Download PDF
CC BY 4.0 · Endoscopy 2025; 57(S 01): E179-E180
DOI: 10.1055/a-2533-2996
E-Videos

Traction-assisted and saline immersion endoscopic submucosal dissection for complete resection of peri-appendiceal large nonpedunculated colorectal polyps

Michele Montori
1   Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy
2   Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium (Ringgold ID: RIN60200)
,
Maria E. Argenziano
1   Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy
2   Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium (Ringgold ID: RIN60200)
3   Faculty of Medicine and Health Sciences, University of Ghent, Gent, Belgium
,
Pieter J. Poortmans 
2   Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium (Ringgold ID: RIN60200)
4   Department of Gastroenterology and Hepatology, University Hospital Brussels, Brussel, Belgium
3   Faculty of Medicine and Health Sciences, University of Ghent, Gent, Belgium
,
Sander Smeets 
2   Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium (Ringgold ID: RIN60200)
3   Faculty of Medicine and Health Sciences, University of Ghent, Gent, Belgium
,
Andrea Sorge
2   Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium (Ringgold ID: RIN60200)
5   Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy (Ringgold ID: RIN9304)
,
Luca Maroni
6   Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy (Ringgold ID: RIN9294)
,
David J. Tate 
2   Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium (Ringgold ID: RIN60200)
3   Faculty of Medicine and Health Sciences, University of Ghent, Gent, Belgium
› Author AffiliationsSupported by: Università Politecnica delle Marche
› Further Information
Also available at
   Permissions and Reprints

Endoscopic resection can be challenging for large nonpedunculated colorectal polyps (LNPCPs) around the appendiceal orifice. Factors predicting failure of endoscopic mucosal resection (EMR) include deep invasion of the appendiceal orifice and >50% involvement of the appendiceal orifice. In contrast, patients with a previous appendectomy are often able to undergo complete resection using EMR for LNPCPs that completely cover the prior appendiceal orifice [1]. Unfortunately, it is often difficult to tell upfront which of these factors is present in a given LNPCP.

Other options include full-thickness resection, which carries a 25% risk of acute appendicitis and is not suitable for large lesions [2]. Surgery may also be considered, but an extended appendectomy is often insufficient for lesions extending into the cecum. More extensive surgery, such as ileocecal resection or right hemicolectomy, carry significant risks, including 20% morbidity and 0.5% mortality [3].

This case series ([Video 1]) demonstrates endoscopic submucosal dissection (ESD) for peri-appendiceal LNPCPs showing type 3a, 1, and 3 lesions according to Toyonaga’s classification [3].


Quality:
Multipoint traction is applied to lift and expose the appendix, facilitating clear visualization and access to the dissection plane. Source for graphical illustration: Created in BioRender. Vanhooren, M. (2025) https://BioRender.com/a33w603 [rerif].Video 1

Other studies have described the ESD technique for LNPCPs of the appendiceal orifice using both traction-assisted and nontraction methods [3] [4] [5]. However, none have described a combined approach using multipoint traction with saline immersion.

In this case series, multipoint traction, using a multiband system ([Fig. 1]), is applied to lift the appendix and expose the submucosal plane between the appendiceal mucosa and muscularis propria ([Video 1]) for precise dissection. Saline immersion is used intermittently to improve visualization and access to the dissection plane ([Fig. 2]).

Zoom Image
Fig. 1 The multiband system is applied with pink bands attached to the lesion margin and purple bands secured to an opposite fold, with the green band serving as a connection between the bands.
Zoom Image
Fig. 2 Assessment of the defect margins is performed in saline immersion and with magnification to ensure clear visualization and precise evaluation of the resection area.

In contrast to EMR, even lesions with deep invasion into the appendiceal orifice can be fully resected using this ESD-based technique as the caudal appendiceal margin can be visualized and the depth of mucosal incision within the appendix completely controlled. Furthermore, lesions fully encircling the orifice can also be completely removed.

In conclusion, using traction-assisted ESD with intermittent saline immersion, the skilled practitioner can avoid the pitfalls of EMR while avoiding the excess risks of full-thickness resection and laparoscopic surgery.

Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD

Endoscopy E-Videos https://eref.thieme.de/e-videos

E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).

This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.



Publication History

Article published online:
20 February 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Tate DJ, Desomer L, Awadie H. et al. EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video). Gastrointest Endosc 2018; 87: 1279-1288.e2
    CrossrefPubMedSearch in Google Scholar
  • 2 Bronzwaer MES, Bastiaansen BAJ, Koens L. et al. Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study. Endosc Int Open 2018; 6: E1112-e1119
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Jacob H, Toyonaga T, Ohara Y. et al. Endoscopic submucosal dissection of cecal lesions in proximity to the appendiceal orifice. Endoscopy 2016; 48: 829-836
    Thieme ConnectPubMedSearch in Google Scholar
  • 4 Figueiredo M, Yzet C, Wallenhorst T. et al. Endoscopic submucosal dissection of appendicular lesions is feasible and safe: a retrospective multicenter study (with video). Gastrointest Endosc 2023; 98: 634-638
    CrossrefPubMedSearch in Google Scholar
  • 5 Oung B, Rivory J, Chabrun E. et al. ESD with double clips and rubber band traction of neoplastic lesions developed in the appendiceal orifice is effective and safe. Endosc Int Open 2020; 8: E388-e395
    Thieme ConnectPubMedSearch in Google Scholar