Reduced recurrence rate with a targeted approach in uncomplicated appendicitis treated with endoscopic direct vs retrograde therapy

doi:10.3748/wjg.v31.i42.112106

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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World J Gastroenterol. Nov 14, 2025; 31(42): 112106
Published online Nov 14, 2025. doi: 10.3748/wjg.v31.i42.112106

Reduced recurrence rate with a targeted approach in uncomplicated appendicitis treated with endoscopic direct vs retrograde therapy

Jun Cai, Yang-Bor Lu, Yang Lv, Xiao-Juan Zhan, Ting Li, Guang Yang, Yu-Tong Ma, Jian-Zhen Ren, Bo Li, Heng Yu, Su-Huan Liao, Yi-Tian Guo, Qiu-Ping Qiu, Xiao-Ping Hong, Long-Bin Huang, Yu Zhang, Si-Lin Huang

Jun Cai, Guang Yang, Jian-Zhen Ren, Bo Li, Heng Yu, Su-Huan Liao, Yi-Tian Guo, Qiu-Ping Qiu, Xiao-Ping Hong, Long-Bin Huang, Si-Lin Huang, Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, Shenzhen 518116, Guangdong Province, China

Yang-Bor Lu, Xiao-Juan Zhan, Department of Digestive Disease, Xiamen Chang Gung Hospital, Hua Qiao University, Xiamen 361028, Fujian Province, China

Yang-Bor Lu, Xiao-Juan Zhan, Endoscopy Center, Xiamen Chang Gung Hospital, Hua Qiao University, Xiamen 361028, Fujian Province, China

Yang Lv, Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen 510086, Guangdong Province, China

Ting Li, Yu-Tong Ma, Yu Zhang, Department of Gastroenterology, The First People’s Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Kunming 650032, Yunnan Province, China

Ting Li, Yu-Tong Ma, Yu Zhang, Yunnan Provincial Clinical Medical Center for Digestive System Diseases, The First People’s Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Kunming 650032, Yunnan Province, China

Co-first authors: Jun Cai and Yang-Bor Lu.

Author contributions: Cai J, Lu YB, Yu H, Qiu QP, and Huang SL contributed to conceptualization; Cai J, Lv Y, Li T, Yang G, Ren JZ, Guo YT, and Zhang Y contributed to data curation; Cai J, Lu YB, Yang G, Qiu QP contributed to formal analysis; Cai J, Lu YB, Li T, Liao SH, Hong XP, Huang LB, and Huang SL contributed to methodology; Cai J and Ren JZ contributed to validation; Zhan XJ, Ma YT, Li B, and Liao SH contributed to investigation; Ma YT, Li B, and Liao SH contributed to visualization; Lv Y, Zhan XJ, Guo YT, and Qiu QP contributed to software; Lu YB, Li T, Yu H, Guo YT, Hong XP, Huang LB, Zhang Y, and Huang SL contributed to resources; Lu YB, Zhang Y, and Huang SL contributed to supervision; Cai J, Li T, and Ren JZ contributed to writing – original draft; Lu YB, Zhang Y, and Huang SL contributed to writing – review & editing; Huang SL contributed to funding acquisition; all authors have read and approved the final manuscript.

Supported by Guangdong Province Clinical Teaching Base Teaching Reform Research Project, No. 2021JD086.

Institutional review board statement: This study was approved by Ethics Committees of South China Hospital of Shenzhen University (approval number: HNLS20240205001-A) and Xiamen Chang Gung Hospital (approval number: XMCGIRB2024020).

Informed consent statement: Written informed consent was waived by the institutional review board for this secondary de-identified data analysis.

Conflict-of-interest statement: The authors declare no conflicts of interest related to the subject matter or materials discussed in this article.

STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.

Data sharing statement: The data that support the findings of this study are available from the authors on reasonable request, see author contributions for specific data sets.

Corresponding author: Si-Lin Huang, MD, Associate Chief Physician, Head, Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, No. 1 Fuxin Road, Longgang District, Shenzhen 518116, Guangdong Province, China. silinhuang@szu.edu.cn

Received: July 24, 2025
Revised: September 1, 2025
Accepted: October 11, 2025
Published online: November 14, 2025
Processing time: 118 Days and 3.9 Hours

Abstract

BACKGROUND

Endoscopic retrograde appendicitis therapy (ERAT) offers an appendix-preserving approach; however, visual and specificity challenges persist. Conversely, endoscopic direct appendicitis therapy (EDAT) provides direct visual observation with diagnostic and therapeutic capabilities.

AIM

To assess the efficacy and feasibility of EDAT and compare them with those of ERAT in uncomplicated appendicitis.

METHODS

In this retrospective cohort study, patients diagnosed with uncomplicated appendicitis and treated with ERAT or EDAT between January 2021 and November 2024 were reviewed. The primary outcome was intervention success. Secondary outcomes were guidewire use, stent placement, hospitalization duration, recurrence, and endoscopic direct-view features. Outcomes were compared between groups via appropriate statistical tests.

RESULTS

Of 170 patients, 136 underwent EDAT and 34 ERAT. EDAT showed higher intervention success than ERAT (99.3% vs 82.4%, P < 0.001), with less guidewire assistance and fewer stent placements (both P < 0.001). Hospital stay was shorter with EDAT (P = 0.039). The overall cumulative recurrence rates at 1 year were 10% in EDAT and 24% in ERAT; in the appendicolith subgroup, the recurrence rates were 5% and 14% in EDAT and ERAT, respectively. Findings were consistent in the propensity score-matched (PSM) cohort.

CONCLUSION

EDAT was demonstrated to be a more effective and feasible approach than ERAT, with a lower overall cumulative recurrence risk and within the appendicolith subgroup. Consistent results after PSM further supported the robustness of these findings.

Keywords: Appendicography; Appendicolith; Appendicoscope; Diagnosis; Endoscopic direct appendicitis therapy; Endoscopic retrograde appendicitis therapy; Fecalith; Negative appendectomy; Uncomplicated appendicitis

Core Tip: Endoscopic direct appendicitis therapy (EDAT) shows clear clinical advantages over endoscopic retrograde appendicitis therapy (ERAT) in the management of uncomplicated appendicitis. EDAT achieved significantly higher intervention success and lower recurrence rates, including in patients with appendicoliths, a subgroup at a high risk of antibiotic treatment failure. It also shortens hospital stay and stent replacement, improving procedural efficiency. As the first head-to-head comparison of EDAT and ERAT, this study provided novel evidence supporting EDAT as a more effective, minimally invasive option, with important implications for evolving non-surgical management strategies.