Clinical Value of Visual endoscopic retrograde appendicitis therapy in Pediatric Appendicitis

Clinical Value of Visual endoscopic retrograde appendicitis therapy in Pediatric Appendicitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Value of Visual endoscopic retrograde appendicitis therapy in Pediatric Appendicitis Jialin Liu, Chuanghong Huang, Yu Luo, Bin Wang, Xiaoshuo Ye, Zhihan Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8106699/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objectives Explore the Clinical Value of Visual endoscopic retrograde appendicitis therapy in Pediatric Appendicitis. Methods Analysis of clinical data from 38 pediatric patients who underwent Visual endoscopic retrograde appendicitis therapy (V-ERAT) for appendicitis at Shenzhen Children's Hospital's Hepatobiliary and Oncology Surgery Department between December 2023 and April 2025. The study evaluated V-ERAT success rates, operative times, first-hospitalization appendectomy rate, and recurrence rate to evaluate the safety and efficacy of this procedure. Results All 38 patients underwent V-ERAT, with a surgical success rate of 92.11%. Three pediatric patients underwent laparoscopic appendectomy during their initial hospitalization, yielding an appendectomy rate of 7.89% during the first admission. The median operative time was 75 (55, 101) minutes. Thirty-three cases (94.29%) achieved a Numerical Rating Scale score < 3 at 6 hours postoperatively. No V-ERAT related complications occurred. Among the 34 patients followed up, 6 experienced recurrence, yielding a recurrence rate of 17.14%. Conclusions V-ERAT for pediatric appendicitis is a novel minimally invasive technique integrating diagnosis and treatment while preserving the appendix. It demonstrates promising preliminary efficacy and operates with high safety and reliability without requiring X-ray or ultrasound guidance. This approach features no external surgical incisions and facilitates rapid postoperative recovery, aligning with the principles of enhanced recovery after surgery (ERAS). Appendicitis Pediatric endoscopic surgery Visual endoscopic retrograde appendicitis therapy (V-ERAT) Diagnosis Figures Figure 1 1. Introduction Acute appendicitis is one of the most common acute abdominal conditions in children, and appendectomy is also a common surgical procedure[ 1 ]. Antibiotic therapy and appendectomy are standard treatments, with guidelines recommending laparoscopic appendectomy as the procedure of choice for pediatric acute appendicitis[ 2 ]. However, the long-term effects of appendectomy remain controversial, as some studies suggest the appendix plays a role in immunity and the regulation of intestinal flora[ 3 ]. Inspired by endoscopic retrograde cholangiopancreatography (ERCP), Prof. Liu Bingrong innovatively applied endoscopic retrograde appendicitis therapy (ERAT) in the treatment of acute appendicitis, and its safety and efficacy have been confirmed through extensive clinical practice[ 4 ]. With technological advancements, we have applied V-ERAT to treat pediatric appendicitis. The purpose of this study is to investigate the clinical value of this endoscopic retrograde appendicitis treatment under direct visual control in children. 2.Methods 2.1Patients This was a retrospective study of thirty-eight children with appendicitis—comprising cases of acute uncomplicated appendicitis[ 5 ], chronic appendicitis, and acute exacerbation of chronic appendicitis—who were admitted to the Department of Hepatobiliary and Oncologic Surgery at Shenzhen Children's Hospital between December 2023 and April 2025. Inclusion criteria: (1) < 18 years old, ability to tolerate colonoscopy with complete data; (2) clinically diagnosed with appendicitis based on clinical symptoms, signs, auxiliary examinations and endoscopic features. Exclusion criteria: (1) complicated appendicitis [ 5 ]; (2) other concomitant diseases; (3) incomplete clinical data. This study was reviewed and approved by the Medical Ethics Committee of Shenzhen Children's Hospital (Approval Number: 2023 − 576) in full compliance with the Helsinki Declaration. The requirement for patient-informed consent for this retrospective study was waived. 2.2 Treatment Method The Olympus CLV-290SL colonoscope and disposable imaging catheter was used. Patients underwent bowel preparation prior to V-ERAT. Polyethylene glycol electrolyte powder was administered in two doses (first dose between 6:00 PM and 8:00 PM the day before the examination; second dose 4 to 6 hours before the procedure on the day of examination). Each dose should not exceed 50 mL/kg, with an administration time of less than 1 hour per dose, and total volume not exceeding 4 L. For patients with inadequate bowel preparation, 0.9% Sodium Chloride Injection enema was used as rescue therapy. The patient was placed under intravenous general anesthesia in the left lateral or supine position. The colonoscope tip was inserted into the intestinal lumen via the cap and advanced to the terminal ileum to observe for redness, swelling, pus, or fecaliths at the appendiceal orifice. With disposable imaging catheter, enter the appendiceal lumen to assess mucosal hyperemia/edema, lumen narrowing, or fecalith obstruction. The disposable imaging catheters was advanced to the distal appendiceal lumen while repeatedly irrigating with 0.9% Sodium Chloride Injection to clear pus and small fecaliths. For large fecaliths, a retrieval basket was used. The disposable imaging catheters was retracted while flushing, allowing for simultaneous assessment of the appendiceal lumen cleanliness, the integrity of the luminal walls, and the presence of active mucosal bleeding (Figure.1). The procedure was then concluded. Postoperatively, empirical antibiotic therapy was administered. 2.3 Statistical analysis Statistical analysis was performed using SPSS 27.0. Continuous variables that met the criteria for normal distribution were expressed as x̄ ± s. Group comparisons were conducted using t-tests. Count data were presented as frequencies and percentages. Differences with P < 0.05 were considered statistically significant. 3.results The mean age of the included 38 children was (9.1 ± 3.2) years, of which 21 were male and 17 were female. Clinical symptoms included metastatic right lower abdominal pain in 36 cases (94.74%), right lower abdominal tenderness in 38 cases (100.00%), rebound tenderness in 10 cases (26.32%), and both anorexia and vomiting in 11 cases (28.95%). Preoperative median Alvarado score was 5 (3, 7). Direct endoscopic retrograde appendicitis treatment was performed after perfect bowel preparation on admission, 35 cases were successfully completed, of which 33 cases were considered acute uncomplicated appendicitis, 1 case of chronic appendicitis, and 1 case of acute exacerbation of chronic appendicitis, with a success rate of 92.11%. 2 cases failed to be flushed due to stenosis and tortuosity of appendiceal lumen, and 1 failed to be retrieved due to a huge faecal stone in the appendiceal lumen, and all these 3 cases were subjected to laparoscopic appendectomy, with the first hospitalisation The appendectomy rate was 7.89%, the median operation time was 75 (55, 101) min, and the median postoperative hospital stay was 4 (3, 4) days; the mean preoperative ultrasound appendiceal outer diameter was (7.60 ± 0.43) mm, and the mean postoperative ultrasound appendiceal outer diameter was (6.03 ± 0.29) mm, which was significantly smaller than that of the preoperative period (t = 5.622, P < 0.001). None of the children had V-ERAT-related complications. The median duration of postoperative diet was 12 (6, 18) h. There were 33 cases (94.29%) with Numerical Rating Scale < 3 at 6 hours postoperatively. Thirty-four cases were followed up through outpatient clinic and telephone, one case was lost, and the median follow-up time was 6 months, 6 children had recurrence, the recurrence rate was 17.14%(Table 1 ). Table 1 Basic characteristics of patients underwent V-ERAT. Patients N(All = 38)༈%༉ Sex Male 21(55.3%) Female 17(44.7%) Age mean ± SD(range) 9.1 ± 3.2(3–17) Clinical symptoms Metastatic right lower abdominal pain 36(94.74%) Right lower abdomen tenderness 38(100%) Rebound pain 10(26.32%) Anorexia 11(28.95%) Vomiting 11(28.95%) Body temperature >37.3℃ 7(18.42%) ≤ 37。3℃ 37(81.58%) Leukocyte >10×10 9 /L 19(50%) ≤ 10×10 9 /L 19(50%) Percentage of neutrophils >70% 20(57.14%) ≤ 70% 18(42.86%) Alvarado score ≤ 4 17(44.74%) 5–6 8(21.05%) 7–8 9(23.68%) 9–10 4(10.53%) Clinical success rate 35(92.11) Operation time(min) 75 (55, 101) a Conversion to Appendectomy 3(7.89%) Appendicitis recurrence 6(17.14%) Resolution of abdominal pain within 6 hours after V-ERAT 33(94.29%) duration of postoperative diet(h) 12 (6, 18) a Postoperative hospital stay(d) 4 (3, 4) a Follow up time(m) 6(4,7) a Postoperative complications None a Median and interquartile range Colonoscopy presentation and treatment: colonoscopy showed congestion and edema in the internal orifice of the appendiceal lumen in 35 cases, pus in the appendiceal lumen in 26 cases, presence of fecaliths in 24 cases, stenosis of the appendiceal lumen in 4 cases, and presence of pinworms and food residues in the lumen in 1 case each. All children were treated with simple irrigation of the appendiceal lumen and fecaliths were removed using mesh basket in 15 cases. 4.Discussion Appendicitis is a common disease in children, although its etiology is not fully understood. One of the most common causes is the formation of appendiceal fecal stones, which obstruct the appendiceal lumen. This obstruction leads to bacterial colonization, toxin production, and mucosal inflammation, ultimately resulting in infection[ 6 ]. Current guidelines recommend laparoscopic appendectomy and conservative antibiotic therapy as the standard treatments for acute uncomplicated appendicitis[ 2 ][ 7 ]. Laparoscopic appendectomy is considered a curative treatment for appendicitis, but its postoperative complications such as surgical incision infections, abdominal abscesses, and intestinal obstruction are often seen[ 8 ]. The appendix was historically regarded as a useless organ; However, studies have revealed that the appendix, as a lymphoid tissue-rich organ, plays an important role in immunomodulation and maintenance of the intestinal microbiota, and appendectomy may increase the long-term risk of several diseases such as colorectal cancer and cardiovascular disease[ 3 ]; Furthermore, the mortality rate after negative appendectomy has been documented to be 0.45%[ 9 ]. Conservative antibiotic treatment, as an alternative to surgery for acute uncomplicated appendicitis, can effectively avoid postoperative complications, but the results of a clinical trial with up to five years of follow-up showed a 39.1% likelihood of distant recurrence within five years and a risk of missed diagnosis of appendiceal-associated tumors[ 10 ]. In 2012, Professor Liu Bingrong pioneered the use of Endoscopic Retrograde Appendicitis Therapy (ERAT) for acute uncomplicated appendicitis through endoscopic appendiceal lumen intubation, decompression, retrograde appendicography, stent drainage, and lumen cleansing, effectively addressed the underlying pathophysiology, thereby establishing ERAT as a feasible and effective treatment option[ 11 ]. With the extensive application of the ERAT, a multicenter prospective study demonstrated a success rate of 94.55% and a recurrence rate of 14.55%, which has the advantage of rapid recovery compared to surgery and is expected to be a new alternative treatment[ 12 ]. Previously appendectomy was the main treatment for chronic appendicitis, and a retrospective study applied ERAT to treat 60 patients with chronic appendicitis, with a postoperative pain relief rate of 90%, reducing the need for negative appendectomy[ 13 ].The safety and efficacy of ERAT has been validated in the adult population, but its application in the pediatric is still lacking. ERAT was performed and followed up in 75 children with appendicitis in the literature, with a success rate of 91.78%, a median operative time of 22 min, a median postoperative hospitalization of 2 days, abdominal pain relief within 6 hours in 76.81% of patients, and resumption of a normal diet within 24 hours of surgery in 92.75%, with a recurrence rate of 14.92% at 1-year follow-up[ 14 ]. Conventional ERAT requires X-ray retrograde appendicography to identify fecaliths and strictures in the appendiceal lumen, which informs the subsequent treatment strategy, and rinsing and reimaging to confirm the appendiceal lumen patency after removing the stent[ 11 ].V-ERAT provides real-time intra-appendiceal view, enabling accurate identification of the luminal environment, reduces the damage to the appendiceal mucosa caused by blind insertion, maximizes the removal of fecaliths, and avoids the need for X-rays and contrast media[ 15 ]. Meanwhile, operation under direct vision avoids direct contact between endoscope and fecal stone, and flushing out the fecal stone by water flow power, which helps to reduce the incidence of appendiceal perforation[ 16 ]. Drainage stent placement has not been clearly standardized, and it is unknown whether drainage stent placement can be eliminated naturally. V-ERAT can identify non-obstructive appendicitis (e.g., lymphoid hyperplasia) from fecal stone obstruction and reduce unnecessary stent placement[ 17 ]. Stent displacement perforation has been reported in adult cases[ 18 ], whereas in Zhang et al. found no significant difference in recurrence rate between stenting and saline flushing alone[ 19 ]. In the present study, V-ERAT was not associated with these complications. Notably, even without stent placement, the postoperative ultrasound-measured appendiceal outer diameter (OD) was significantly reduced compared to the preoperative measurement, indicating effective decompression and drainage of the appendiceal lumen. In this study, 38 children underwent V-ERAT with a success rate of 92.11%. The median operative time was 76 minutes, with a median postoperative hospitalization of 4 days and a median time to resume a diet of 6 hours. At the 6-hour postoperative assessment, 94.29% of children reported a Numeric Rating Scale (NRS) score of < 3 points, which no need for painkillers . Based on telephone and outpatient follow-up, there was 1 case of lost visit and 6 children had recurrence, with a recurrence rate of 17.14%. The therapeutic efficacy was comparable to existing reports, and the procedure was associated with no related complications, reduced stress response, early dietary resumption, and rapid pain relief, consistent with the principles of enhanced recovery after surgery (ERAS). However, the operative time and postoperative hospitalization days were longer than in other centers. This discrepancy is likely attributable to the learning curve associated with the surgeons' initial experience with colonoscopy and the V-ERAT technique, and the follow-up time has been gradually shortened with the increase in surgical volume. V-ERAT was unsuccessful in three children. Two cases were due to an inability to perform irrigation caused by a stenotic and tortuous appendiceal lumen. The third child occurred in a patient with a large fecal stone that could not be removed from the appendiceal lumen; three patients subsequently underwent laparoscopic appendectomy. The rate of appendectomy during the initial hospitalization was 7.9%. A significant advantage of V-ERAT is the capability to use a mesh basket and laser for fecal stone removal. There are reports of using Spy Glass-guided laser lithotripsy combined with mesh baskets to extract large fecal stones, followed by stent placement to ensure adequate drainage of a narrowed appendiceal lumen[ 15 ]. In our series, a mesh basket and laser were used to remove fecal stones in 15 cases. The laser is an energetic device, and its application in pediatric patients is rarely reported. A study of the value of high-frequency ultrasound for ERAT in children found that fecaliths ≥ 0.8 cm in diameter and a tortuous appendiceal lumen with ≥ 3 bends adversely affected the difficulty and success of ERAT, and there was a risk of appendiceal perforation if fecaliths were forcibly removed using a mesh basket[ 20 ]. Based on our unit's experience, changing the patient's position intraoperatively can be attempted to dislodge the fecalith and flush the lumen. However, if the luminal obstruction cannot be adequately resolved, appendectomy should be considered to avoid the need for secondary anesthesia. Children with vague complaints, difficulty cooperating with examinations, atypical early symptoms, and rapid progression of the disease are prone to delayed diagnosis and treatment. The sensitivity of B-mode ultrasonography for the diagnosis of appendicitis is 85–90%, with a specificity of 90–95%, while the sensitivity and specificity of CT examination for appendicitis is about 95%[ 2 ]. The Alvarado score has a sensitivity of 67–71% and a specificity of 74–80%, with a score of > 7 considered positive for appendicitis[ 21 ]. It has been suggested that the endoscopic presence of congestion and edema, fecaliths, pus, tortuous, dilated or narrowed lumen in the appendiceal lumen may provide a basis for the diagnosis of appendicitis[ 14 ]. Our results were similar to the present study in which colonoscopy findings revealed congestion and edema at the appendiceal orifice in 35 cases, intraluminal pus in 26 cases, fecaliths in 24 cases, luminal stenosis in 4 cases, and pinworms or food residues in one case each. Therefore, we believe that V-ERAT is expected to be a new technique for the diagnosis of appendicitis, which is applicable to the early stage of acute appendicitis and chronic appendicitis, but needs to be mutually verified by subsequent endoscopic pathologic examination. 4.1Limitations However, this study has several shortcomings. Preoperative bowel preparation may increase the discomfort of the child, intraoperative pathology was not taken, and the effect of antibiotics could not be excluded. These areas represent the focus of our future research. 5.Conclusions In summary, V-ERAT is a novel, minimally invasive, diagnostic-therapeutic technique for pediatric appendicitis that preserves the appendix. which has a relatively significant preliminary efficacy. It demonstrates significant preliminary efficacy and a high safety profile. This technique does not require X-ray or ultrasound guidance and is characterized by the absence of a superficial surgical incision and rapid postoperative recovery, aligning with the principles of ERAS. Declarations Declaration of Competing Interest The authors declare that they have no competing interest. Author statement Jialin Liu: Writing - Original Draft、Visualization Chuanghong Huang: Data Curation Yu Luo: Investigation Bin Wang: Funding acquisition Xiaoshuo Ye: Project administration、Methodology Zhihan Li: Writing - Review & Editing、Conceptualization Funding This work was supported by Sanming Project of Medicine in Shenzhen, China (No.SZSM202411010). Author Contribution Jialin Liu: Writing - Original Draft、Visualization Chuanghong Huang: Data Curation Yu Luo: Investigation Bin Wang: Funding acquisition Xiaoshuo Ye: Project administration、Methodology Zhihan Li: Writing - Review & Editing、Conceptualization References Gil LA, Deans KJ, Minneci PC. Appendicitis in Children. Adv Pediatr 2023; 70(1):105–122. https://doi.org/10.1016/j.yapd.2023.03.003 Salö M, Tiselius C, Rosemar A, Öst E, Sohlberg S, Andersson RE. Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children. BJSOpen 2025;9(2):zrae165. https://doi.org/10.1093/bjsopen/zrae165 Song MY, Ullah S, Yang HY, Ahmed MR, Saleh AA, Liu BR. Long-term effects of appendectomy in humans: is it the optimal management of appendicitis? Expert Rev Gastroenterol Hepatol 2021; 15(6):657–664. https://doi.org/10.1080/17474124.2021.1868298 Liu D, Zhang J, Liu B. Endoscopic retrograde appendicitis therapy: current and the future. Gastroenterol Rep (Oxf) 2024; 12:goae037. Published 2024 Apr 27. https://doi.org/10.1093/gastro/goae037 Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015; 386(10000):1278–1287. https://doi.org/10.1016/S0140-6736(15)00275-5 Ke Zhan, Yang Bai, Tianyu Liu, Xing Su, Qingqing Yang, Yang Liu, et al. Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis. Am J Gastroenterol 2025; 120(5):1036–1044. https://doi.org/10.14309/ajg.0000000000003118 Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15(1):27. Published 2020 Apr 15. https://doi.org/10.1186/s13017-020-00306-3 Coccolini F, Licitra G, De'Angelis N, Martinez A, Cremonini C, Musetti S, et al. Complication analysis in acute appendicitis, results from an international multicenter study. Eur J Trauma Emerg Surg 2024; 50(1):305–314. https://doi.org/10.1007/s00068-023-02361-2 Ahmed HO, Muhedin R, Boujan A, et al. A five-year longitudinal observational study in morbidity and mortality of negative appendectomy in Sulaimani teaching Hospital/Kurdistan Region/Iraq. Sci Rep 2020; 10(1):2028. Published 2020 Feb 6. https://doi.org/10.1038/s41598-020-58847-1 Salminen P, Tuominen R, Paajanen H, et al. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA 2018; 320(12):1259–1265. https://doi.org/10.1001/jama.2018.13201 Liu BR, Song JT, Han FY, Li H, Yin JB. Endoscopic retrograde appendicitis therapy: a pilot minimally invasive technique (with videos). Gastrointest Endosc 2012; 76(4):862–866. https://doi.org/10.1016/j.gie.2012.05.029 Liu BR, Kong LJ, Ullah S, et al. Endoscopic retrograde appendicitis therapy (ERAT) vs appendectomy for acute uncomplicated appendicitis: A prospective multicenter randomized clinical trial. J Dig Dis 2022; 23(11):636–641. https://doi.org/10.1111/1751-2980.13148 Li Q, Liu T, Qin T. Cholangioscope-Assisted Endoscopic Retrograde Appendicitis Therapy in the Management of Chronic Abdominal Pain Related to the Appendix: A Single-Center Retrospective Study. Dig Dis Sci 2025; 70(3):1126–1131. https://doi.org/10.1007/s10620-024-08795-x Tu Q, Ullah S, Li D, et al. Safety and Efficacy of Endoscopic Retrograde Appendicitis Therapy for Pediatric Patients: A Single-Center Retrospective Study in Chinese Children. Am J Gastroenterol Published 2025 Mar 27. https://doi.org/10.14309/ajg.0000000000003428 Kong LJ, Liu D, Zhang JY, et al. Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy. Endoscopy 2022; 54(4):396–400. https://doi.org/10.1055/a-1490-0434 Pan JY, Zhi HX, Chen JL, et al. Direct visualization endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy for management of acute uncomplicated appendicitis. Endosc Int Open 2025; 13:a26386177. Published 2025 Aug 7. https://doi.org/10.1055/a-2638-6177 Liu Z, Ma X, Ullah S, et al. Endoscopic Retrograde Appendicography: An Alternative Diagnostic Method for Acute Appendicitis. Int J Gen Med 2021; 14:7043–7049. Published 2021 Oct 21. https://doi.org/10.2147/IJGM.S336040 Wang Q, Han Z, Zhao Q, Xu W. Stent migration after endoscopic retrograde appendicitis therapy. Gastrointest Endosc 2024; 100(3):573–574. https://doi.org/10.1016/j.gie.2024.03.016 Zhang A, Zhang Y, Fan N, et al. Modified endoscopic retrograde appendicitis therapy vs. laparoscopic appendectomy for uncomplicated acute appendicitis in children. Dig Endosc 2024; 36(9):1012–1020. https://doi.org/10.1111/den.14753 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. Sci Rep 2023; 13(1):19291. Published 2023 Nov 7. https://doi.org/10.1038/s41598-023-46387-3 Frountzas M, Stergios K, Kopsini D, Schizas D, Kontzoglou K, Toutouzas K. Alvarado or RIPASA score for diagnosis of acute appendicitis? A meta-analysis of randomized trials. Int J Surg 2018; 56:307–314. https://doi.org/10.1016/j.ijsu.2018.07.003 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Dec, 2025 Reviews received at journal 22 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 30 Nov, 2025 Reviewers invited by journal 19 Nov, 2025 Editor assigned by journal 18 Nov, 2025 Submission checks completed at journal 14 Nov, 2025 First submitted to journal 13 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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08:48:29","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1332340,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8106699/v1/71fbcea364ce10996b181ee2.jpeg"},{"id":96977682,"identity":"ace0fa35-d680-4b53-8928-536eaf8ad294","added_by":"auto","created_at":"2025-11-28 08:48:29","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":155159,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8106699/v1/72e312744875c025e6ee255f.png"},{"id":96977680,"identity":"e66f7aa7-170f-4bbb-b41a-07c529e61fef","added_by":"auto","created_at":"2025-11-28 08:48:29","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66604,"visible":true,"origin":"","legend":"","description":"","filename":"2eaf7882bfd340e7806ff1d9ee0aaf651structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8106699/v1/70d46196a0384211bc6a4dc0.xml"},{"id":97136754,"identity":"23f5d636-8e82-4188-979a-40762b98648c","added_by":"auto","created_at":"2025-12-01 09:56:58","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73629,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8106699/v1/a46c2e47a05fdd7058cc2459.html"},{"id":96977674,"identity":"3d2553d6-cbaa-4321-a533-3e7940449649","added_by":"auto","created_at":"2025-11-28 08:48:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":154706,"visible":true,"origin":"","legend":"\u003cp\u003eVisual endoscopic retrograde appendicitis therapy procedure. (A) Finding and exposing the orifice of the appendix. (B) Disposable imaging catheter intubation. (C) Appendix mucosal hyperemia/edema. (D,E) Flushing out pus and fecalith. (F) Fecalith was removed by the basket.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8106699/v1/696acf84e604739699c18bcf.jpg"},{"id":97144746,"identity":"c77910c9-26b4-4429-bb63-4c74adf3d000","added_by":"auto","created_at":"2025-12-01 10:11:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":636616,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8106699/v1/cf4c120c-7301-4275-9fbe-d73179401622.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Value of Visual endoscopic retrograde appendicitis therapy in Pediatric Appendicitis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAcute appendicitis is one of the most common acute abdominal conditions in children, and appendectomy is also a common surgical procedure[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Antibiotic therapy and appendectomy are standard treatments, with guidelines recommending laparoscopic appendectomy as the procedure of choice for pediatric acute appendicitis[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, the long-term effects of appendectomy remain controversial, as some studies suggest the appendix plays a role in immunity and the regulation of intestinal flora[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Inspired by endoscopic retrograde cholangiopancreatography (ERCP), Prof. Liu Bingrong innovatively applied endoscopic retrograde appendicitis therapy (ERAT) in the treatment of acute appendicitis, and its safety and efficacy have been confirmed through extensive clinical practice[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With technological advancements, we have applied V-ERAT to treat pediatric appendicitis. The purpose of this study is to investigate the clinical value of this endoscopic retrograde appendicitis treatment under direct visual control in children.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"2.Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1Patients\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis was a retrospective study of thirty-eight children with appendicitis\u0026mdash;comprising cases of acute uncomplicated appendicitis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], chronic appendicitis, and acute exacerbation of chronic appendicitis\u0026mdash;who were admitted to the Department of Hepatobiliary and Oncologic Surgery at Shenzhen Children's Hospital between December 2023 and April 2025. Inclusion criteria: (1)\u0026thinsp;\u0026lt;\u0026thinsp;18 years old, ability to tolerate colonoscopy with complete data; (2) clinically diagnosed with appendicitis based on clinical symptoms, signs, auxiliary examinations and endoscopic features. Exclusion criteria: (1) complicated appendicitis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]; (2) other concomitant diseases; (3) incomplete clinical data. This study was reviewed and approved by the Medical Ethics Committee of Shenzhen Children's Hospital (Approval Number: 2023\u0026thinsp;\u0026minus;\u0026thinsp;576) in full compliance with the Helsinki Declaration. The requirement for patient-informed consent for this retrospective study was waived.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Treatment Method\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe Olympus CLV-290SL colonoscope and disposable imaging catheter was used. Patients underwent bowel preparation prior to V-ERAT. Polyethylene glycol electrolyte powder was administered in two doses (first dose between 6:00 PM and 8:00 PM the day before the examination; second dose 4 to 6 hours before the procedure on the day of examination). Each dose should not exceed 50 mL/kg, with an administration time of less than 1 hour per dose, and total volume not exceeding 4 L. For patients with inadequate bowel preparation, 0.9% Sodium Chloride Injection enema was used as rescue therapy. The patient was placed under intravenous general anesthesia in the left lateral or supine position. The colonoscope tip was inserted into the intestinal lumen via the cap and advanced to the terminal ileum to observe for redness, swelling, pus, or fecaliths at the appendiceal orifice. With disposable imaging catheter, enter the appendiceal lumen to assess mucosal hyperemia/edema, lumen narrowing, or fecalith obstruction. The disposable imaging catheters was advanced to the distal appendiceal lumen while repeatedly irrigating with 0.9% Sodium Chloride Injection to clear pus and small fecaliths. For large fecaliths, a retrieval basket was used. The disposable imaging catheters was retracted while flushing, allowing for simultaneous assessment of the appendiceal lumen cleanliness, the integrity of the luminal walls, and the presence of active mucosal bleeding (Figure.1). The procedure was then concluded. Postoperatively, empirical antibiotic therapy was administered.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eStatistical analysis was performed using SPSS 27.0. Continuous variables that met the criteria for normal distribution were expressed as x̄ \u0026plusmn; s. Group comparisons were conducted using t-tests. Count data were presented as frequencies and percentages. Differences with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3.results","content":"\u003cp\u003eThe mean age of the included 38 children was (9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2) years, of which 21 were male and 17 were female. Clinical symptoms included metastatic right lower abdominal pain in 36 cases (94.74%), right lower abdominal tenderness in 38 cases (100.00%), rebound tenderness in 10 cases (26.32%), and both anorexia and vomiting in 11 cases (28.95%). Preoperative median Alvarado score was 5 (3, 7). Direct endoscopic retrograde appendicitis treatment was performed after perfect bowel preparation on admission, 35 cases were successfully completed, of which 33 cases were considered acute uncomplicated appendicitis, 1 case of chronic appendicitis, and 1 case of acute exacerbation of chronic appendicitis, with a success rate of 92.11%. 2 cases failed to be flushed due to stenosis and tortuosity of appendiceal lumen, and 1 failed to be retrieved due to a huge faecal stone in the appendiceal lumen, and all these 3 cases were subjected to laparoscopic appendectomy, with the first hospitalisation The appendectomy rate was 7.89%, the median operation time was 75 (55, 101) min, and the median postoperative hospital stay was 4 (3, 4) days; the mean preoperative ultrasound appendiceal outer diameter was (7.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43) mm, and the mean postoperative ultrasound appendiceal outer diameter was (6.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29) mm, which was significantly smaller than that of the preoperative period (t\u0026thinsp;=\u0026thinsp;5.622, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). None of the children had V-ERAT-related complications. The median duration of postoperative diet was 12 (6, 18) h. There were 33 cases (94.29%) with Numerical Rating Scale\u0026thinsp;\u0026lt;\u0026thinsp;3 at 6 hours postoperatively. Thirty-four cases were followed up through outpatient clinic and telephone, one case was lost, and the median follow-up time was 6 months, 6 children had recurrence, the recurrence rate was 17.14%(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBasic characteristics of patients underwent V-ERAT.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN(All =\u0026thinsp;38)༈%༉\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21(55.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(44.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2(3\u0026ndash;17)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetastatic right lower abdominal pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36(94.74%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight lower abdomen tenderness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38(100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRebound pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(26.32%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnorexia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(28.95%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVomiting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(28.95%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody temperature\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;37.3℃\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(18.42%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;37。3℃\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37(81.58%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeukocyte\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;10\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;10\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePercentage of neutrophils\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;70%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20(57.14%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;70%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18(42.86%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlvarado score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(44.74%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u0026ndash;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(21.05%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9(23.68%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(10.53%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical success rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35(92.11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperation time(min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (55, 101) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConversion to Appendectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(7.89%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAppendicitis recurrence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(17.14%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResolution of abdominal pain within 6 hours after V-ERAT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33(94.29%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eduration of postoperative diet(h)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (6, 18) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative hospital stay(d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (3, 4) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow up time(m)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(4,7) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative complications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e \u003cb\u003eMedian and interquartile range\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eColonoscopy presentation and treatment: colonoscopy showed congestion and edema in the internal orifice of the appendiceal lumen in 35 cases, pus in the appendiceal lumen in 26 cases, presence of fecaliths in 24 cases, stenosis of the appendiceal lumen in 4 cases, and presence of pinworms and food residues in the lumen in 1 case each. All children were treated with simple irrigation of the appendiceal lumen and fecaliths were removed using mesh basket in 15 cases.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"4.Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAppendicitis is a common disease in children, although its etiology is not fully understood. One of the most common causes is the formation of appendiceal fecal stones, which obstruct the appendiceal lumen. This obstruction leads to bacterial colonization, toxin production, and mucosal inflammation, ultimately resulting in infection[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Current guidelines recommend laparoscopic appendectomy and conservative antibiotic therapy as the standard treatments for acute uncomplicated appendicitis[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Laparoscopic appendectomy is considered a curative treatment for appendicitis, but its postoperative complications such as surgical incision infections, abdominal abscesses, and intestinal obstruction are often seen[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The appendix was historically regarded as a useless organ; However, studies have revealed that the appendix, as a lymphoid tissue-rich organ, plays an important role in immunomodulation and maintenance of the intestinal microbiota, and appendectomy may increase the long-term risk of several diseases such as colorectal cancer and cardiovascular disease[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; Furthermore, the mortality rate after negative appendectomy has been documented to be 0.45%[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Conservative antibiotic treatment, as an alternative to surgery for acute uncomplicated appendicitis, can effectively avoid postoperative complications, but the results of a clinical trial with up to five years of follow-up showed a 39.1% likelihood of distant recurrence within five years and a risk of missed diagnosis of appendiceal-associated tumors[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In 2012, Professor Liu Bingrong pioneered the use of Endoscopic Retrograde Appendicitis Therapy (ERAT) for acute uncomplicated appendicitis through endoscopic appendiceal lumen intubation, decompression, retrograde appendicography, stent drainage, and lumen cleansing, effectively addressed the underlying pathophysiology, thereby establishing ERAT as a feasible and effective treatment option[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. With the extensive application of the ERAT, a multicenter prospective study demonstrated a success rate of 94.55% and a recurrence rate of 14.55%, which has the advantage of rapid recovery compared to surgery and is expected to be a new alternative treatment[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Previously appendectomy was the main treatment for chronic appendicitis, and a retrospective study applied ERAT to treat 60 patients with chronic appendicitis, with a postoperative pain relief rate of 90%, reducing the need for negative appendectomy[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].The safety and efficacy of ERAT has been validated in the adult population, but its application in the pediatric is still lacking. ERAT was performed and followed up in 75 children with appendicitis in the literature, with a success rate of 91.78%, a median operative time of 22 min, a median postoperative hospitalization of 2 days, abdominal pain relief within 6 hours in 76.81% of patients, and resumption of a normal diet within 24 hours of surgery in 92.75%, with a recurrence rate of 14.92% at 1-year follow-up[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConventional ERAT requires X-ray retrograde appendicography to identify fecaliths and strictures in the appendiceal lumen, which informs the subsequent treatment strategy, and rinsing and reimaging to confirm the appendiceal lumen patency after removing the stent[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].V-ERAT provides real-time intra-appendiceal view, enabling accurate identification of the luminal environment, reduces the damage to the appendiceal mucosa caused by blind insertion, maximizes the removal of fecaliths, and avoids the need for X-rays and contrast media[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Meanwhile, operation under direct vision avoids direct contact between endoscope and fecal stone, and flushing out the fecal stone by water flow power, which helps to reduce the incidence of appendiceal perforation[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Drainage stent placement has not been clearly standardized, and it is unknown whether drainage stent placement can be eliminated naturally. V-ERAT can identify non-obstructive appendicitis (e.g., lymphoid hyperplasia) from fecal stone obstruction and reduce unnecessary stent placement[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Stent displacement perforation has been reported in adult cases[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], whereas in Zhang et al. found no significant difference in recurrence rate between stenting and saline flushing alone[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In the present study, V-ERAT was not associated with these complications. Notably, even without stent placement, the postoperative ultrasound-measured appendiceal outer diameter (OD) was significantly reduced compared to the preoperative measurement, indicating effective decompression and drainage of the appendiceal lumen. In this study, 38 children underwent V-ERAT with a success rate of 92.11%. The median operative time was 76 minutes, with a median postoperative hospitalization of 4 days and a median time to resume a diet of 6 hours. At the 6-hour postoperative assessment, 94.29% of children reported a Numeric Rating Scale (NRS) score of \u0026lt;\u0026thinsp;3 points, which \u003cb\u003eno need for painkillers\u003c/b\u003e. Based on telephone and outpatient follow-up, there was 1 case of lost visit and 6 children had recurrence, with a recurrence rate of 17.14%. The therapeutic efficacy was comparable to existing reports, and the procedure was associated with no related complications, reduced stress response, early dietary resumption, and rapid pain relief, consistent with the principles of enhanced recovery after surgery (ERAS). However, the operative time and postoperative hospitalization days were longer than in other centers. This discrepancy is likely attributable to the learning curve associated with the surgeons' initial experience with colonoscopy and the V-ERAT technique, and the follow-up time has been gradually shortened with the increase in surgical volume.\u003c/p\u003e\u003cp\u003eV-ERAT was unsuccessful in three children. Two cases were due to an inability to perform irrigation caused by a stenotic and tortuous appendiceal lumen. The third child occurred in a patient with a large fecal stone that could not be removed from the appendiceal lumen; three patients subsequently underwent laparoscopic appendectomy. The rate of appendectomy during the initial hospitalization was 7.9%. A significant advantage of V-ERAT is the capability to use a mesh basket and laser for fecal stone removal. There are reports of using Spy Glass-guided laser lithotripsy combined with mesh baskets to extract large fecal stones, followed by stent placement to ensure adequate drainage of a narrowed appendiceal lumen[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our series, a mesh basket and laser were used to remove fecal stones in 15 cases. The laser is an energetic device, and its application in pediatric patients is rarely reported. A study of the value of high-frequency ultrasound for ERAT in children found that fecaliths\u0026thinsp;\u0026ge;\u0026thinsp;0.8 cm in diameter and a tortuous appendiceal lumen with \u0026ge;\u0026thinsp;3 bends adversely affected the difficulty and success of ERAT, and there was a risk of appendiceal perforation if fecaliths were forcibly removed using a mesh basket[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Based on our unit's experience, changing the patient's position intraoperatively can be attempted to dislodge the fecalith and flush the lumen. However, if the luminal obstruction cannot be adequately resolved, appendectomy should be considered to avoid the need for secondary anesthesia.\u003c/p\u003e\u003cp\u003eChildren with vague complaints, difficulty cooperating with examinations, atypical early symptoms, and rapid progression of the disease are prone to delayed diagnosis and treatment. The sensitivity of B-mode ultrasonography for the diagnosis of appendicitis is 85\u0026ndash;90%, with a specificity of 90\u0026ndash;95%, while the sensitivity and specificity of CT examination for appendicitis is about 95%[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The Alvarado score has a sensitivity of 67\u0026ndash;71% and a specificity of 74\u0026ndash;80%, with a score of \u0026gt;\u0026thinsp;7 considered positive for appendicitis[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. It has been suggested that the endoscopic presence of congestion and edema, fecaliths, pus, tortuous, dilated or narrowed lumen in the appendiceal lumen may provide a basis for the diagnosis of appendicitis[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our results were similar to the present study in which colonoscopy findings revealed congestion and edema at the appendiceal orifice in 35 cases, intraluminal pus in 26 cases, fecaliths in 24 cases, luminal stenosis in 4 cases, and pinworms or food residues in one case each. Therefore, we believe that V-ERAT is expected to be a new technique for the diagnosis of appendicitis, which is applicable to the early stage of acute appendicitis and chronic appendicitis, but needs to be mutually verified by subsequent endoscopic pathologic examination.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e4.1Limitations\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHowever, this study has several shortcomings. Preoperative bowel preparation may increase the discomfort of the child, intraoperative pathology was not taken, and the effect of antibiotics could not be excluded. These areas represent the focus of our future research.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"5.Conclusions","content":"\u003cp\u003eIn summary, V-ERAT is a novel, minimally invasive, diagnostic-therapeutic technique for pediatric appendicitis that preserves the appendix. which has a relatively significant preliminary efficacy. It demonstrates significant preliminary efficacy and a high safety profile. This technique does not require X-ray or ultrasound guidance and is characterized by the absence of a superficial surgical incision and rapid postoperative recovery, aligning with the principles of ERAS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eDeclaration of Competing Interest\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAuthor statement\u003c/h2\u003e\u003cp\u003eJialin Liu: Writing - Original Draft、Visualization Chuanghong Huang: Data Curation Yu Luo: Investigation Bin Wang: Funding acquisition Xiaoshuo Ye: Project administration、Methodology Zhihan Li: Writing - Review \u0026amp; Editing、Conceptualization\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by Sanming Project of Medicine in Shenzhen, China (No.SZSM202411010).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJialin Liu: Writing - Original Draft、Visualization Chuanghong Huang: Data Curation Yu Luo: Investigation Bin Wang: Funding acquisition Xiaoshuo Ye: Project administration、Methodology Zhihan Li: Writing - Review \u0026amp;amp; Editing、Conceptualization\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGil LA, Deans KJ, Minneci PC. Appendicitis in Children. \u003cem\u003eAdv Pediatr\u003c/em\u003e 2023; 70(1):105\u0026ndash;122. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yapd.2023.03.003\u003c/span\u003e\u003cspan address=\"10.1016/j.yapd.2023.03.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSal\u0026ouml; M, Tiselius C, Rosemar A, \u0026Ouml;st E, Sohlberg S, Andersson RE. Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children. \u003cem\u003eBJSOpen\u003c/em\u003e 2025;9(2):zrae165. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/bjsopen/zrae165\u003c/span\u003e\u003cspan address=\"10.1093/bjsopen/zrae165\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSong MY, Ullah S, Yang HY, Ahmed MR, Saleh AA, Liu BR. Long-term effects of appendectomy in humans: is it the optimal management of appendicitis? \u003cem\u003eExpert Rev Gastroenterol Hepatol\u003c/em\u003e 2021; 15(6):657\u0026ndash;664. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/17474124.2021.1868298\u003c/span\u003e\u003cspan address=\"10.1080/17474124.2021.1868298\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu D, Zhang J, Liu B. Endoscopic retrograde appendicitis therapy: current and the future. \u003cem\u003eGastroenterol Rep (Oxf)\u003c/em\u003e 2024; 12:goae037. Published 2024 Apr 27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/gastro/goae037\u003c/span\u003e\u003cspan address=\"10.1093/gastro/goae037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhangu A, S\u0026oslash;reide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. \u003cem\u003eLancet\u003c/em\u003e 2015; 386(10000):1278\u0026ndash;1287. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(15)00275-5\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(15)00275-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKe Zhan, Yang Bai, Tianyu Liu, Xing Su, Qingqing Yang, Yang Liu, et al. Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis. \u003cem\u003eAm J Gastroenterol\u003c/em\u003e 2025; 120(5):1036\u0026ndash;1044. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.14309/ajg.0000000000003118\u003c/span\u003e\u003cspan address=\"10.14309/ajg.0000000000003118\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDi Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. \u003cem\u003eWorld J Emerg Surg\u003c/em\u003e 2020; 15(1):27. Published 2020 Apr 15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13017-020-00306-3\u003c/span\u003e\u003cspan address=\"10.1186/s13017-020-00306-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoccolini F, Licitra G, De'Angelis N, Martinez A, Cremonini C, Musetti S, et al. Complication analysis in acute appendicitis, results from an international multicenter study. \u003cem\u003eEur J Trauma Emerg Surg\u003c/em\u003e 2024; 50(1):305\u0026ndash;314. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00068-023-02361-2\u003c/span\u003e\u003cspan address=\"10.1007/s00068-023-02361-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmed HO, Muhedin R, Boujan A, et al. A five-year longitudinal observational study in morbidity and mortality of negative appendectomy in Sulaimani teaching Hospital/Kurdistan Region/Iraq. \u003cem\u003eSci Rep\u003c/em\u003e 2020; 10(1):2028. Published 2020 Feb 6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-020-58847-1\u003c/span\u003e\u003cspan address=\"10.1038/s41598-020-58847-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalminen P, Tuominen R, Paajanen H, et al. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. \u003cem\u003eJAMA\u003c/em\u003e 2018; 320(12):1259\u0026ndash;1265. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.2018.13201\u003c/span\u003e\u003cspan address=\"10.1001/jama.2018.13201\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu BR, Song JT, Han FY, Li H, Yin JB. Endoscopic retrograde appendicitis therapy: a pilot minimally invasive technique (with videos). \u003cem\u003eGastrointest Endosc\u003c/em\u003e 2012; 76(4):862\u0026ndash;866. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.gie.2012.05.029\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2012.05.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu BR, Kong LJ, Ullah S, et al. Endoscopic retrograde appendicitis therapy (ERAT) vs appendectomy for acute uncomplicated appendicitis: A prospective multicenter randomized clinical trial. \u003cem\u003eJ Dig Dis\u003c/em\u003e 2022; 23(11):636\u0026ndash;641. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1751-2980.13148\u003c/span\u003e\u003cspan address=\"10.1111/1751-2980.13148\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Q, Liu T, Qin T. Cholangioscope-Assisted Endoscopic Retrograde Appendicitis Therapy in the Management of Chronic Abdominal Pain Related to the Appendix: A Single-Center Retrospective Study. \u003cem\u003eDig Dis Sci\u003c/em\u003e 2025; 70(3):1126\u0026ndash;1131. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10620-024-08795-x\u003c/span\u003e\u003cspan address=\"10.1007/s10620-024-08795-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTu Q, Ullah S, Li D, et al. Safety and Efficacy of Endoscopic Retrograde Appendicitis Therapy for Pediatric Patients: A Single-Center Retrospective Study in Chinese Children. \u003cem\u003eAm J Gastroenterol\u003c/em\u003e Published 2025 Mar 27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.14309/ajg.0000000000003428\u003c/span\u003e\u003cspan address=\"10.14309/ajg.0000000000003428\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKong LJ, Liu D, Zhang JY, et al. Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy. \u003cem\u003eEndoscopy\u003c/em\u003e 2022; 54(4):396\u0026ndash;400. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/a-1490-0434\u003c/span\u003e\u003cspan address=\"10.1055/a-1490-0434\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePan JY, Zhi HX, Chen JL, et al. Direct visualization endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy for management of acute uncomplicated appendicitis. \u003cem\u003eEndosc Int Open\u003c/em\u003e 2025; 13:a26386177. Published 2025 Aug 7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/a-2638-6177\u003c/span\u003e\u003cspan address=\"10.1055/a-2638-6177\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu Z, Ma X, Ullah S, et al. Endoscopic Retrograde Appendicography: An Alternative Diagnostic Method for Acute Appendicitis. \u003cem\u003eInt J Gen Med\u003c/em\u003e 2021; 14:7043\u0026ndash;7049. Published 2021 Oct 21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/IJGM.S336040\u003c/span\u003e\u003cspan address=\"10.2147/IJGM.S336040\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Q, Han Z, Zhao Q, Xu W. Stent migration after endoscopic retrograde appendicitis therapy. \u003cem\u003eGastrointest Endosc\u003c/em\u003e 2024; 100(3):573\u0026ndash;574. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.gie.2024.03.016\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2024.03.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang A, Zhang Y, Fan N, et al. Modified endoscopic retrograde appendicitis therapy vs. laparoscopic appendectomy for uncomplicated acute appendicitis in children. \u003cem\u003eDig Endosc\u003c/em\u003e 2024; 36(9):1012\u0026ndash;1020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/den.14753\u003c/span\u003e\u003cspan address=\"10.1111/den.14753\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuo 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. \u003cem\u003eSci Rep\u003c/em\u003e 2023; 13(1):19291. Published 2023 Nov 7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-023-46387-3\u003c/span\u003e\u003cspan address=\"10.1038/s41598-023-46387-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrountzas M, Stergios K, Kopsini D, Schizas D, Kontzoglou K, Toutouzas K. Alvarado or RIPASA score for diagnosis of acute appendicitis? A meta-analysis of randomized trials. \u003cem\u003eInt J Surg\u003c/em\u003e 2018; 56:307\u0026ndash;314. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijsu.2018.07.003\u003c/span\u003e\u003cspan address=\"10.1016/j.ijsu.2018.07.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Appendicitis, Pediatric, endoscopic surgery, Visual endoscopic retrograde appendicitis therapy (V-ERAT), Diagnosis","lastPublishedDoi":"10.21203/rs.3.rs-8106699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8106699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eExplore the Clinical Value of Visual endoscopic retrograde appendicitis therapy in Pediatric Appendicitis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eAnalysis of clinical data from 38 pediatric patients who underwent Visual endoscopic retrograde appendicitis therapy (V-ERAT) for appendicitis at Shenzhen Children's Hospital's Hepatobiliary and Oncology Surgery Department between December 2023 and April 2025. The study evaluated V-ERAT success rates, operative times, first-hospitalization appendectomy rate, and recurrence rate to evaluate the safety and efficacy of this procedure.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll 38 patients underwent V-ERAT, with a surgical success rate of 92.11%. Three pediatric patients underwent laparoscopic appendectomy during their initial hospitalization, yielding an appendectomy rate of 7.89% during the first admission. The median operative time was 75 (55, 101) minutes. Thirty-three cases (94.29%) achieved a Numerical Rating Scale score\u0026thinsp;\u0026lt;\u0026thinsp;3 at 6 hours postoperatively. No V-ERAT related complications occurred. Among the 34 patients followed up, 6 experienced recurrence, yielding a recurrence rate of 17.14%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eV-ERAT for pediatric appendicitis is a novel minimally invasive technique integrating diagnosis and treatment while preserving the appendix. It demonstrates promising preliminary efficacy and operates with high safety and reliability without requiring X-ray or ultrasound guidance. This approach features no external surgical incisions and facilitates rapid postoperative recovery, aligning with the principles of enhanced recovery after surgery (ERAS).\u003c/p\u003e","manuscriptTitle":"Clinical Value of Visual endoscopic retrograde appendicitis therapy in Pediatric Appendicitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-28 08:48:25","doi":"10.21203/rs.3.rs-8106699/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-23T00:52:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T17:33:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T18:33:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145346565220613168048285519060238088571","date":"2025-12-02T17:26:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126190692983888038641753476147329815363","date":"2025-11-30T09:02:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-19T11:33:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-19T02:11:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-14T05:25:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Digestive Diseases and Sciences","date":"2025-11-13T14:21:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0dfdbc0a-8933-42a7-ad0d-4ba7fe427f2e","owner":[],"postedDate":"November 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-01T14:55:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-28 08:48:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8106699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8106699","identity":"rs-8106699","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}