The first rule that I follow if you're going to resect a lesion at the appendiceal orifice by traditional means is that the entire circumference of the lesion has to be visible and this is a serrated lesion that is surrounding the appendiceal orifice and we look down into the appendiceal orifice we can see that there's polyp, there's a little bump of polyp right down in the base in narrow band imaging and we never actually see the perimeter of this polyp it's down in the appendiceal orifice so I don't think traditional options are a good approach here we can either use the full thickness resection device if the appendix is intact we'll have about a 20% risk of appendicitis despite the use of antibiotics. My own preference in these cases is to send these lesions to my colorectal surgery colleagues and they do a basically distal cichectomy it's a very simple operation where the patient goes home the next day it's a laparoscopic operation and very low risk of a complication and very high cure rate for these lesions but if the appendix is missing then I think the full thickness resection device is a great option and obviously there's controversy about it because there's quite a literature developing on the use of FTRD for treatment of this kind of lesion but certainly for traditional simple methods like EMR this is not going to be successful in getting the entire lesion out because we can't see the entire lesion quite a bit of it is down the appendiceal lumen. Here's a more typical situation where we have a lesion right adjacent to the appendiceal orifice going down perhaps a bit into the lumen and the first thing is verify that we can see the entire circumference of the lesion if we can't see it initially we can do an injection into the mucosa in the appendiceal lumen on the same side as the lesion now we don't want to inject in the cecum on the side of the lesion opposite the appendiceal orifice because we push the lesion down into the orifice that's the same principle that that we followed on the ileocecal valve but now you can see that the margin closest to the appendix is visible at least for part of the lesion so we're going to go ahead and do some snaring and then we have to carefully inspect the margin close to the lumen to make sure that we've got all of it if we've missed part of it and this happens uh quite a bit there are a couple of ways to get that out of there one is to go underwater a second one is to use the cap technique that's what we're doing here we have the snare tip down the lumen and then we're sucking a little nodule of residual polyp up into the cap and then closing on it and removing it we can also just put the snare across the appendiceal lumen and then suck the appendiceal mucosa up into the cap that's what we're doing here and then once we've got a hold of the tissue i like to pull it up out of the um of the appendix so that we can see that we've got the margin of the polyp that's what's going on right now and you can see that the margin of the polyp is visible so we can be confident that we got the entire thing uh there's a high um a set of stakes associated with getting the whole thing and i like to use electrocautery for that reason because as we've discussed the recurrence rate seems to be lower when you use electrocauter if you take these these things out cold you'll still get a lot of scarring and the appendiceal lumen may be very narrow when you come back and if there is a recurrence or area of residual polyp it can be very hard to access it here's a serrated lesion you can't see it initially but in a second it's going to roll out of the appendiceal lumen and now we're going to inject it and again we're injecting on the side of the appendiceal lumen so that we push the lesion out away from the opening to the appendix if we inject on on this side away from the lumen we could push it down and make access very very difficult and we don't want to over inject because that opening there won't elevate the um appendix won't elevate and if you let the fluid spread all the way around the circumference you'll be ending up in a funnel where you are having very difficult um access and so now we're putting the snare tip down the appendiceal lumen again and uh snaring again using electrocautery and we talked before about the cap technique in this instance in order to clean up um the side of the lesion around the appendiceal opening we are using avulsion and notice that we're grabbing tissue and then stretching it out so we can examine the pit pattern there to make sure that uh everything is um absent serrated type pits so we're grabbing pulling up and uh the pits outside the forceps look normal just to make sure we're going to pull off by avulsion what's in uh the forceps and again the stakes are high to get complete eradication that's the rationale for electrocautery because when you come back the opening to the appendix will be very small if there's a recurrence going down into the lumen it'll be very difficult to access it if you do decide to clip it you don't have to for a lesion this size make sure you don't close the orifice to the appendix as the lesions get bigger you can follow the same principles here's a larger adenoma make sure you can see the whole circumference inject initially on the side by the appendiceal lumen and finally make sure that all the polyp at the luminal opening is gone so here's a lesion that's a little bit larger than the ones we saw earlier but it's serrated the last one we saw was an adenoma but again the principles are basically the same the emr of the portion that's away from the appendiceal orifice is going to be done by standard methods except in this case different than what we've advocated earlier for ssls we're removing this using electrocauterine again it's because the stakes are higher to get a complete resection because of the scarring and the narrowing of the luminal orifice of the appendix so we injected on the on the side of the appendiceal lumen we did the initial snaring often there's a little bit of residual polyp and again here we're using the cap technique we've gotten a hold of that and then we're going to resect that then we're going to get in really close to that appendiceal luminal opening inspect for any serrated glands that might have survived the resection remove them by cap or avulsion to summarize some key points about resection of appendiceal orifice lesions first of all the risk of appendicitis from traditional methods like emr is minimal i will admit i've never actually seen it happen if you can see the full circumference of the lesion then traditional emr will generally work and is relatively safe you should start the injection on the side of the lesion adjacent to the appendiceal lumen don't over inject i like electrocautery because we want to avoid recurrence there will be narrowing of the opening to the appendix and if there's lesion going down that appendiceal orifice it'll be hard to access it if you choose to clip close i will admit that i've closed some lesions in these videos that didn't meet the size criteria for closure but for various reasons decided to close them then i think it makes sense to not close the appendiceal opening put one prong or one jaw down the appendiceal luminal orifice but not across that orifice if you can't see the margin and there's no prior appendectomy then ftrd with antibiotics can be appropriate but there's a risk of appendicitis or you can do the distal catechumy operation but try to avoid right hemicolectomy in fact just emphatically avoid that for benign lesions if there's a prior appendectomy then ftrd is a great approach if the lesion is quite large you can use emr to scale it back to a size appropriate for ftrd thanks and see you next week on the asge suit tip of the week

lesions

resection techniques

colorectal surgery

electrocautery

margin inspection