SciELO - Scientific Electronic Library Online

 
vol.28 número1Síndrome de Budd-Chiari e Falência Hepática Aguda: Uma Apresentação Incomum de Leucemia Mieloide AgudaResolução endoscópica de penetração gástrica por espinha de peixe índice de autoresíndice de assuntosPesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados

Journal

Artigo

Indicadores

Links relacionados

  • Não possue artigos similaresSimilares em SciELO

Compartilhar


GE-Portuguese Journal of Gastroenterology

versão impressa ISSN 2341-4545versão On-line ISSN 2387-1954

GE Port J Gastroenterol vol.28 no.1 Lisboa fev. 2021  Epub 03-Nov-2021

https://doi.org/10.1159/000508343 

Endoscopic Snapshot

A Submerged Serrated Lesion in the Appendix Rest as Identified by the “Cecal Mucus Sign” and Forceps Exposition

Uma Lesão Serreada Submersa no Coto Apendicular Identificada Pelo “Sinal de Muco no Cego” e Exposição Com Pinça

Vincent Zimmera  b 

Elke Eltzec 

aDepartment of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany;

bDepartment of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany;

cInsitute of Pathology Saarbrücken-Rastpfuhl, Saarbrücken, Germany


Keywords Screening colonoscopy; Colorectal cancer; Appendix; Appendectomy; Endoscopic resection

Palavras-chave Colonoscopia de rastreio; Cancro colorretal; Apêndice; Apendicectomia; Resseção endoscópica

A 66-year-old female patient presented for screening colonoscopy after an incomplete office-based procedure due to failed sigmoid passage. Medical history included hysterectomy with adnexectomy and appendectomy. Apart from cecal angiodysplasias, a tenacious mucus lake was detected at the appendix base (“cecal mucus sign”) [1, 2] (Fig. 1a). After extensive washings, at first, no clear-cut mucosal abnormality was identified by white light and image-enhanced endoscopy (Fig. 1b, c). Only after manipulation by a standard biopsy forceps, a submerged lesion was unmasked, pathologically confirmed as a sessile serrated adenoma/polyp (SSA/P) without dysplasia (Fig. 1d). In consideration of her significant surgical history, nota bene including appendectomy, and significant obesity (BMI 43.0 kg/m2), we abstained from up-front surgery for this benign colorectal lesion, and the patient consented to undergo endoscopic resection [3]. However, the intended device-assisted endoscopic full-thickness resection (EFTR) could not be performed due to lack of passage through the sharply angulated sigmoid by the full-thickness resection device (FTRD) test cap (FTRD prOVE Cap, Ovesco, Germany) [4]. Beyond the previously detected small sessile lesion, the full lesion extent was, at the time, visualized after ineffective submucosal indigo carmine injection related to exuberant postsurgical fibrosis and acetic acid spraying, albeit as yet with lowlevel evidence, highlighting the serrated lesion and its borders [5, 6]. The appendix rest was, in addition, distended by underwater endoscopy, revealing a carpet-like involvement with a diffusely velvety appearance (Fig. 1e). Albeit post-piecemeal endoscopic mucosal resection (pEMR) surveillance has been scheduled in 9 months and is, thus, still pending, presumably complete pEMR was achieved by cold snare resection of sessile parts, and na uncomplicated (standard) cap-assisted aspiration mucosectomy of the remaining appendix (Fig. 1f). Visualization of the resection bed excluded deep mural injury and/ or bleeding-prone vessels, thus clip-closure of the defect was not warranted, and the patient took an uncomplicated clinical course. Notwithstanding that recent data indicate feasibility of simple EMR in appendiceal lesions involving < 50 % of the circumference with an identifiable proximal extension, the presented clinical report is unique in terms of status post-appendectomy as well as a carpetlike, utterly flat extension of an estimated 15-mm serrated lesion occupying the whole appendix rest [7].

Fig. 1 a A “cecal mucus sign” was identified during screening colonoscopy. b, c After extensive washings, no clear-cut mucosal abnormality was identified by white light and image-enhanced endoscopy - note argon plasma coagulation (APC) sites due to cecal angiodysplasias. d Only after forceps manipulation, a submerged lesion was unmasked, pathologically confirmed as a sessile serrated adenoma/polyp (SSA/P) without dysplasia. e Beyond previously detected small sessile parts, the full lesion extent was visualized after acetic acid spraying and underwater endoscopy, revealing a carpet-like involvement with a diffusely velvety appearance. f Endoscopic piecemeal resection was achieved by cold snare resection and cap-assisted aspiration mucosectomy. 

References

1 Behary J, Hui JM. The caecal mucus sign. Gut. 2018 Feb;67(2):298. [ Links ]

2 Figueroa-Rivera IM, Santiago-Rivera L, Magno P. Sessile Serrated Adenoma of the Appendix in an Asymptomatic Patient. Clin Gastroenterol Hepatol. 2018 Apr;16(4):A27. [ Links ]

3 Dumoulin FL, Gorris DG, Berger S, Hildenbrand R, Sido B. Full-thickness resection with an over-the-scope device: possible translocation of adenoma tissue in a case of an incomplete resection at the appendix. Endosc Int Open. 2018 May;6(5):E622-4. [ Links ]

4 Zimmer V, Heinrich C. The “Doughnut Sign” Indicating Base Appendectomy in Device-Assisted Endoscopic Full-Thickness Resection. Am J Gastroenterol. 2019 Aug;114(8):1192. [ Links ]

5 Yamamoto S, Varkey J, Hedenström P. Acetic acid spray for better delineation of recurrent sessile serrated adenoma in the colon. VideoGIE. 2019 Aug;4(12):547-8. [ Links ]

6 Wiessner JR, Brown H, Haller B, Abdelhafez M, Poszler A, Schmid RM, et al. Near focus NBI endoscopy plus acetic acid for optical polyp characterization in the colorectum - A proof of principle study. Scand J Gastroenterol. 2019 Mar;54(3):377-83. [ Links ]

7 Tate DJ, Desomer L, Awadie H, Goodrick K, Hourigan L, Singh R, et al. EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video). Gastrointest Endosc. 2018;87(5):1279-88.e2. [ Links ]

Statement of Ethics Patient consent has been obtained for the publication of this report, including images.

Received: February 28, 2020; Accepted: April 29, 2020

Corresponding author Vincent Zimmer Department of Medicine Marienhausklinik St. Josef Kohlhof Klinikweg 1-5, DE-66539 Neunkirchen (Germany) vincent.zimmer@gmx.de

Conflict of Interest Statement

The authors have no conflicts of interest to declare

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License