Endoscopic Removal of an Appendiceal Orifice Polyp Using Double Forceps

Abstract

Polyps at the appendiceal orifice (AO) are rare and can pose unfamiliar endoscopic territory to colonoscopists. AO polyps pose a risk for appendiceal obstruction and resulting appendicitis in addition to malignant potential. Surgical removal via appendectomy or ileocecal resection has traditionally been indicated for such polyps but is associated with increased patient risk and cost. Currently, there is a lack of alternative methods for polyp resection. We describe a case of successful endoscopic AO polyp endoscopic mucosal resection (EMR) using two forceps introduced with a double-channel colonoscope. A 69-year-old male with a history of multiple colonic polyps was referred to our institution for removal of a polyp at the appendiceal orifice. Cecal intubation during colonoscopy showed a 4mm polypoid lesion extending down into the appendix. EMR was attempted and a modest lift of the polyp attained. Most of the polyp was removed with jumbo biopsy forceps, but it remained unclear if the entirety of the polyp was visible. A therapeutic double channel colonoscope was introduced, enabling the use of two biopsy forceps. One forceps was used to grasp the edge of the AO and stretch the tissue laterally, thus exposing the area within the AO that was previously not visualized. The other forceps was used to completely resect the remainder of the polyp. The same technique was used to apply argon plasma coagulation (APC) to the entire polypectomy defect. There were no adverse events, including bleeding or perforation. Follow-up colonoscopy with biopsy of the site three months later showed complete resection of the polyp. Technique Highlights: Most AO polyps are removed surgically. Surgery of any type poses increased healthcare costs to the patient and hospital, as well as complications related to anesthesia, infection, scarring, and bleeding, among others. Other previously described methods of AO polypectomy include underwater EMR, over-the-scope clip-assisted resection, and use of loop diathermy. Our method resection utilized less potentially expensive equipment, allowed the endoscopist to obtain a better view of the polyp, and resulted in complete resection without complications. Additional study is needed to determine the efficacy and safety of our double forcep method in the resection of inconveniently located polyps.Figure: Initial view of the AO polyp.Figure: Grasping of the polyp with one forceps while the other is being used to resect the remainder.Figure: Follow-up colonoscopy 3 months after polypectomy showing complete resection of the polyp.