No Incision, No Resection: A New Method for Diagnosing and Treating Appendicitis—Endoscopic Retrograde Appendicitis Therapy (ERAT)

The general impression of the appendix is often that

it's useless, and if it gets inflamed, surgery is needed

As one of the human organs, is the appendix really useless?

What is the Appendix, and What is its Function?

The appendix is a section of intestine located at the junction of the small and large intestines. One end is a blind pouch, and the other end opens into the large intestine; hence, the part of the large intestine where the appendix opens is also called the cecum. Previously, the medical community believed the appendix was not an important structure, and appendectomy became the gold standard for treating acute appendicitis. However, in recent years, with deeper research, scientists have discovered that the appendix is not as useless as once thought. The appendix contains abundant lymphoid tissue, participates in the body's immune function, helps maintain intestinal flora balance, and effectively prevents enteritis. Furthermore, secretory cells in the appendix release digestive enzymes and hormones that can promote intestinal peristalsis, enhance intestinal motility, reduce the occurrence of constipation, and aid digestion and absorption. It is particularly noteworthy that the appendix has an important impact on the immune function of adolescents. Therefore, the concept of "preserving the appendix if possible" is gaining increasing recognition among medical professionals.

Why Do People Get Appendicitis?

The first reason is obstruction of the appendiceal lumen. Obstruction leads to fluid accumulation. Hyperplasia of the lymphoid follicles in the appendix wall is a common cause of appendiceal lumen obstruction; followed by fecalith obstruction; foreign bodies, inflammatory strictures, food residues, roundworms, and tumors are less common causes.

The second reason is bacterial invasion. After bacteria multiply extensively within the appendiceal lumen, they damage the appendiceal mucosa. Bacteria then enter the muscular layer of the appendix from ulcerated areas of the mucosa. After invading the appendiceal wall, they cause inflammation.

Why is Surgery Needed for Appendicitis?

Without exception, any surgical procedure causes new trauma to the patient. For a doctor, deciding whether a patient needs surgery is essentially a process of choosing the lesser of two evils. Let's look at what might happen if appendicitis is treated without surgery.

Non-surgical treatment may not be successful. Even if successful, it can lead to endless future troubles. If appendicitis occurs and is not treated with surgical removal, even if the inflammation is controlled, scars will form on the appendiceal lumen. Circular scars on the lumen can cause stenosis of the appendiceal lumen, which in turn can lead to future obstruction of the lumen. Therefore, once acute appendicitis has occurred, many patients, after healing with anti-inflammatory treatment, experience a recurrence after some time.

If appendicitis is treated non-surgically, it may lead to intra-abdominal abscesses, including appendiceal abscesses. Inside our abdominal cavity, there is the greater omentum, which hangs below the stomach and acts as a guardian in the abdomen. In ordinary people, after the appendix becomes inflamed, the greater omentum wraps around the inflamed appendix. So, even if the appendix perforates, the pus is contained within the greater omentum, causing at most a localized abscess and not leading to diffuse peritonitis, which rarely becomes life-threatening. However, treating an abdominal abscess is also very troublesome, costly, and painful for the patient. For women, an appendiceal abscess increases the risk of ectopic pregnancy. The right fallopian tube in women is very close to the appendix. When the appendix is inflamed, the inflammation can affect the fallopian tube, also causing salpingitis. If appendicitis is not treated promptly and an abscess forms, it often envelops the right fallopian tube within the abscess, making salpingitis more likely. Salpingitis can lead to stenosis of the fallopian tube. Fallopian tube stenosis increases the risk of future infertility or ectopic pregnancy. Therefore, if women develop appendicitis, they should actively seek early surgical treatment to avoid future complications.

If appendicitis is not treated surgically in time, it may lead to perforation, causing diffuse peritonitis. Generally, in children under 13 years old, because the greater omentum is not fully developed and its length does not reach the appendix, it cannot wrap the appendix. The same applies to some adults with poor constitution, especially the elderly. Once appendicitis in a child causes appendiceal perforation, it can easily lead to diffuse peritonitis, which can be life-threatening. Therefore, children and the elderly need early surgery even more and should not delay.

Non-surgical treatment of appendicitis can lead to some serious extra-appendiceal infections. For example, suppurative pylephlebitis, bacterial liver abscesses, etc. Clinically, we have also encountered patients with appendicitis leading to purulent meningitis.

Is There a Method Without Surgery?

Yes, it's called Endoscopic Retrograde Appendicitis Therapy (ERAT)

Endoscopic Retrograde Appendicitis Therapy (ERAT) involves procedures such as cannulation, contrast imaging, irrigation, and drainage to rapidly reduce pressure within the appendiceal lumen and resolve inflammation, while preserving the intact appendix. It is a simple, minimally invasive, scarless endoscopic procedure.

What are the Advantages of ERAT?

1. Fast Recovery! After endoscopic decompression of the appendiceal lumen, the patient's pain symptoms resolve quickly. Patients can resume daily activities immediately, avoiding the incision pain associated with surgical intervention.
2. 2.Wide Applicability! It provides a better treatment option for elderly, frail, or patients who cannot tolerate surgery for various reasons.
3. 3.Minimally Invasive! ERAT is minimally invasive, quick, and convenient. Preliminary clinical results show no complications such as bleeding, perforation, or periappendiceal abscess formation in patients.
4. 4.No Scar! The ERAT technique does not require incision; it is a minimally invasive endoscopic treatment leaving no wound or scar postoperatively.
5. 5.Preserves the Appendix!

Indications for ERAT Technique

• Acute simple appendicitis;
• Acute suppurative appendicitis;
• Some cases of appendicitis complicated by periappendiceal abscess;
• Contained appendiceal perforation;
  

Contraindications for ERAT Technique

• Acute gangrenous appendicitis;
• Appendiceal perforation complicated by intra-abdominal infection;
• Patients who cannot undergo colonoscopy.

Third Department of Gastroenterology

The Third Department of Gastroenterology has a total of 7 physicians and 9 nurses, including 2 associate chief physicians, 3 attending physicians, 2 resident physicians, 2 nurse-in-charge, 3 senior nurses, and 4 nurses. It has 48 open beds.

The department currently diagnoses and treats common and frequently occurring diseases such as gastroesophageal reflux disease, gastritis, peptic ulcers, gastrointestinal bleeding, functional gastrointestinal disorders, inflammatory bowel disease, etc. It is also particularly skilled in treating malignant tumors of the digestive tract like esophageal cancer, gastric cancer, pancreatic cancer, liver cancer, cholangiocarcinoma, and colorectal cancer, especially early-stage digestive tract cancers. The department has successfully performed: dilation of benign and malignant strictures and stent placement in the digestive tract, esophageal dilation and stent placement, endoscopic repair of esophageal-tracheal/mediastinal fistulas, endoscopic variceal sclerotherapy/ligation for esophageal and gastric varices, percutaneous endoscopic gastrostomy (PEG), endoscopic treatment of gastric and colonic polyps, endoscopic treatment of early digestive tract cancers (EMR, ESD), endoscopic sclerotherapy and ligation for esophageal and gastric varices, submucosal tunneling endoscopic resection (STER), peroral endoscopic myotomy (POEM), gastric peroral endoscopic myotomy (G-POEM), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound-guided puncture and treatment for pancreatobiliary diseases, and Endoscopic Retrograde Appendicitis Therapy (ERAT).

It also includes the diagnosis of malignant tumors such as gastric cancer, esophageal cancer, liver cancer, colon cancer, rectal cancer, gallbladder cancer, and lymphoma, as well as neoadjuvant chemotherapy, postoperative adjuvant chemotherapy, radical chemotherapy for mid-to-late stage tumors, comprehensive treatment for advanced metastatic tumors, biological immunotherapy, endocrine therapy, hyperthermic intraperitoneal chemotherapy (HIPEC), local drug injection therapy. Additionally, it offers procedures such as enteroscopy and endoscopic treatments, and capsule endoscopy.