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Is it time to consider prophylactic appendectomy in patients with serrated polyposis syndrome undergoing surveillance?
  1. Owen McKay1,
  2. Neal Shahidi1,2,3,
  3. Sunil Gupta1,3,
  4. W Arnout van Hattem1,
  5. Toufic El-Khoury4,5,
  6. Michael J Bourke1,3
  1. 1 Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
  2. 2 Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  3. 3 Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
  4. 4 Department of Surgery, Westmead Hospital, Westmead, New South Wales, Australia
  5. 5 The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
  1. Correspondence to Dr Michael J Bourke, Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW 2145, Australia; michael{at}citywestgastro.com.au

https://doi.org/10.1136/gutjnl-2020-321445

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    Universal colorectal cancer (CRC) screening and minimally invasive endoscopic resection techniques are transforming serrated polyposis syndrome (SPS) management. However, serrated lesions of the appendix (SLAs) are an emerging concern. The prevalence and clinical ramifications of SLAs are likely understated due to the historical role of surgery. Covert intra-appendiceal lesions are surprisingly common but cannot be detected endoscopically nor surveyed. Of those with extension into the caecum, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) all have intrinsic limitations in this location. Herein we discuss the potential role for prophylactic appendectomy in patients with SPS.

    In more detail

    Although SPS is now in the purview of the endoscopist, SLAs remain a challenge from two perspectives: (1) covert lesions which cannot be detected nor surveyed; (2) endoscopic management limitations in this location. As a true diverticulum, the appendix shares the histological layers of the colon with an average length and diameter of 8 cm and 8 mm, respectively. Assuming a cylindrical shape, it reflects 7% of the surface area of the right colon (online supplementary figure 1).1–3 However, due to its narrow calibre the appendiceal lumen cannot be evaluated. Thus, the patient remains at risk for covert disease progression and ultimately interval CRC. In a retrospective analysis of 34 patients with SPS who underwent surgery, SLAs were identified incidentally in 68%, with 26% having advanced histopathology.4

    Supplemental material

    [gutjnl-2020-321445supp001.pdf]

    The relevance of these findings has been understated in existing SPS cohorts. Until recently, universal CRC screening has not been the international standard. Consequently, many patients with SPS are not detected by screening but present with CRC or CRC is detected at the time of …

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    Footnotes

    • Contributors OM performed the drafting of the manuscript. Critical revision of the manuscript for important intellectual content was done by NS, SG, WAvH, TEK and MJB. Original concept, manuscript supervision and approval was provided by MJB.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.