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Appendoscopy in patients with serrated polyposis syndrome

We read with great interest the study by McKay et al highlighting the topic of appendiceal involvement in patients with serrated polyposis syndrome (SPS). Considering a 68% prevalence of serrated lesions of the appendix in a series of 34 patients with SPS treated by colectomy, and the difficulty of ruling out an invasion of the appendiceal lumen in case of periappendiceal serrated lesions, the authors advocated prophylactic appendectomy in patients with SPS. SPS is the most frequent polyposis syndrome, with a prevalence of 0.42% in primary screening cohorts. While surgery remains needed for a third of the patients at inception due to the presence of an adenocarcinoma or a lesion burden not amenable to endoscopic resection, the management of SPS relies, in most of the cases, on the endoscopic clearance of all lesions, followed by a close endoscopic surveillance. 4 We agree with McKay et al on the impossibility to examine endoscopically the appendiceal lumen and mucosa, with the risk of overlooking an appendiceal or appendixinvading serrated lesion. Thus, we performed an appendoscopy during a surveillance colonoscopy, using cholangioscope (Spyglass DS, Boston Scientific, Boston, Natick, Massachusetts, USA), in a 40yearold woman with an SPS. The patient had a 20 mm, Paris II a, Nice I, lesion located in the periappendiceal region, suggestive of a sessileserrated lesion. Before performing endoscopic resection, we wanted to rule out an intraappendiceal extension of the lesion. A guidewire (Jagwire, Boston Scientific) was introduced into the appendix, and a singleuse cholangioscope (SpyScope, Boston Scientific) introduced through the colonoscope working channel in the appendiceal lumen. Using saline flushing, we expanded and washed the appendiceal lumen and ruled out an intraappendiceal extension of the caecal lesion and any other appendiceal serrated lesion (video 1, figure 1). The lesion was then resected by piecemeal endoscopic mucosal resection. The patient received an antibioprophylaxis by amoxicillinclavulanate for 5 days and was discharged after 24 hours. No appendicitis, abdominal pain or fever had occurred at the latest followup, 1 month after the endoscopy. Ferlitsch et al were the first to demonstrate the feasibility of performing an appendoscopy using a cholangioscope and used this technique to diagnose chronic appendicitis. The use of this technique to all patients with SPS is far from being financially sustainable, given the current costs of singleuse cholangioscopes. However, appendoscopy offers the possibility to avoid unnecessary appendectomies in patients with SPS with no appendiceal serrated lesions.