Endoscopic Retrograde Appendicitis Therapy – A Review of an Innovative Appendix Preserving Treatment Modality

Document Type : Review Article

Author

Department of Surgery, College of Medicine , Qassim University , Saudi Arabia .

10.30476/acrr.2025.107293.1250

Abstract

Acute appendicitis (AA) is one of the most frequent surgical emergencies and typically results from obstruction
of the appendiceal orifice. Currently, laparoscopic appendectomy is the gold standard treatment for appendicitis.
However, recent research has demonstrated the importance of the vermiform appendix in maintaining gut
flora and immunological function, and it is no longer considered vestigial. Consequently, there is a growing
need to develop appendix-preserving treatment modalities for AA. Antibiotic therapy was the first attempt
in this direction, and endoscopic retrograde appendicitis therapy (ERAT) represents a recent advancement.
The objective of this article is to provide an overview of this novel treatment modality and raise awareness
among healthcare professionals. A search of PubMed Gateway, Google Scholar search engine, Web of Science
platform, and ResearchGate social networking site was conducted to obtain relevant scientific articles published
in English. Since its introduction in China in 2012, several case series have confirmed the use of ERAT in both
uncomplicated and complicated appendicitis. ERAT is a promising treatment option for AA that preserves the
appendix; however, it has potential limitations and complications, just like other therapeutic approaches.

Highlights

Sajad Ahmad Salati (Google Scholar)

Keywords


1. Rajendran S, Natarajan K, Mohanty
A, et al. Caecal faecolith, a cause of
acute appendicitis. BMJ case reports.
2014;2014.
2. A ndy Pet roia nu T V V B.
Pathophysiology of Acute
Appendicitis. JSM Gastroenterology
and Hepatology. 2016;4(3):1062.
3. Lee MS, Purcell R, McCombie A, et
al. Retrospective cohort study of the
impact of faecoliths on the natural
history of acute appendicitis. World
journal of emergency surgery : WJES.
2023;18(1):18.
4. Kaewlai R, Wongveerasin
P, Lekanamongkol W, et al.
CT of appendicoliths in adult
appendicitis: clinical significance
and characteristics of overlooked
cases. European radiology.
2024;34(4):2534-45.
5. Teixeira PG, Demetriades D.
Appendicitis: changing perspectives.
Advances in surgery. 2013;47:119-40.
6. Singh JP, Mariadason JG. Role
of the faecolith in modern-day
appendicitis. Annals of the Royal
College of Surgeons of England.
2013;95(1):48-51.
7. Jaschinski T, Mosch C, Eikermann
M, et al. Laparoscopic versus
open appendectomy in patients
with suspected appendicitis: a
systematic review of meta-analyses
of randomised controlled trials. BMC
gastroenterology. 2015;15:48.
8. Kooij IA, Sahami S, Meijer SL,
et al. The immunology of the
vermiform appendix: a review of the
literature. Clinical and experimental
immunology. 2016;186(1):1-9.
9. de Almeida Leite RM, Seo DJ,
Gomez-Eslava B, et al. Nonoperative
vs Operative Management of
Uncomplicated Acute Appendicitis: A
Systematic Review and Meta-analysis.
JAMA surgery. 2022;157(9):828-34.
10. St Peter SD, Noel-MacDonnell JR,
Hall NJ, et al. Appendicectomy versus
antibiotics for acute uncomplicated
appendicitis in children: an openlabel,
international, multicentre,
randomised, non-inferiority
trial. Lancet (London, England).
2025;405(10474):233-40.
11. Sallinen V, Akl EA, You JJ, et al.
Meta-analysis of antibiotics versus
appendicectomy for non-perforated
acute appendicitis. The British journal
of surgery. 2016;103(6):656-67.
12. Podda M. Endoscopic retrograde
appendicitis therapy: a starting point
for a change of perspective in treating
acute appendicitis (and beyond).
Endoscopy. 2022;54.
13. Zhang A, Fan N, Zhang X,
et al. Endoscopic retrograde
appendicitis therapy. Therapeutic
advances in gastroenterology.
2024;17:17562848241275314.
14. Liu BR, Song JT, Han FY, et al.
Endoscopic retrograde appendicitis
therapy: a pilot minimally
invasive technique (with videos).
Gastrointestinal endoscopy.
2012;76(4):862-6.
15. Liu D, Zhang J, Liu B. Endoscopic
r e t rog r ade appendici t i s
therapy: current and the future.
G a s t r o e nt e r olog y r e p o r t .
2024;12:goae037.
16. Kang J, Zhang W, Zeng L, et al.
The modified endoscopic retrograde
appendicitis therapy versus antibiotic
therapy alone for acute uncomplicated
appendicitis in children. Surgical
endoscopy. 2021;35(11):6291-9.
17. Kong LJ, Zhang JY, Ullah S, et al.
SpyGlass-Guided Laser Lithotripsy
for the Treatment of Giant
Appendiceal Fecalith: First Human
Case Report. The American journal of
gastroenterology. 2021;116(10):1981-2.
18. Raxwal B, Payappagoudar J, Patel S.
Endoscopic Retrograde Appendicitis
Therapy in Subacute Appendicitis
With Abscess: A Comprehensive
Case Study and Innovative Insights.
Cureus. 2024;16(2):e54087.
19. Guo X, Yang H, Zhao P, et al. The
application value of high-frequency
ultrasound in the feasibility
assessment of endoscopic retrograde
appendicitis therapy in children with
appendicitis. Scientific Reports.
2023;13(1):19291.
20. Song M, Ullah S, Liu B. Endoscopic
Retrograde Appendicitis Therapy for
Treating Periappendiceal Abscess:
First Human Case Report. The
American journal of gastroenterology.
2021;116(6):1119.
21. Salati SA. Stump appendicitis - a
systematic analysis. Polski przeglad
chirurgiczny. 2021;94(1):62-9.
22. Haller F, Gasche C. Endoscopic
retrograde appendicitis therapy:
new approach in the treatment of
stump appendicitis. Endoscopy.
2022;54(1):E15-e6.
23. Kong L, Zhang H, Liu K, et al. How
to manage appendicitis in pregnancy
better. Gastrointestinal endoscopy. 2022;95(5):1018-9.
24. Wang XQ, Kong CH. Pediatric
chronic appendicitis without surgical
resection: A case study of endoscopic
retrograde appendicitis therapy
(ERAT). International journal of
surgery case reports. 2024;124:110386.
25. Liu L, Zeng H, Fang Y, et al. The
endoscopic retrograde appendicitis
therapy for acute appendicitis in
children: a systematic review and
meta-analysis. Research Square. 2023.
26. Cai J, Wang Y, Huang S, et al.
Unexpectedly detected appendiceal
perforation during endoscopic direct
appendicitis therapy despite negative
preoperative computed tomography
imaging. Endoscopy. 2024;56(S
01):E1026-e7.
27. Ma L, Hu J-W, Cai X-L, et al.
Endoscopic retrograde appendicitis
therapy for management of chronic
fecalith appendicitis. Surgical
endoscopy. 2024;39:409-16.
28. Pata F, Nardo B, Ielpo B, et al.
Endoscopic retrograde appendicitis
therapy versus appendectomy or
antibiotics in the modern approach to
uncomplicated acute appendicitis: A
systematic review and meta-analysis.
Surgery. 2023;174(6):1292-301.
29. Basukala S, Shrestha O, Thapa N, et al.
Outcomes of Endoscopic Retrograde
Appendicitis Therapy (ERAT) Vs
Laparoscopic Appendectomy (LA): A
systematic review and meta-analysis.
International Journal of Surgery
Open. 2023;59:100688.