eP179 - A Combined Endoscopic-Laparoscopic Surgical (CELS) Approach for a Rare Appendiceal Pathology

Purpose/Background: The authors seek to present an interesting case of a patient with a type five appendiceal intussusception. The patient presented after a gastroenterologist found a large cecal polyp arising from the appendiceal orifice after a cecal filling defect was seen on an abdominal CT. He was brought to the operating room for a Combined Endoscopic-Laparoscopic Surgical (CELS) approach polypectomy. However, upon discovery of the appendiceal intussusception, an endoscopic hot snare appendectomy and a laparoscopic partial cecectomy was performed. The authors seek to highlight this CELS approach to resect an intussuscepted appendix. We hope that other patients with type V appendiceal intussusception can undergo a similar procedure, leading to an earlier diagnosis, fewer complications, and ultimately better oncologic outcomes.Methods/Interventions: This is a case report and literature review regarding appendiceal intussusception and its treatment strategies. Initially, the patient presented to the colorectal surgery clinic for an unresectable cecal polyp. He was scheduled for a CELS polypectomy. However, upon laparoscopic inspection of the right colon, no identifiable appendix was seen and after cecal mobilization from the right pelvic sidewall a cecal invagination was noted where the appendix would be located near the base of the tinea. Intraoperative colonoscopy was performed, and the polyp was noted to be a completely intussuscepted appendix. The decision was made to perform an appendectomy. The mesoappendix was reduced laparoscopically and divided with an endoseal device. Endoscopically, a hot snare was used to remove the appendix at its presumed base. Finally, a partial cecectomy was performed to assure the entire appendix had been removed and to decrease the risk of perforation from the hot snare portion of the procedure. The appendix was removed transanally with the colonoscope. Post-operatively, his pathology revealed a T2 appendiceal adenocarcinoma. He is now status-post an oncologic resection with a laparoscopic right hemicolectomy, pathology pending.Results/Outcomes: The patient in our case had an appendiceal neoplasm discovered due to his appendiceal intussusception. His pathology was found to be well-differentiated colonic adenocarcinoma (pT2) arising in a tubulovillous adenoma confined only to the appendix. Once properly diagnosed, he underwent a laparoscopic right hemicolectomy. Final pathology is pending. Without this intervention, the malignancy could have continued to go undiscovered, potentially leading to a more advanced case and a poorer outcome.Conclusion/

Discussion: Appendiceal intussusception is a rare presentation for an appendiceal neoplasm. Appendiceal intussusception can mimic a cecal polyp and lead to a delay in diagnosis and treatment of this rare, aggressive cancer. When it is encountered it is paramount to investigate the presence of an underlying malignancy. There have been many different methods of appendectomy for appendiceal intussusception. In this scenario, we describe a CELS approach allowing for complete excision of the appendix with minimal risk of perforation. In this patient, recognizing a “cecal polyp” as an intussuscepted appendix led to an earlier diagnosis of appendiceal adenocarcinoma and ultimately a curative resection of an otherwise unsuspected malignancy.