Endoscopic retrograde appendicitis therapy versus sub-endoscopic retrograde appendicitis therapy for acute appendicitis

Endoscopic retrograde appendicitis therapy versus sub-endoscopic retrograde appendicitis therapy for acute 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 Endoscopic retrograde appendicitis therapy versus sub-endoscopic retrograde appendicitis therapy for acute appendicitis Shouli Cao, Song Li, Jinming Yan, Dongyun Xue, Fanlu Meng, Junshan Li, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4773779/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Objective This study aims to compare the effectiveness and clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT) with sub-endoscopic retrograde appendicitis therapy (SERAT) in treating acute appendicitis. Method This retrospective study analyzed 40 patients undergoing ERAT and 43 undergoing SERAT for acute appendicitis at Shandong Provincial Third Hospital, China, from November 2021 to November 2023. The analysis included patient clinicopathological characteristics, technical aspects of ERAT and SERAT, clinical success (symptom resolution and laboratory test normalization), length of hospital stay, complications, and recurrence rates. Results No significant differences were observed between the groups in terms of age, gender, complications, clinical manifestations, laboratory and imaging data, Alvarado score, etc. (P > 0.05); The SERAT group had significantly shorter operation and intubation times compared to the ERAT group (43.9 min vs. 20.8 min, P < 0.001; 257 sec vs. 103 sec, P < 0.001). No significant differences were found in stent implantation, fecalith removal, postoperative temperature normalization, VAS score 6 hours post-treatment, days to normal temperature and white blood cell count, length of hospital stay, and hospitalization costs (P > 0.05); The recurrence rate was significantly lower in the SERAT group (2.3%) compared to the ERAT group (17.5%) (P = 0.019). Conclusion SERAT is an effective and safe approach for the diagnosis and treatment of acute appendicitis, offering shorter operation and intubation times, a lower recurrence rate, and minimally invasive treatment. acute appendicitis endoscopic retrograde appendicitis therapy sub-endoscopic retrograde appendicitis therapy minimally invasive Figures Figure 1 Figure 2 Figure 3 Introduction Acute appendicitis is one of the most common acute abdominal conditions, typically arises from appendix obstruction, often due to fecalith blockage[ 1 , 2 ]. However, tumors or lymphoid hyperplasia can also frequently cause appendix obstruction. Surgical appendectomy, the standard treatment for over a century, often employs laparoscopic appendectomy (LA). However, complications like bleeding, wound infection, and intestinal obstruction are common[ 3 – 6 ]。Additionally, the risk of a negative appendectomy ranges from 8–15%[ 7 , 8 ]. Recent advancements in minimally invasive endoscopic technology have led to the emergence of endoscopic retrograde appendicitis therapy (ERAT), a novel, nonoperative approach for treating acute appendicitis[ 9 , 10 ]. ERAT combines endoscopy with interventional therapy to intubate the appendix lumen, relieving obstruction through appendix irrigation, fecalith extraction, and stent placement[ 9 , 11 ]. However, A limitation of ERAT is its inability to directly view images within the appendiceal cavity, fully exclude tumors, or precisely remove appendiceal fecalith[ 1 , 12 , 13 ]. eyeMax, a novel disposable biliary imaging system, enables direct observation of the appendix cavity in sub-endoscopic retrograde appendicitis therapy (SERAT). This system facilitates directional irrigation and, when required, lithotripsy. To date, no studies have compared the efficacy of ERAT and SERAT in treating acute appendicitis. This study aims to evaluate the feasibility of SERAT and ERAT in diagnosing and treating acute appendicitis. METHODS Patient Selection This retrospective study analyzed 83 patients diagnosed with acute appendicitis admitted to the Third Hospital of Shandong Province between November 2021 and November 2023. Inclusion criteria were: (1) Acute appendicitis confirmed or suspected based on CT or B-ultrasonography, with patients opting out of appendectomy; (2) Patients with an Alvarado score of ≥ 5. Exclusion criteria included: (1) Appendix perforation or other forms of complicated appendicitis; (2) Contraindications to colonoscopy; (3) Hemorrhagic, neurological, mental disorders, or other severe diseases; (4) Impaired cognitive function. A detailed flow chart on patient selection is shown in Fig. 1 . The study protocol was approved by the Medical Ethics Committee of the the Third Hospital of Shandong Province. Written informed consent was obtained from all participants. All experimental protocols involving human subjects adhered to the relevant national/international/institutional guidelines or the Declaration of Helsinki. Description of technique In the ERAT group, patients received either 2L of polyethylene glycol electrolyte solution or 300-500ml of clean enema, administered five times. The ERAT procedure included: 1) Inserting a colonoscope (CF-H290AI, Olympus, Japan) into the ileocecal area with a conical transparent cap to assess the appendix opening and surrounding mucosa for coprolite incarceration and abscess discharge; 2) Using a conical transparent cap to push the Gerlach valve and insert a wire-guided catheter into the appendiceal cavity; 3) Conducting appendiceal angiography with iohexol contrast medium to examine the appendiceal cavity's morphology and diameter, assess contrast medium leakage or filling defects, and identify appendiceal stones or perforations. Fecaliths were removed using a net basket or balloon as needed. 4) Repeatedly rinsing the appendiceal cavity with 50–100 mL of normal saline; 5) In cases with significant pus or a narrow appendiceal cavity, a 7F-8.5F plastic stent (SPSOF7-7, Cook, USA) was inserted for continuous drainage and rinsing; The endoscopic image of the ERAT procedure is depicted in Fig. 2 . In the SERAT group, preoperative preparations were identical to those in the ERAT group. The procedure involved pushing the Gerlach valve with a conical transparent cap and inserting a wire guide into the appendiceal cavity. Subsequently, the eyeMax was introduced along the guide wire to examine the cavity and inner wall of the appendix for stones or intraluminal pus. Treatments like stone removal, washing, and biopsy were performed as required. The endoscopic image of the SERAT procedure is depicted in Fig. 3. Antibiotics were administered to all patients for a maximum of three days post-surgery. Once abdominal pain subsided, patients were put on a liquid diet and discharged upon symptom relief and normalization of laboratory tests. Demographic and clinical data collected included age, sex, comorbidities, history of abdominal surgery, clinical symptoms (abdominal pain, fever, tenderness, rebound pain), and laboratory/imaging results (white blood cell count, neutrophil percentage, CRP, CT or ultrasound). Short-term surgical success was defined as effective appendicitis treatment without perforation or intraoperative complications like bleeding. Operation time, intubation time, stent placement, and fecalith extraction were compared between the two groups. Postoperative recovery metrics evaluated included time for temperature normalization, VAS score for abdominal pain 6 hours post-treatment, days until normal temperature and white blood cell count, length of hospital stay, and hospitalization costs. Endoscopic findings encompassed congestion and edema at the appendix opening and surrounding mucosa, presence of fecaliths, and pus discharge. eyeMax microscopic observations included intracavitary fecaliths, pus, pus moss attachment, hyperemia, edema on the appendix's inner wall, and lumen distortion, tortuosity, dilation, or stenosis. Recurrence rates and long-term postoperative outcomes, including abdominal pain, perforation, and diarrhea, were recorded and compared between the two groups. Statistical analyses Statistical analyses were conducted with SPSS 23.0 (IBM, Armonk, New York, USA). Differences in clinical characteristics were evaluated using the two-tailed Student’s t-test and the chi-square test. For categorical variables, statistical significance was determined using the chi-square test. A p-value < 0.05 was deemed statistically significant. Result Patient characteristics Patient Characteristics: The study comprised 40 patients in the ERAT group and 43 in the SERAT group. As detailed in Table 1 , no significant differences were observed between the groups in terms of age, gender, complications, history of abdominal surgery, clinical manifestations (abdominal pain, fever, other digestive symptoms, abdominal tenderness, rebound pain), laboratory and imaging findings (including white blood cell count, neutrophil percentage, CT or B-ultrasound), and Alvarado score (P > 0.05). Table 1 Comparison of patient characteristics ERAT SERAT P gender,(%) 0.953 Male 23(57.5) 25(58.1) Female 17(42.5) 18(41.9) age,(%) year 0.574 ≥60 7(17.5) 7(16.3) <60 33(82.5) 36(83.7) complications,(%) 0.843 Diabetes mellitus 2(5) 1(2.3) Hypertension 7(17.5) 6(14.0) Cardiovascular disease 1(2.5) 4(9.3) Liver cirrhosis 1(2.5) 0(0) history of abdominal operation, (%) 1(2.5) 2(4.7) 0.600 Symptoms Temperature > 37.2°C, (%) 11(27.5) 16(37.2) 0.361 Right lower abdominal tenderness,(%) 40(100) 43(100) - Nausea,(%) 30(75) 29(67.4) 0.478 Vomiting,(%) 18(45) 18(41.9) 0.800 Anorexia,(%) 32(80) 30(69.8) 0.321 Signs Right lower abdominal tenderness,(%) 40(100) 43(48.8) - Rebound tenderness,(%) 21(52.5) 18(41.9) 0.383 Laboratory examination WBC count (10 9 /L) > 10,(%) 17(42.5) 18(41.9) 0.953 Neutrophil percentages (%) > 70,(%) 30(75) 24(55.8) 0.282 Alvrrado score 7 ± 1.2(5–9) 6.81 ± 1.11(4–9) 0.462 VAS score 6.65 ± 1.07(5–9) 6.86 ± 1.12(5–9) 0.387 CT or B-ultrasound (%) 40(100) 43(100) - Table 2 Comparison of short-term efficacy ERAT SERAT P operate successfully, (%) 38(95) 41(95.3) 0.227 operation time, (min) 43.9 ± 17.8(18–85) 20.8 ± 14.3(5–58) < 0.001 intubation time,(s) 257 ± 90.0(65–415) 103 ± 70.1(10–312) < 0.001 stent implantation, (%) 21(52.5) 20(46.5) 0.941 fecalith removal, (%) 16(40) 23(53.5) 0.213 Failed intubation, (%) 2(5) 2(4.7) 0.941 transferred to surgery, (%) 2(5) 2(4.7) 0.941 Endoscopic manifestations, (%) Congestion and edema of appendiceal orifice 31(77.5) 39(90.7) 0.098 Dung stone and its incarceration 16(40) 15(34.9) 0.630 Pus and filth can be seen at appendiceal orifice 30(75) 39(90.7) 0.056 eyeMax manifestations, (%) - Congestion and edema of inner wall - 43(100) Excrement stone in cavity - 23(53.5) Intraluminal pus - 40(93.0) complication, (%) 0(0) 0(0) - WBC return to normal time (day), (%) 0.991 0–1 34(85) 37(86) 1–3 4(10) 4(9.3) >3 2(5) 2(4.7) temperature return to normal time (day), (%) 0.327 0–1 34(85) 39(90.7) 1–3 4(10) 4(9.3) >3 2(5) 0(0) VAS score 6h after treatment < 3, (%) 34(85) 40(93) 0.302 hospital stay, (day) 4.3 ± 2.6(1–14) 3.9 ± 2.6(1–12) 0.576 hospitalization cost, (RMB) 15735 ± 4975.4(12036–34365) 13967 ± 4848.5(5798–31205) 0.513 Table 3 Comparison of long-term efficacy ERAT SERAT P follow-up time, (day) 298(30–403) 264(27–381) 0.612 recurrence, (%) 7(17.5) 1(2.3) 0.019 surgery 2 1 follow-up 3 0 SERAT 2 0 Long-term adverse events, (%) - abdominal pain 0 0 perforate 0 0 diarrhea 0 0 Comparison of short-term efficacy Compared to the ERAT group, the SERAT group had significantly shorter operative and intubation times (44.8 min vs. 20.8 min, P < 0.001; 258 sec vs. 103 sec, P < 0.001). No significant differences were observed between the groups in stent implantation, fecalith removal rate, time for postoperative temperature normalization, VAS score at 6 hours post-treatment, days to normal temperature and white blood cell count, length of hospital stay, and hospitalization costs (P > 0.05). Endoscopic findings in the 43 SERAT patients included: congestion and edema at the appendiceal orifice in 39 cases (90.7%), fecalith in 15 cases (34.9%), and purulent discharge adhesion in 39 cases (90.7%). Direct examination with eyeMax revealed hyperemia and edema on the inner wall of the appendix in all 43 cases (100%), intracavitary fecalith in 23 cases (53.5%), and intracavitary pus and pus moss in 40 cases (93%). Comparison of long-term efficacy The average follow-up duration for the SERAT group was 264 days, during which 1 case experienced a relapse and underwent surgical resection. In contrast, the ERAT group had an average follow-up of 298 days, with 7 cases relapsing and a recurrence rate of 17.5%, a statistically significant difference (P = 0.019). Of these, 2 cases required surgical resection, 3 received conservative treatment, and 2 improved with additional SERAT treatment. During the follow-up period, no long-term adverse events like abdominal pain, perforation, or diarrhea were reported in either group. DISCUSSION Acute appendicitis ranks as one of the most frequent abdominal surgical emergencies globally. Appendiceal obstruction, often caused by appendiceal fecalith or stenosis, is the primary cause of acute appendicitis.[ 1 ] Other causes of appendiceal obstruction include tumors, infections, or lymphoid hyperplasia[ 14 , 15 ]. Regardless of its cause, appendix obstruction results in its dilation, presenting clinically as abdominal pain localized to the right lower abdomen, accompanied by fever, nausea, and vomiting. Historically, the most common treatment for appendicitis has been surgical resection. However, a significant proportion of patients (8–15%) undergo negative appendectomies[ 7 , 8 ], exposing them to unnecessary invasive procedures and associated risks, and increasing the economic burden on patients, healthcare systems, and society. Furthermore, the appendix plays a role in immunity, hosting beneficial microorganisms and contributing to the maintenance of intestinal bacterial homeostasis[ 16 ]. Additionally, a study has indicated a correlation between appendectomy and an increased risk of Crohn's disease[ 17 ]. The rapid advancement of endoscopic technology has introduced new, minimally invasive treatment options in clinical practice. ERAT, a novel approach for appendicitis treatment, enables observation of the appendiceal opening and surrounding mucosa.[ 9 ] This method involves decompressing the appendiceal cavity through endoscopic intubation. Based on endoscopic retrograde appendix angiography, appendix irrigation and stent drainage are conducted in cases of lumen stenosis or fecal stone obstruction. The procedure is straightforward and effectively addresses the underlying cause of the disease, yielding positive outcomes. While ERAT can diagnose appendicular fecalith via endoscopic retrograde appendectomy, complete removal of all fecaliths is not guaranteed[ 12 , 13 ]. EyeMax-assisted endoscopic retrograde appendicitis treatment allows for direct observation of the appendiceal cavity through colonoscopy, clearly revealing fecalith, pus, and hyperemia and edema in the inner wall of the appendix. This method circumvents the need for X-rays and contrast agents in cases of lumen distortion and stenosis. This approach not only resolves the issue of needing X-ray guidance for appendiceal irrigation and stent placement but also allows for examination of the entire appendiceal cavity, crucial in selecting the appropriate stent. The comparative efficacy of ERAT and SERAT in treating acute appendicitis has not been previously reported. The study is the first to highlight SERAT's advantages over ERAT in acute appendicitis treatment. The study included 83 patients with acute appendicitis, showing no significant differences in baseline data when compared to the ERAT group. In the ERAT group, 2 patients required direct surgical resection due to failure of catheterization caused by appendix edema. Similarly, in the SERAT group, 2 patients experienced catheterization failure. Causes of catheterization failure included fecalith embedded in the appendix opening, swelling and bulbous formation at the appendix opening, and blockage of the appendix opening. The study revealed that the SERAT group's operation time was significantly shorter than the ERAT. This efficiency stems from avoiding intubation imaging, as SERAT allows for direct visualization of the appendix cavity, irrigation, and fecalith extraction using eyeMax, making the process more intuitive, convenient, and time-efficient. eyeMax findings included: hyperemia and edema in the inner wall of the appendix in all 43 cases (100%), intracavitary fecalith in 23 cases (53.5%), and intracavitary pus and pus moss in 40 cases (93%). During the follow-up, the SERAT group experienced 1 recurrence, whereas the ERAT group had 7 recurrences, with a recurrence rate of 23.3%. Of these, 2 cases in the ERAT group required surgical resection with postoperative pathology confirming appendicitis, 3 were treated conservatively, and 2 improved with subsequent SERAT treatment. The study concluded that ERAT and SERAT are viable treatments for acute appendicitis, offering benefits like appendix preservation, avoidance of surgical resection, high success rates, and shorter hospital stays. However, there remains a risk of appendicitis recurrence, potentially necessitating an appendectomy in the future. SERAT allows for direct and clear observation of the inner wall congestion and edema of the appendix cavity, fecalith, and lumen stenosis. Postoperatively, SERAT features a shorter recovery time and a significantly lower recurrence rate compared to the ERAT group. Additionally, SERAT is a feasible option for certain pregnant women, children, and patients who are unsuitable for or unwilling to undergo radiological examinations. This study has certain limitations, including potential selection bias inherent in its retrospective, single-center design. The study is limited by a small sample size and a relatively short follow-up period. A larger sample size in a randomized controlled study is needed to confirm the superiority of SERAT in appendicitis treatment. Although conducted in a major tertiary medical center with extensive experience, there remains a need for further refinement of the operative technique. In conclusion, SERAT is a safe and effective treatment for acute appendicitis, offering shorter operation and intubation times, and a lower recurrence rate compared to ERAT. eyeMax enables direct visualization of the appendix cavity, facilitating targeted irrigation and lithotripsy when required. Declarations Ethics approval and consent to participate The study protocol was approved by the Medical Ethics Committee of the the Third Hospital of Shandong Province. Written informed consent was obtained from all participants. All experimental protocols involving human subjects adhered to the relevant national/international/institutional guidelines or the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution XPL proposed the study and were accountable for all aspects of the work. SLC,SL,JMY and DYX contributed to the article in the aspects of drafting work as well as collecting, analyzing and interpreting the data;FLM and JSL made essential contribution to the manuscript. All authors read and approved the final manuscript. Data Availability All data generated or analysed during this study are included in this published article and its supplementary information files. References Bhangu A, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278–87. Humes DJ. J Acute appendicitis BMJ. 2006;333:530–4. Simpson. National Surgical Research. Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy. Br J Surg. 2013;100(9):1240–52. Poprom N, et al. The efficacy of antibiotic treatment versus surgical treatment of uncomplicated acute appendicitis: Systematic review and network meta-analysis of randomized controlled trial. Am J Surg. 2019;218(1):192–200. Andersson RE. Small bowel obstruction after appendicectomy. Br J Surg. 2001;88:1387–91. ) . Tingstedt B, et al. Late abdominal complaints after appendectomy–readmissions during long-term follow-up. Dig Surg. 2004;21(1):23–7. Seetahal SA, et al. Negative appendectomy: a 10-year review of a nationally representative sample. Am J Surg. 2011;201(4):433–7. Lu CL, et al. Irritable bowel syndrome and negative appendectomy: a prospective multivariable investigation. Gut. 2007;56(5):655–60. Liu BR, et al. Endoscopic retrograde appendicitis therapy (ERAT): a multicenter retrospective study in China. Surg Endosc. 2015;29(4):905–9. Liu BR, et al. Endoscopic retrograde appendicitis therapy: a pilot minimally invasive technique (with videos). Gastrointest Endosc. 2012;76(4):862–6. Li Y, et al. Diagnosis of Acute Appendicitis by Endoscopic Retrograde Appendicitis Therapy (ERAT): Combination of Colonoscopy and Endoscopic Retrograde Appendicography. Dig Dis Sci. 2016;61(11):3285–91. Wang F et al. Digital single-operator cholangioscopy-guided appendiceal intubation for endoscopic retrograde appendicitis therapy in a pregnant woman (with video). Gastrointest Endosc, 2023. 98(6): pp. 1034–1035. Kong LJ, et al. Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy. Endoscopy. 2022;54(4):396–400. Krzyzak M, Mulrooney SM. Acute Appendicitis Review: Background, Epidemiology, Diagnosis, and Treatment. Cureus. 2020;12(6):e8562. Gaetke-Udager K, Maturen KE, Hammer SG. Beyond acute appendicitis: imaging and pathologic spectrum of appendiceal pathology. Emerg Radiol. 2014;21(5):535–42. Randal Bollinger R, et al. Biofilms in the large bowel suggest an apparent function of the human vermiform appendix. J Theor Biol. 2007;249(4):826–31. Andersson RE, et al. Appendectomy is followed by increased risk of Crohn's disease. Gastroenterology. 2003;124(1):40–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Jul, 2024 Editor assigned by journal 25 Jul, 2024 Submission checks completed at journal 25 Jul, 2024 First submitted to journal 20 Jul, 2024 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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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4773779","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331731219,"identity":"5d40bb32-82b7-4992-99dc-be9a750f7ec3","order_by":0,"name":"Shouli Cao","email":"","orcid":"","institution":"Shandong Provincial Third Hospital, Cheeloo College of Medcine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Shouli","middleName":"","lastName":"Cao","suffix":""},{"id":331731221,"identity":"3fdb40b0-e422-442f-b410-7549c638532f","order_by":1,"name":"Song Li","email":"","orcid":"","institution":"Shandong Provincial Third Hospital, Cheeloo College of Medcine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Song","middleName":"","lastName":"Li","suffix":""},{"id":331731222,"identity":"ad0e51bd-7a06-4b78-834b-e52bb01164ff","order_by":2,"name":"Jinming Yan","email":"","orcid":"","institution":"Shandong Provincial Third Hospital, Cheeloo College of Medcine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Jinming","middleName":"","lastName":"Yan","suffix":""},{"id":331731224,"identity":"eb5fa6c7-e9ea-4bc4-94e1-fe9d61cb0f5a","order_by":3,"name":"Dongyun Xue","email":"","orcid":"","institution":"Shandong Provincial Third Hospital, Cheeloo College of Medcine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Dongyun","middleName":"","lastName":"Xue","suffix":""},{"id":331731225,"identity":"b652c7c8-f4ff-456c-a840-6ef956ebc5b8","order_by":4,"name":"Fanlu Meng","email":"","orcid":"","institution":"Shandong Provincial Third Hospital, Cheeloo College of Medcine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Fanlu","middleName":"","lastName":"Meng","suffix":""},{"id":331731226,"identity":"2b6f4905-bc6e-4219-88e1-f404305486d1","order_by":5,"name":"Junshan Li","email":"","orcid":"","institution":"Shandong Provincial Third Hospital, Cheeloo College of Medcine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Junshan","middleName":"","lastName":"Li","suffix":""},{"id":331731228,"identity":"f1b8cb5e-1a05-479e-8cca-b74510467537","order_by":6,"name":"Xiaopei Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYDACZjApkcDY3tj44ANpWnoONxvOIMWyBAaJ9DZpDmKUGhxnfvi4oMIij3nmwwZpBgY7Od0GAlokm9mMjWeckShmnJ3YYFzAkGxsdoCAFn5mBjNp3jaJxEagluQZDAcStxHSwsbM/k2a9x9Qy8yDDYd5iNHCz8wDtKUBqGUGY2MzUVokm3mKjWccA/qlJ7GZcYYBEX4xOH984+OCmro8w/bjz398qLCTI6gFBMCxadgANoEI5XAt8kQqHgWjYBSMghEIAHDXP2wkiZVfAAAAAElFTkSuQmCC","orcid":"","institution":"Shandong Provincial Third Hospital, Cheeloo College of Medcine, Shandong University","correspondingAuthor":true,"prefix":"","firstName":"Xiaopei","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-07-20 15:30:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4773779/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4773779/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63365626,"identity":"5d6e3182-dbf9-4432-bb42-c3c301f14857","added_by":"auto","created_at":"2024-08-27 11:12:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":158868,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram for the patients in this study.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4773779/v1/59a1937143c7da638f427091.jpg"},{"id":63364808,"identity":"26a99eea-fa50-43c7-a5c8-9dc022e6c12a","added_by":"auto","created_at":"2024-08-27 11:04:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":132863,"visible":true,"origin":"","legend":"\u003cp\u003eProcedures of endoscopic retrograde appendicitis therapy (ERAT). A： Appendiceal edema. (B) Pus extraction. (C) The endoscopic retrograde appendicography (ERA) fluoroscopy show the appendix lumen. D: Remove the appendix fecalith.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4773779/v1/59243a4dea70f78608adbb65.jpg"},{"id":63366309,"identity":"6be7ac8c-3e91-4897-b6e3-2d853e5947da","added_by":"auto","created_at":"2024-08-27 11:20:04","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1547057,"visible":true,"origin":"","legend":"\u003cp\u003eProcedures of sub-endoscopic retrograde appendicitis therapy (SERAT). A: Congestion and edema around the mucosa of appendix orifice. B: Spyglass insertion. C: Edema of the inner wall of the appendix. D: Appendix fecalith\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4773779/v1/1a3109f803051245aca4ddc4.jpg"},{"id":63366310,"identity":"40d93311-87bd-43cd-97ca-80fc13dd3cc6","added_by":"auto","created_at":"2024-08-27 11:20:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2317936,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4773779/v1/16e16cfb-c11b-4718-8385-41e63a0556a8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endoscopic retrograde appendicitis therapy versus sub-endoscopic retrograde appendicitis therapy for acute appendicitis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute appendicitis is one of the most common acute abdominal conditions, typically arises from appendix obstruction, often due to fecalith blockage[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, tumors or lymphoid hyperplasia can also frequently cause appendix obstruction. Surgical appendectomy, the standard treatment for over a century, often employs laparoscopic appendectomy (LA). However, complications like bleeding, wound infection, and intestinal obstruction are common[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]。Additionally, the risk of a negative appendectomy ranges from 8\u0026ndash;15%[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent advancements in minimally invasive endoscopic technology have led to the emergence of endoscopic retrograde appendicitis therapy (ERAT), a novel, nonoperative approach for treating acute appendicitis[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. ERAT combines endoscopy with interventional therapy to intubate the appendix lumen, relieving obstruction through appendix irrigation, fecalith extraction, and stent placement[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, A limitation of ERAT is its inability to directly view images within the appendiceal cavity, fully exclude tumors, or precisely remove appendiceal fecalith[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eeyeMax, a novel disposable biliary imaging system, enables direct observation of the appendix cavity in sub-endoscopic retrograde appendicitis therapy (SERAT). This system facilitates directional irrigation and, when required, lithotripsy.\u003c/p\u003e \u003cp\u003eTo date, no studies have compared the efficacy of ERAT and SERAT in treating acute appendicitis. This study aims to evaluate the feasibility of SERAT and ERAT in diagnosing and treating acute appendicitis.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Selection\u003c/h2\u003e \u003cp\u003eThis retrospective study analyzed 83 patients diagnosed with acute appendicitis admitted to the Third Hospital of Shandong Province between November 2021 and November 2023. Inclusion criteria were: (1) Acute appendicitis confirmed or suspected based on CT or B-ultrasonography, with patients opting out of appendectomy; (2) Patients with an Alvarado score of \u0026ge;\u0026thinsp;5. Exclusion criteria included: (1) Appendix perforation or other forms of complicated appendicitis; (2) Contraindications to colonoscopy; (3) Hemorrhagic, neurological, mental disorders, or other severe diseases; (4) Impaired cognitive function. A detailed flow chart on patient selection is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The study protocol was approved by the Medical Ethics Committee of the the Third Hospital of Shandong Province. Written informed consent was obtained from all participants. All experimental protocols involving human subjects adhered to the relevant national/international/institutional guidelines or the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDescription of technique\u003c/h2\u003e \u003cp\u003eIn the ERAT group, patients received either 2L of polyethylene glycol electrolyte solution or 300-500ml of clean enema, administered five times. The ERAT procedure included: 1) Inserting a colonoscope (CF-H290AI, Olympus, Japan) into the ileocecal area with a conical transparent cap to assess the appendix opening and surrounding mucosa for coprolite incarceration and abscess discharge; 2) Using a conical transparent cap to push the Gerlach valve and insert a wire-guided catheter into the appendiceal cavity; 3) Conducting appendiceal angiography with iohexol contrast medium to examine the appendiceal cavity's morphology and diameter, assess contrast medium leakage or filling defects, and identify appendiceal stones or perforations. Fecaliths were removed using a net basket or balloon as needed. 4) Repeatedly rinsing the appendiceal cavity with 50\u0026ndash;100 mL of normal saline; 5) In cases with significant pus or a narrow appendiceal cavity, a 7F-8.5F plastic stent (SPSOF7-7, Cook, USA) was inserted for continuous drainage and rinsing; The endoscopic image of the ERAT procedure is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the SERAT group, preoperative preparations were identical to those in the ERAT group. The procedure involved pushing the Gerlach valve with a conical transparent cap and inserting a wire guide into the appendiceal cavity. Subsequently, the eyeMax was introduced along the guide wire to examine the cavity and inner wall of the appendix for stones or intraluminal pus. Treatments like stone removal, washing, and biopsy were performed as required. The endoscopic image of the SERAT procedure is depicted in Fig.\u0026nbsp;3.\u003c/p\u003e \u003cp\u003eAntibiotics were administered to all patients for a maximum of three days post-surgery. Once abdominal pain subsided, patients were put on a liquid diet and discharged upon symptom relief and normalization of laboratory tests.\u003c/p\u003e \u003cp\u003eDemographic and clinical data collected included age, sex, comorbidities, history of abdominal surgery, clinical symptoms (abdominal pain, fever, tenderness, rebound pain), and laboratory/imaging results (white blood cell count, neutrophil percentage, CRP, CT or ultrasound).\u003c/p\u003e \u003cp\u003eShort-term surgical success was defined as effective appendicitis treatment without perforation or intraoperative complications like bleeding. Operation time, intubation time, stent placement, and fecalith extraction were compared between the two groups. Postoperative recovery metrics evaluated included time for temperature normalization, VAS score for abdominal pain 6 hours post-treatment, days until normal temperature and white blood cell count, length of hospital stay, and hospitalization costs. Endoscopic findings encompassed congestion and edema at the appendix opening and surrounding mucosa, presence of fecaliths, and pus discharge. eyeMax microscopic observations included intracavitary fecaliths, pus, pus moss attachment, hyperemia, edema on the appendix's inner wall, and lumen distortion, tortuosity, dilation, or stenosis. Recurrence rates and long-term postoperative outcomes, including abdominal pain, perforation, and diarrhea, were recorded and compared between the two groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted with SPSS 23.0 (IBM, Armonk, New York, USA). Differences in clinical characteristics were evaluated using the two-tailed Student\u0026rsquo;s t-test and the chi-square test. For categorical variables, statistical significance was determined using the chi-square test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was deemed statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003ePatient Characteristics: The study comprised 40 patients in the ERAT group and 43 in the SERAT group. As detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, no significant differences were observed between the groups in terms of age, gender, complications, history of abdominal surgery, clinical manifestations (abdominal pain, fever, other digestive symptoms, abdominal tenderness, rebound pain), laboratory and imaging findings (including white blood cell count, neutrophil percentage, CT or B-ultrasound), and Alvarado score (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\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\u003eComparison of patient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSERAT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egender,(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.953\u003c/p\u003e \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\u003e23(57.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(58.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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(42.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eage,(%) year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.574\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33(82.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36(83.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplications,(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver cirrhosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehistory of abdominal operation, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTemperature\u0026thinsp;\u0026gt;\u0026thinsp;37.2\u0026deg;C, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.361\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight lower abdominal tenderness,(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea,(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.478\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\u003e18(45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.800\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\u003e32(80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(69.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSigns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight lower abdominal tenderness,(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRebound tenderness,(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21(52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.383\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaboratory examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC count (10\u003csup\u003e9\u003c/sup\u003e/L)\u0026thinsp;\u0026gt;\u0026thinsp;10,(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(42.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.953\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutrophil percentages (%)\u0026thinsp;\u0026gt;\u0026thinsp;70,(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(55.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.282\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvrrado score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2(5\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11(4\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.462\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07(5\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12(5\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT or B-ultrasound (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of short-term efficacy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSERAT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eoperate successfully, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38(95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.227\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\u003e43.9\u0026thinsp;\u0026plusmn;\u0026thinsp;17.8(18\u0026ndash;85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3(5\u0026ndash;58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eintubation time,(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e257\u0026thinsp;\u0026plusmn;\u0026thinsp;90.0(65\u0026ndash;415)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103\u0026thinsp;\u0026plusmn;\u0026thinsp;70.1(10\u0026ndash;312)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estent implantation, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21(52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efecalith removal, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.213\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailed intubation, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etransferred to surgery, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoscopic manifestations, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongestion and edema of appendiceal orifice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31(77.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(90.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDung stone and its incarceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(34.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.630\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePus and filth can be seen at appendiceal orifice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(90.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeyeMax manifestations, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongestion and edema of inner wall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcrement stone in cavity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraluminal pus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplication, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC return to normal time (day), (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.991\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37(86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etemperature return to normal time (day), (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.327\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(90.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score 6h after treatment\u0026thinsp;\u0026lt;\u0026thinsp;3, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehospital stay, (day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6(1\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6(1\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehospitalization cost, (RMB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15735\u0026thinsp;\u0026plusmn;\u0026thinsp;4975.4(12036\u0026ndash;34365)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13967\u0026thinsp;\u0026plusmn;\u0026thinsp;4848.5(5798\u0026ndash;31205)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of long-term efficacy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERAT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSERAT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efollow-up time, (day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e298(30\u0026ndash;403)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e264(27\u0026ndash;381)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.612\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003erecurrence, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efollow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSERAT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLong-term adverse events, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eabdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperforate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ediarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eComparison of short-term efficacy\u003c/h2\u003e \u003cp\u003eCompared to the ERAT group, the SERAT group had significantly shorter operative and intubation times (44.8 min vs. 20.8 min, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 258 sec vs. 103 sec, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant differences were observed between the groups in stent implantation, fecalith removal rate, time for postoperative temperature normalization, VAS score at 6 hours post-treatment, days to normal temperature and white blood cell count, length of hospital stay, and hospitalization costs (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Endoscopic findings in the 43 SERAT patients included: congestion and edema at the appendiceal orifice in 39 cases (90.7%), fecalith in 15 cases (34.9%), and purulent discharge adhesion in 39 cases (90.7%). Direct examination with eyeMax revealed hyperemia and edema on the inner wall of the appendix in all 43 cases (100%), intracavitary fecalith in 23 cases (53.5%), and intracavitary pus and pus moss in 40 cases (93%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eComparison of long-term efficacy\u003c/h2\u003e \u003cp\u003eThe average follow-up duration for the SERAT group was 264 days, during which 1 case experienced a relapse and underwent surgical resection. In contrast, the ERAT group had an average follow-up of 298 days, with 7 cases relapsing and a recurrence rate of 17.5%, a statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.019). Of these, 2 cases required surgical resection, 3 received conservative treatment, and 2 improved with additional SERAT treatment. During the follow-up period, no long-term adverse events like abdominal pain, perforation, or diarrhea were reported in either group.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAcute appendicitis ranks as one of the most frequent abdominal surgical emergencies globally. Appendiceal obstruction, often caused by appendiceal fecalith or stenosis, is the primary cause of acute appendicitis.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Other causes of appendiceal obstruction include tumors, infections, or lymphoid hyperplasia[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Regardless of its cause, appendix obstruction results in its dilation, presenting clinically as abdominal pain localized to the right lower abdomen, accompanied by fever, nausea, and vomiting. Historically, the most common treatment for appendicitis has been surgical resection. However, a significant proportion of patients (8\u0026ndash;15%) undergo negative appendectomies[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], exposing them to unnecessary invasive procedures and associated risks, and increasing the economic burden on patients, healthcare systems, and society. Furthermore, the appendix plays a role in immunity, hosting beneficial microorganisms and contributing to the maintenance of intestinal bacterial homeostasis[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Additionally, a study has indicated a correlation between appendectomy and an increased risk of Crohn's disease[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rapid advancement of endoscopic technology has introduced new, minimally invasive treatment options in clinical practice. ERAT, a novel approach for appendicitis treatment, enables observation of the appendiceal opening and surrounding mucosa.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] This method involves decompressing the appendiceal cavity through endoscopic intubation. Based on endoscopic retrograde appendix angiography, appendix irrigation and stent drainage are conducted in cases of lumen stenosis or fecal stone obstruction. The procedure is straightforward and effectively addresses the underlying cause of the disease, yielding positive outcomes.\u003c/p\u003e \u003cp\u003eWhile ERAT can diagnose appendicular fecalith via endoscopic retrograde appendectomy, complete removal of all fecaliths is not guaranteed[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. EyeMax-assisted endoscopic retrograde appendicitis treatment allows for direct observation of the appendiceal cavity through colonoscopy, clearly revealing fecalith, pus, and hyperemia and edema in the inner wall of the appendix. This method circumvents the need for X-rays and contrast agents in cases of lumen distortion and stenosis. This approach not only resolves the issue of needing X-ray guidance for appendiceal irrigation and stent placement but also allows for examination of the entire appendiceal cavity, crucial in selecting the appropriate stent.\u003c/p\u003e \u003cp\u003eThe comparative efficacy of ERAT and SERAT in treating acute appendicitis has not been previously reported. The study is the first to highlight SERAT's advantages over ERAT in acute appendicitis treatment. The study included 83 patients with acute appendicitis, showing no significant differences in baseline data when compared to the ERAT group. In the ERAT group, 2 patients required direct surgical resection due to failure of catheterization caused by appendix edema. Similarly, in the SERAT group, 2 patients experienced catheterization failure. Causes of catheterization failure included fecalith embedded in the appendix opening, swelling and bulbous formation at the appendix opening, and blockage of the appendix opening. The study revealed that the SERAT group's operation time was significantly shorter than the ERAT. This efficiency stems from avoiding intubation imaging, as SERAT allows for direct visualization of the appendix cavity, irrigation, and fecalith extraction using eyeMax, making the process more intuitive, convenient, and time-efficient. eyeMax findings included: hyperemia and edema in the inner wall of the appendix in all 43 cases (100%), intracavitary fecalith in 23 cases (53.5%), and intracavitary pus and pus moss in 40 cases (93%). During the follow-up, the SERAT group experienced 1 recurrence, whereas the ERAT group had 7 recurrences, with a recurrence rate of 23.3%. Of these, 2 cases in the ERAT group required surgical resection with postoperative pathology confirming appendicitis, 3 were treated conservatively, and 2 improved with subsequent SERAT treatment.\u003c/p\u003e \u003cp\u003eThe study concluded that ERAT and SERAT are viable treatments for acute appendicitis, offering benefits like appendix preservation, avoidance of surgical resection, high success rates, and shorter hospital stays. However, there remains a risk of appendicitis recurrence, potentially necessitating an appendectomy in the future. SERAT allows for direct and clear observation of the inner wall congestion and edema of the appendix cavity, fecalith, and lumen stenosis. Postoperatively, SERAT features a shorter recovery time and a significantly lower recurrence rate compared to the ERAT group. Additionally, SERAT is a feasible option for certain pregnant women, children, and patients who are unsuitable for or unwilling to undergo radiological examinations.\u003c/p\u003e \u003cp\u003eThis study has certain limitations, including potential selection bias inherent in its retrospective, single-center design. The study is limited by a small sample size and a relatively short follow-up period. A larger sample size in a randomized controlled study is needed to confirm the superiority of SERAT in appendicitis treatment. Although conducted in a major tertiary medical center with extensive experience, there remains a need for further refinement of the operative technique.\u003c/p\u003e \u003cp\u003eIn conclusion, SERAT is a safe and effective treatment for acute appendicitis, offering shorter operation and intubation times, and a lower recurrence rate compared to ERAT. eyeMax enables direct visualization of the appendix cavity, facilitating targeted irrigation and lithotripsy when required.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe study protocol was approved by the Medical Ethics Committee of the the Third Hospital of Shandong Province. Written informed consent was obtained from all participants. All experimental protocols involving human subjects adhered to the relevant national/international/institutional guidelines or the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eXPL proposed the study and were accountable for all aspects of the work. SLC,SL,JMY and DYX contributed to the article in the aspects of drafting work as well as collecting, analyzing and interpreting the data;FLM and JSL made essential contribution to the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBhangu A, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHumes DJ. J Acute appendicitis BMJ. 2006;333:530\u0026ndash;4. Simpson.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Surgical Research. Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy. Br J Surg. 2013;100(9):1240\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoprom N, et al. The efficacy of antibiotic treatment versus surgical treatment of uncomplicated acute appendicitis: Systematic review and network meta-analysis of randomized controlled trial. Am J Surg. 2019;218(1):192\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersson RE. Small bowel obstruction after appendicectomy. Br J Surg. 2001;88:1387\u0026ndash;91. \u003cem\u003e)\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTingstedt B, et al. Late abdominal complaints after appendectomy\u0026ndash;readmissions during long-term follow-up. Dig Surg. 2004;21(1):23\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeetahal SA, et al. Negative appendectomy: a 10-year review of a nationally representative sample. Am J Surg. 2011;201(4):433\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu CL, et al. Irritable bowel syndrome and negative appendectomy: a prospective multivariable investigation. Gut. 2007;56(5):655\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu BR, et al. Endoscopic retrograde appendicitis therapy (ERAT): a multicenter retrospective study in China. Surg Endosc. 2015;29(4):905\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu BR, et al. Endoscopic retrograde appendicitis therapy: a pilot minimally invasive technique (with videos). Gastrointest Endosc. 2012;76(4):862\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, et al. Diagnosis of Acute Appendicitis by Endoscopic Retrograde Appendicitis Therapy (ERAT): Combination of Colonoscopy and Endoscopic Retrograde Appendicography. Dig Dis Sci. 2016;61(11):3285\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang F et al. \u003cem\u003eDigital single-operator cholangioscopy-guided appendiceal intubation for endoscopic retrograde appendicitis therapy in a pregnant woman (with video).\u003c/em\u003e Gastrointest Endosc, 2023. 98(6): pp. 1034\u0026ndash;1035.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKong LJ, et al. Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy. Endoscopy. 2022;54(4):396\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrzyzak M, Mulrooney SM. Acute Appendicitis Review: Background, Epidemiology, Diagnosis, and Treatment. Cureus. 2020;12(6):e8562.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaetke-Udager K, Maturen KE, Hammer SG. Beyond acute appendicitis: imaging and pathologic spectrum of appendiceal pathology. Emerg Radiol. 2014;21(5):535\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRandal Bollinger R, et al. Biofilms in the large bowel suggest an apparent function of the human vermiform appendix. J Theor Biol. 2007;249(4):826\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersson RE, et al. Appendectomy is followed by increased risk of Crohn's disease. Gastroenterology. 2003;124(1):40\u0026ndash;6.\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":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"acute appendicitis, endoscopic retrograde appendicitis therapy, sub-endoscopic retrograde appendicitis therapy, minimally invasive","lastPublishedDoi":"10.21203/rs.3.rs-4773779/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4773779/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aims to compare the effectiveness and clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT) with sub-endoscopic retrograde appendicitis therapy (SERAT) in treating acute appendicitis.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis retrospective study analyzed 40 patients undergoing ERAT and 43 undergoing SERAT for acute appendicitis at Shandong Provincial Third Hospital, China, from November 2021 to November 2023. The analysis included patient clinicopathological characteristics, technical aspects of ERAT and SERAT, clinical success (symptom resolution and laboratory test normalization), length of hospital stay, complications, and recurrence rates.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNo significant differences were observed between the groups in terms of age, gender, complications, clinical manifestations, laboratory and imaging data, Alvarado score, etc. (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05); The SERAT group had significantly shorter operation and intubation times compared to the ERAT group (43.9 min vs. 20.8 min, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 257 sec vs. 103 sec, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant differences were found in stent implantation, fecalith removal, postoperative temperature normalization, VAS score 6 hours post-treatment, days to normal temperature and white blood cell count, length of hospital stay, and hospitalization costs (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05); The recurrence rate was significantly lower in the SERAT group (2.3%) compared to the ERAT group (17.5%) (P\u0026thinsp;=\u0026thinsp;0.019).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSERAT is an effective and safe approach for the diagnosis and treatment of acute appendicitis, offering shorter operation and intubation times, a lower recurrence rate, and minimally invasive treatment.\u003c/p\u003e","manuscriptTitle":"Endoscopic retrograde appendicitis therapy versus sub-endoscopic retrograde appendicitis therapy for acute appendicitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-27 11:03:59","doi":"10.21203/rs.3.rs-4773779/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-25T13:15:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-25T10:56:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-25T10:54:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2024-07-20T15:29:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"75b77ff9-ab9e-462e-8895-c613a0274521","owner":[],"postedDate":"August 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-11T17:08:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-27 11:03:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4773779","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4773779","identity":"rs-4773779","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}