title: Endoscopic submucosal dissection of cecal lesions in proximity to the appendiceal orifice.
abstract: OBJECTIVE
  Endoscopic submucosal dissection (ESD) is performed for treatment of various gastrointestinal lesions; however, the cecum in proximity to the appendiceal orifice remains a challenging area. We reviewed our experience with cecal ESD near the appendiceal orifice in order to clarify whether this procedure is a safe and effective therapeutic option.
  
  
  METHODS
  We retrospectively reviewed ESD for lesions within approximately 12 mm of the appendiceal orifice at Kobe University Hospital and an affiliated hospital between January 2003 and December 2014. Lesions were classified as: Type 0, proximity to the appendiceal orifice but does not reach it; Type 1, reaches border of the appendix, but does not enter orifice; Type 2, enters orifice, and transition to normal appendiceal mucosa is discernible on inspection of the appendiceal lumen; and Type 3, enters orifice deeply and tumor edge cannot be observed. ESD was not performed for Type 3 lesions unless appendectomy was performed prior to ESD.
  
  
  RESULTS
  A total of 76 lesions satisfied the inclusion criteria (47 Type 0 lesions, 20 Type 1, 6 Type 2, and 3 Type 3). En bloc resection was achieved in 72 lesions (94.7 %). Median specimen size was 49 mm (range 15 - 114 mm), and median tumor size was 35.5 mm (10 - 110 mm). One patient experienced postoperative bleeding, which was treated by endoscopic hemostasis. Another patient who experienced intraoperative perforation and was treated by clip closure later developed appendicitis; he underwent emergency ileocecal surgical resection. Another patient experienced postoperative appendicitis and recovered with antibiotic treatment.
  
  
  CONCLUSIONS
  ESD in close proximity to the appendiceal orifice seems safe and effective.
authors.affiliation: Department of Gastroenterology, Hadassah University Medical Center, Jerusalem, Israel.
authors.forename: Harold
authors.initials: H
authors.lastname: Jacob
authors.affiliation: Department of Endoscopy, Kobe University Hospital, Kobe, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Toyonaga
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Yoshiko
authors.initials: Y
authors.lastname: Ohara
authors.affiliation: Department of Endoscopy, Kishiwada Tokushukai Hospital, Kishiwada, Japan.
authors.forename: Eiji
authors.initials: E
authors.lastname: Tsubouchi
authors.affiliation: Department of Endoscopy, Kishiwada Tokushukai Hospital, Kishiwada, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Takihara
authors.affiliation: Department of Endoscopy, Kishiwada Tokushukai Hospital, Kishiwada, Japan.
authors.forename: Shinichi
authors.initials: S
authors.lastname: Baba
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Tetsuya
authors.initials: T
authors.lastname: Yoshizaki
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Fumiaki
authors.initials: F
authors.lastname: Kawara
authors.affiliation: Department of Endoscopy, Kobe University Hospital, Kobe, Japan.
authors.forename: Shinwa
authors.initials: S
authors.lastname: Tanaka
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Tsukasa
authors.initials: T
authors.lastname: Ishida
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Namiko
authors.initials: N
authors.lastname: Hoshi
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Morita
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Eiji
authors.initials: E
authors.lastname: Umegaki
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Azuma
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001065:Appendix; D002430:Cecal Neoplasms / Q000473:pathology* / Q000601:surgery*; D000069916:Endoscopic Mucosal Resection / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D012189:Retrospective Studies; D047368:Tumor Burden