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Endoscopic treatment for acute appendicitis with coexistent acute pancreatitis: Two case reports

BACKGROUND Appendectomy is the procedure of choice for the treatment of acute appendicitis. However, surgery may not be appropriate for patients with coexisting severe illness or comorbidities such as acute pancreatitis (AP). Endoscopic retrograde appendicitis treatment (ERAT) may be a novel alternative to surgery for treating such patients where existing medical therapies have failed. CASE SUMMARY We report 2 cases of moderately severe AP who developed acute uncomplicated appendicitis during their hospital stay and did not respond to traditional medical therapy. One patient had moderately severe AP due to hyperlipidemia, while the other patient had a gallstone induced by moderately severe AP. Neither patient was fit to undergo an appendectomy procedure because of the concurrent AP. Therefore, the alternative and minimally invasive ERAT was considered. After written informed consent was collected from the patients, the ERAT procedure was performed. Both patients exhibited fast postoperative recovery after ERAT with minimal surgical trauma. CONCLUSION ERAT is a safe and effective minimally invasive endoscopic procedure for acute appendicitis in patients with coexistent AP.


INTRODUCTION
Acute pancreatitis (severe acute pancreatitis) (AP) is mainly caused by biliary diseases and alcoholism. The incidence of AP is increasing [1] , and severe AP is associated with multiorgan dysfunction including cardiorespiratory failure, resulting in a higher rate of mortality [2] . The treatment of choice for acute appendicitis is laparoscopic or open appendectomy [3] , however, endoscopic retrograde appendicitis therapy (ERAT) is an emerging technique for the treatment of acute appendicitis. Inspired by endoscopic retrograde cholangiopancreatography for acute suppurative cholangitis, Liu et al [4] proposed the feasibility of endoscopic treatment of acute appendicitis in 2012 and subsequently conducted a multicenter study in China [5] . ERAT is a minimally invasive procedure that can be performed in uncomplicated cases of acute appendicitis. We report 2 cases of moderately severe AP where the patients also developed acute uncomplicated appendicitis and did not respond to medical therapy during the hospital stay. However, both laparoscopic and open appendectomies require anesthesia, which is associated with its own morbidity and risk of mortality in critically ill patients. Therefore, the 2 patients were treated by ERAT with minimal surgical trauma and fast postoperative recovery. Both patients were successfully treated.

Case 1
The patient started empirical intravenous antibiotics. Despite 2 d of antibiotic treatment, the patient had no significant improvement. Hence, the patient was considered for appendectomy, but the presence of moderately severe AP indicated a risk of respiratory and other complications associated with anesthesia for a laparoscopic or open appendectomy. On the other hand, there was no evidence of appendicular abscess or perforation. Therefore, an alternative minimally invasive ERAT was considered and was explained to the patient and his relatives.
ERAT does not require anesthesia. Therefore, after obtaining written informed consent, the ERAT procedure was performed. Before the procedure, the patient was given a low-pressure clean soap water enema (200-300 mL) 2-3 times. A conical transparent cap (Olympus Medical Corporation of Japan) was fixed to the tip of the enteroscope (Fujineng 4450, Japan) and then introduced into the large intestine. For the colonic insufflation, carbon dioxide gas was used. On reaching the ileocecal region, the opening of the appendix and Gerlach's valve was identified and the colonoscope was fixed near the appendix. The transparent cap was used to push the Gerlach's valve to the side to expose the appendix ( Figure 3A). The tip of the transparent cap was then aligned with the opening of the appendix. A loach guide wire was built into the enteroscope forceps. Under the guidance of the loach, the catheter was inserted into the appendiceal cavity for a length of about 2 cm. After the insertion of the catheter into the appendiceal cavity, the contrast agent ioversol (Jiangsu Hengrui Medicine Co., Ltd) was injected in a 1:1 ratio under fluoroscopic guidance ( Figure 3B). The appendiceal cavity was retrospectively visualized to reveal luminal stenosis and fecal impaction. The appendiceal cavity was irrigated with normal saline (100 mL) and tinidazole (200 mL) (Sichuan Kelun Pharmaceutical Co., Ltd.) using a 5 mL syringe, January 6, 2021 Volume 9 Issue 1 endoscopic forceps and pressure perfusion. This liquified the feces and facilitated its discharge into the cecum ( Figure 3C). After repeated flushing until the flushing liquid was clear, we observed that the appendiceal cavity had cleared. The procedure time was 40 min.

Case 2
ERAT was considered and explained to the patient and her relatives. After providing written informed consent, the ERAT procedure was performed. Before the procedure, the patient was given a low-pressure clean soap water enema (200-300 mL) 2-3 times.
The transparent cap was fixed to the enteroscope and advanced into the cecum ( Figure 4A and 4B). The opening of the appendix was seen with pus flowing out, and the mucosa at the opening of the appendix was markedly congested and edematous ( Figure 4C). Using catheter-guide wire technology, a catheter was inserted into the appendiceal cavity along with the guide wire, and the pus was suctioned to reduce the pressure in the appendiceal cavity. Under the guidance of bedside ultrasound, the appendiceal lumen was irrigated with saline (150 mL) and tinidazole (200 mL) ( Figure 4D). There was obstruction in the cavity due to fecal stones. After repeated flushing, the sediment-like fecal stones and pus were flushed out. Repeated flushing was performed until the irrigation fluid became clear. On bedside ultrasound, the cord-like material seen in the appendiceal cavity had disappeared. The procedure time was 60 min. The medical management of AP including antibiotics were continued.

Case 1
After 2 h of observation, the pain in the right lower quadrant gradually eased. The medical management of AP including antibiotics were continued. The fever and right lower quadrant pain resolved by the 3 rd d. Postoperative review of the appendix Bultrasound showed that the swelling of the appendix was significantly reduced, no fecal stones were seen in the appendix cavity, and the exudation around the appendix was significantly reduced. The patient recovered and was discharged after 4 d of hospital stay. At the last follow-up at 6 mo after discharge, the patient was symptom free.

Case 2
The pain in the right lower abdomen disappeared on the 3 rd d. Postoperative review of the appendix B-ultrasound showed that the swelling of the appendix was significantly reduced, no fecal stones were seen in the appendix cavity, the exudation around the appendix was significantly reduced, and the cord-shaped material disappeared. The patient recovered and was discharged after 5 d of hospital stay. At the last follow-up at 6 mo after discharge, the patient was symptom free.

DISCUSSION
For more than a century, an appendectomy has been the standard method for the January 6, 2021 Volume 9 Issue 1 treatment of acute appendicitis [6] . However, this procedure requires anesthesia, which has its own morbidity and risk of mortality in critically ill patients, similar to the 2 cases of moderately severe AP seen in this case series. In recent years, there is a consensus that surgical removal of the appendix increases the incidence of digestive tract tumors. Various studies have shown that the incidence of colonic tumors in patients after appendectomy is 14%, which is higher than those who have not had their appendix removed [7] . The appendix secretes digestive enzymes and hormones that promote intestinal motility [8] . In addition, recent experimental evidence suggests that the appendix may play an important role in the immune system [9] and may retain the normal microbial community of the individual [10] . Therefore, the appendix and its function must be preserved as much as possible.
In 2012, Liu et al [4] was the first to report the use of a novel ERAT for the treatment of acute uncomplicated appendicitis. ERAT is a new type of minimally invasive endoscopic treatment with less damage, higher safety and lower cost than general surgery. The main principle is to find the opening of the appendix using an enteroscope. The appendiceal lumen is then cannulated and repeated irrigation with antibiotics is performed to relieve the luminal obstruction and reduce the inflammatory edema of the appendix. For those with severe appendicitis and suppuration, a guide tube can be inserted into the irrigation tube to insert into the appendix after purging the internal pus. The fecal stones in the cavity can be removed by washing, mesh basket or balloon. If required, a stent can be placed to relieve the stenosis, drain the cavity and then flush the lumen with antibiotics. The procedure can be guided by ultrasound, which provides real-time intra-abdominal images to make the procedure safer. Later, several further studies confirmed that ERAT is effective for the direct diagnosis and treatment of acute appendicitis without excision of the appendix [11] .
In the 2 patients presented here, we used a soapy water low-pressure clean enema because soapy water can reduce the surface tension of water. This allows water to enter the stools quickly and facilitate the dilution and softening of the stools. Also, soapy water stimulates bowel motility, promotes defecation and facilitates bowel preparation. We used an enteroscope and carbon dioxide for insufflation as it is easily absorbed and thereby reduces the possibility of abdominal distension and aggravation of AP [12] . We successfully treated both patients with ERAT without any complications. ERAT also helped to retain the potential physiological function of the appendix. To the best of our knowledge, there is no previous study on the use of ERAT for patients with coexistent AP and appendicitis.
Recent systematic reviews and meta-analyses of random control trials have concluded that the majority of patients with uncomplicated acute appendicitis can be treated with an antibiotic-first approach [13][14][15] . But the 5-year follow-up results of the APPAC trial reported that among patients who were initially treated with antibiotics, the likelihood of late recurrence was 39.1% [16] . If antibiotics are combined with ERAT, we believe that better efficacy and lower recurrence rates can be achieved.