Comment on: Endoscopic appendix opening sphincter incision to remove faecolith

Correspondence to: Chahrazed Dous

(email: douschahrazed@yahoo.com)

Tazoult City

BATNA

Algeria

5011

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BJS, https://doi.org/10.1093/bjs/znaf012, published 10 February 2025

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First of all, I appreciate the great work done by Lili Dong and et al.1 in presenting the case of endoscopic appendix opening sphincter incision to remove a faecolith. The procedure is clear and instructive.

However, endoscopic retrograde appendicitis therapy (ERAT) in adults with uncomplicated acute appendicitis remains controversial. The main issue is recurrence, which remains higher compared to laparoscopic appendicectomy2.

Additionally, this procedure is inspired by biliary sphincterotomy for treating common bile duct stones at the duodenal papilla. The difference is that in biliary sphincterotomy, we remove secondarily the cause of lithiasis by cholecystectomy. Conversely, ERAT only removes the faecolith and destroys the appendix's physiological sphincter. As a result, the appendix lumen will then be connected to the right colon cavity, where faecal matter could be a source of recurrence. This raises the question of the role of stent deployment, which should be discussed3.

Another concern is the long-term outcome. The authors did not provide long-term follow-up (reporting only 30 days postoperative outcome). I would like to know how the patient is doing in the longer term.

Moreover, this case describes a 62-year-old patient with chronic intermittent abdominal pain (a two-year history of intermittent pain). This clinical presentation does not align with acute appendicitis, it is more suggestive of appendicular tumour. This is a further worry with ERAT. It is often beneficial for positive diagnosis and differential diagnosis (e.g.  Crohn’s disease), but it is not always therapeutic.

Finally, there is a need to improve ERAT through international studies, as all studies on ERAT so far have originated from a single country, China.