Intrapendicular lesions can be challenging. Their management can be by surgery or by advanced endoscopic techniques, like for example EMR, ESD or endoscopic full thickness resection. Cap suction underwater endoscopic mucosal resection could be helpful when conventional snaring is not possible. It consists in applying suction underwater to create enfolding of the lesion. This enfolding will make snaring easier, especially for flat or depressed lesions. Applying the same technique in the appendix by using a cap to suction the intrapendicial component could be helpful and make snaring easier. Herein we present two video cases of intrapendicial lesions resected and blocked by cap suction underwater endoscopic mucosal resection. There were no previous history of appendectomy in these patients. Procedures were performed under deep sedation with Propofol. Colonoscope was inserted with a conic-shaped cap. Once the lesion was reached, all gas was aspirated. Then saline is infused to fill the lumen in all the working area. The intrapendicial lesion is faced underwater. Cap suction is applied to invaginate the intrapendicial lesion into the lumen. Then the lesion is snared and resected. In this example, all the gas was already aspirated and you can see the lesion that is intrapendicial. Thank you. The elision is faced underwater with a conic-shaped cap. Suction is applied, with the objective of creating, unfolding or reimagination of the intrapendice elision. Once the lesion is invaginated, the snare is used for resection. It is important to maintain the underwater environment to maintain the muscularis propria away from the resection plane. The enfolder or invagination of the lesion keeps floating also due to the underwater environment. And block resection was complete without complications. In this second example, we can see a serrated lesion, it is affecting the appendicial orifice. Again, applying suction with a conic-shaped cup underwater, we create invagination of the lesion into the lumen. Then, a snaring is performed underwater and a block resection is completed without complications. Both patients were discharged on same day, after 1 to 2 hours of observation. Final histology shows right adhesion without dysplasia. There were no complications. The intra-appendicitis adhesions could be challenging, even if they are not too big. Cap suction underwater endoscopic mucosal resection might be a simple and safe alternative to other more complex treatments, such as ESD, endoscopic fulcinect resection or surgery. In conclusion, cap suction underwater endoscopic mucosal resection can be a useful and simple technique for endoscopic management of lesions with an intra-appendicial component.

cap suction underwater endoscopic mucosal resection

intrapendicular lesions

suction underwater

snaring

Propofol sedation