seen in the TEA video. Moreover, the ELA removes the mesoappendix entirely, of importance if malignancy is found in the appendiceal lumen, providing a more complete resection specimen. 4 Fourth, the postoperative care described deviates considerably from the principles of enhanced recovery after surgery and has health economic consequences for the individual and the healthcare providers. Typically, laparoscopic appendicectomy patients even in acute settings would resume oral intake immediately after recovery for anaesthesia and may be discharged home the same day. In contrast, the patients included in this study were starved for an average of 5 days and had average hospitalisation of 8 days. Finally, we have concerns about safety of the TEA closure of caecal pole compared with closure with endoscopic stapler in ELA and we have also encountered retained clips at EMR sites even 3 months later causing some challenges in the event of polyp recurrence. We believe that, while in this small series no complication related to closure of caecal pole was reported, a wider adoption of this technique will inevitably encounter intraabdominal septic complications. We hope that our comments will help other clinicians with the appraisal of risk–benefit balance before they consider adopting TEA.