Endoscopic Retrograde Appendicitis Therapy
Condition: Acute Appendicitis
MeSH terms: Appendicitis
Study type: Interventional

Summary: 
      This is a prospective pilot study on the efficacy of endoscopic therapy for adult
      uncomplicated acute appendicitis. In recent years, antibiotics treatment has been a new
      alternative approach to surgical appendicectomy for acute appendicitis, however, there is a
      risk of failed antibiotics treatment and chance of recurrent appendicitis.

      Endoscopic therapy of acute appendicitis (ERAT) has been recently described that involves
      colonoscopic insertion of plastic stent and removal of appendicolith. The investigators
      conduct this pilot study to investigate the feasibility, technical and clinical success rate
      of endoscopic retrograde appendicitis therapy among adult patients with uncomplicated acute
      appendicitis. 20 patients would be recruited for the pilot study.
    

Detailed description: 
      Acute appendicitis is one of the most common surgical emergencies in adult patients. The
      lifetime risk of developing acute appendicitis in the United States is 8.6% for males and
      6.7% for females. For many decades, surgical appendicectomy is the gold standard of treatment
      of acute appendicitis. Appendicectomy could be performed in an open manner via a right lower
      abdominal incision, or more popular nowadays with the laparoscopic approach by placing three
      abdominal trocars. Earlier studies have identified high treatment success rate with both open
      and laparoscopic approaches, but adverse events were lower in laparoscopic group.
      Intra-abdominal abscesses were a potential concern with laparoscopic appendicectomy. In
      recent few years, antibiotics treatment for acute appendicitis has been a promising
      management option. By avoid the need of surgery and general anaesthesia, the non-operative
      approach was associated with a lower morbidity than the surgical approach. The major drawback
      of antibiotic treatment was the risk of failed primary treatment and subsequent recurrent
      appendicitis. A recent randomized controlled study demonstrated a primary clinical success
      treatment at index attack of 94.2%. 72.7% of the patients who received antibiotics alone did
      not require appendicectomy at 1-year follow-up. While antibiotics therapy could be a safe
      alternative to surgical therapy, many are still skeptical of the treatment due to the
      potential high recurrence rate.

      Endoscopic therapy of acute appendicitis (Endoscopic retrograde appendicitis therapy, ERAT)
      was recently described recently in the literature. The technique involves a two-staged
      procedure with endoscopic plastic stent drainage of appendiceal orifice followed by stent and
      appendicolith retrieval. These were small case series conducted in China demonstrating
      technical feasibility and initial clinical success rate of this alternative approach. The
      technique has not been practiced in most centers across the world. The merit of endoscopic
      treatment lies in its potential to remove the appendicolith thereby reducing the recurrence
      rate. It could provide an invaluable treatment option that overcomes the drawback of high
      recurrence rate with antibiotics alone.

      Given that the novel endoscopic technique has not been widely adopted, the investigators plan
      to conduct this pilot study to investigate the feasibility, technical and clinical success
      rate of endoscopic retrograde appendicitis therapy among adult patients with uncomplicated
      acute appendicitis.
    

Intervention name(s): Endoscopic retrograde appendicitis therapy
Intervention type(s): Procedure
Intervention description(s): Colonoscopy would be introduced until visualization of the appendiceal orifice. Catheter would be placed in the appendix and decompression performed. After removal of appendicolith, plastic stent would be placed for drainage of appendix.
For patients successfully treated with initial endoscopic drainage, they would be re-admitted at 1 weeks after index procedure for repeat colonoscopy. After reaching the appendiceal orifice, the previous plastic stent would be removed. A contrast appendicogram would be repeated by introducing a wire-guided catheter in the appendix, and any residual fecalith would be removed. Finally, a repeat contrast appendicogram would be performed to confirm complete clearance of fecalith.
Intervention model: Single Group Assignment
Intervention model description: Single arm case series
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: appendicitis; endoscopic drainage