Externally Applied "Through-the-Scope" Clip Closure During Endorobotic Submucosal Dissection.

Endorobotic submucosal dissection (ERSD) is a recent, novel technique combining submucosal dissection and robotic transanal approach. We strongly believe that ERSD increases precise dissection and dexterity, improves visuality, and enables the dissection to be completed in the submucosal plane. However, during these procedures, adverted defects and bleeding can occur. These complications can be managed by suturing and/or coagulation using the da Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Closing defects with sutures can be time-consuming and technically more demanding. Nevertheless, through-the-scope (TTS) clips can manage these complications faster and potentially more cost-effectively. This prevents using additional robotic instruments (needle driver) and barbed sutures. This video aims to show using externally applied TTS clips for defect closure with robotic assistance following ERSD. TTS clips are flexible endoscopic clips in the market. They are designed for hemostasis, endoscopic marking, and defect closure in endoscopic procedures. The TTS clips are sent to the surgical field through the GelPOINT® Path transanal platform (Applied Medical, Rancho Santa Margarita, CA, USA), and it can be controlled with a robotic instrument indirectly. The TTS clips were used in 3 patients who underwent ERSD due to rectal lesion, and informed consents were obtained. The first patient was a 49-year-old woman referred with a rectal lesion at 12 cm from the anal verge found on screening colonoscopy. After submucosal injection, dissection was started, and the lesion was removed successfully. The mucosal defect in the upper rectum was successfully closed with a single externally placed TTS clip. The second patient was a 39-year-old man with a 40-mm recurrent polyp extending from 6 to 10 cm of the anal verge. Due to submucosal fibrosis, a larger defect area was left at the end of the tissue resection, and two TTS clips were used to approximate this defect. The last patient was a 53-year-old woman with a 35 mm lesion at 11 cm from the anal verge. Some bleeding was observed during the excision, and multiple TTS clips were used to prevent post-procedure bleeding. TTS clips were placed successfully in all cases. All 3 patients were discharged home the same day without complication. Histopathology revealed benign lesions with free deep and radial margins. No morbidity was detected after the procedures. Our video demonstrates the successful application of externally applied TTS clips for defect closure and hemostasis following ERSD in varying cases. The externally applied clip management is a viable alternative for accelerated, reliable, and inexpensive defect closures after ERSD. See Video Vignette.

Role of Lateral Pelvic Node Dissection in Rectal Cancer Surgery.

The role of lateral pelvic lymph node dissection in the treatment of patients with locally advanced rectal cancer is a matter of controversy. Surgical practices in Korea and Japan have accepted this approach and are widely utilized; however, it is not routinely incorporated in the practice of countries in the Western hemisphere. This review will examine the role of lateral pelvic lymph node dissection.

Acute colonic pseudo-obstruction: a retrospective review of the surgical outcomes.

PURPOSE: Limited data exist regarding the surgical outcomes of acute colonic pseudo-obstruction (ACPO), commonly referred to as Ogilvie syndrome, in modern clinical practice. The prevailing belief is that surgery should be avoided due to previously reported high mortality rates. We aimed to describe the surgical results of ACPO treated within our institution. METHODS: Our prospectively maintained colorectal surgery registry was queried for patients diagnosed with ACPO, who underwent surgery between 2009 and 2022. Postoperative complications were graded according to Clavien-Dindo (CD) classification. The primary outcome was postoperative mortality. RESULTS: A total of 32 patients who underwent surgery for ACPO were identified. Overall, nonoperative therapy was initially administered to 21 patients (65.6%). The surgeries performed included total abdominal colectomy (15, 43.1%), ascending colectomy with end ileostomy (8, 25%), transverse colostomy (5, 15.6%), ileostomy and transverse colostomy (3, 9.4%), and Hartmann's operation (1, 3.1%). Severe postoperative complications (CD grade 3 or 4) occurred in five patients (15.6%). No recurrence of ACPO was observed and no patient required reoperation. The average postoperative length of stay was 14.5 days, 30-day mortality was 6.3% (n = 2), and 90-day mortality was 15.6% (n = 5) due to complications of underlying comorbidities. CONCLUSIONS: Surgical treatment was effective for patients with ACPO refractory to medical therapy or presenting with acute complications. Although postoperative complications were frequent, both the 30- and 90-day mortality rates were lower than previously documented in the literature. Further investigations are warranted to determine the optimal surgical strategy, which may involve total or segmental colectomy, or diversion alone without resection.

A multicenter, retrospective study of a through-the-needle injection-capable electrosurgical knife for endoscopic submucosal dissection.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is a technically challenging resection technique for en-bloc removal of dysplastic and early cancerous gastrointestinal (GI) lesions. We conducted a single-arm retrospective study evaluating the safety and efficacy of a new through-the-needle injection-capable electrosurgical knife used in upper and lower ESD procedures performed at 6 US academic centers. METHODS: Data were retrospectively collected on consecutive cases in which the new ESD knife was used. The primary efficacy endpoint was successful ESD (en bloc resection with negative margins). Secondary efficacy endpoints included en-bloc resection rate, curative resection rate, median ESD time, and median dissection speed. The safety endpoint was device- or procedure-related serious adverse events (SAEs). RESULTS: ESD of 581 lesions in 579 patients were reviewed, including 187 (32.2%) upper GI and 394 (67.8%) lower GI lesions. Prior treatment was reported in 283 (48.9%) patients. Successful ESD was achieved in 477 (82.1% of 581) lesions ‒ lower for patients with versus without submucosal fibrosis (73.6% versus 87.0%, respectively, P < 0.001), but similar for those with versus without previous treatment (81.7% versus 82.3%, respectively, P = 0.848). Four hundred and forty-three (76.2% of 581) lesions met criteria for curative resection. Median ESD time was 1.0 (range 0.1-4.5) hour. Median dissection speed was 17.1 (IQR 5.3-29.8) cm2/hour. Related SAEs were reported in 15 (2.6%) patients, including delayed hemorrhage (1.9%), perforation (0.5%), or postpolypectomy syndrome (0.2%). CONCLUSION: A newly developed through-the-needle injection-capable ESD knife showed a good success rate and excellent safety at US centers. (ClinicalTrials.gov number, NCT04580940).

Predictors of En Bloc, R0 Resection and Post-Procedural Complications Following Advanced Endoscopic Resections for Colorectal Neoplasms: Results of 1213 Procedures.

BACKGROUND: Advanced endoscopic resection techniques are used for treatment of colorectal neoplasms that are not amenable for conventional colonoscopic resection. Literature regarding the predictors of the outcomes of advanced endoscopic resections, especially from a colorectal surgical unit, is limited. OBJECTIVE: To determine the predictors of short- and long-term outcomes following advanced endoscopic resections. DESIGN: Retrospective case series. SETTINGS: Tertiary care center. PATIENTS: Patients who underwent advanced endoscopic resections for colorectal neoplasms from November 2011 to August 2022. INTERVENTION: Endoscopic mucosal resection, endoscopic submucosal dissection, hybrid endoscopic submucosal dissection, combined endoscopic laparoscopic surgery. MAIN OUTCOME MEASURES: Predictors of en bloc and R0 resection, bleeding, perforation was determined using univariable and multivariable logistic regression models. Cox regression models were used to determine the predictors of tumor recurrence. RESULTS: A total of 1213 colorectal lesions from 1047 patients were resected [median age 66 (58-72) years, 484 (46.2%) female, median body mass index 28.6 (24.8-32.6) kg/m 2]. Most neoplasms were in the proximal colon (898, 74%). Median lesion size was 30 (IQR: 20-40, range: 0-120) mm. 911 (75.1%) lesions had previous interventions. Most common Paris and Kudo classifications were 0-IIa flat elevation (444, 36.6%) and IIIs (301, 24.8%), respectively. En bloc and R0 resection rates were 56.6% and 54.3%, respectively. Smaller lesions, rectal location, and procedure type (endoscopic submucosal dissection) were associated with significantly higher en bloc and R0 resection rates. Bleeding and perforation rates were 5% and 6.6%, respectively. Increased age [1.06 (1.03-1.09), p < 0.0001] was a predictor for bleeding. Lesion size [1.02 (1.00-1.03), p = 0.03] was a predictor for perforation. Tumor recurrence rate was 6.6%. En bloc [HR 1.41 (95% CI 1.05-1.93), p = 0.02] and R0 resection [HR 1.49 (95% CI 1.11-2.06), p = 0.008] were associated with decreased recurrence risk. LIMITATIONS: Single center, retrospective study. CONCLUSIONS: Outcomes of advanced endoscopic resections can be predicted by patient and lesion-related characteristics. See Video Abstract.

A Propensity Score-Matched Analysis of Single-Port vs. Multi-Port Laparoscopic Total Abdominal Colectomy with End Ileostomy for Medically Refractory Ulcerative Colitis.

BACKGROUND: Medically refractory ulcerative colitis (UC) necessitates surgical intervention, with total abdominal colectomy with end ileostomy being a definitive treatment. The comparison between single-port and multi-port laparoscopic surgery outcomes remains underexplored. OBJECTIVE: To compare the surgical outcomes of single-port versus multi-port laparoscopic surgery in patients undergoing total abdominal colectomy with end ileostomy for medically refractory UC. DESIGN: A retrospective analysis comparing single-port to multi-port surgery in UC patients from 2010 to 2020. Patients were propensity score-matched 3:1 (multi-port to single-port) on baseline characteristics. SETTINGS: Single center academic hospital. MAIN OUTCOME MEASURES: Binary outcomes were compared using a multivariable logistic regression model, and a subset analysis was conducted for postoperative stump leak based on stump implantation during surgery. These metrics were compared between the single-port and multi-port groups to assess the differences in surgical outcomes. RESULTS: The multi-port and single-port groups included 642 and 114 patients, respectively. Matched cohort included 342 multi-ports and 114 single-ports. We observed a statistically significant difference in mean operation time, with the single-port procedure taking 43 minutes less than the multi-port laparoscopy. There were no significant differences between the two groups in postoperative stump leaks, postoperative ileus, stoma site complications, postoperative readmission within 30 days, postoperative reoperation within 30 days, and subsequent IPAA surgery. In the subset analysis, stump implantation was associated with a higher risk of stump leak in the multiport group. The single-port group had a shorter hospital stay. LIMITATIONS: Retrospective nature, being conducted at a single center. CONCLUSION: Single-incision laparoscopic total abdominal colectomy in the treatment of mucosal ulcerative colitis is a safe, effective, and efficient approach. In our cohort, as compared to multi-port approach, single incision laparoscopy has shown shorter operation times and better overall length of stay. Taking into account less invasive approach, decreased abdominal trauma, and faster recovery, single-port surgery is a viable alternative to multi-port surgery. See Video Abstract.

Managing prostate cancer after proctocolectomy and ileal pouch-anal anastomosis: feasibility and outcomes of single-port transvesical robot-assisted radical prostatectomy.

INTRODUCTION: Patients with proctocolectomy and ileal pouch-anal anastomosis (PC-IPAA) face unique challenges in managing prostate cancer due to their hostile abdomens and heightened small bowel mucosa radiosensitivity. In such cases, external beam radiation therapy (EBRT) is contraindicated, and while brachytherapy provides a safer option, its oncologic effectiveness is limited. The Single-Port Transvesical Robot-Assisted Radical Prostatectomy (SP TV-RARP) offers promise by avoiding the peritoneal cavity. Our study aims to evaluate its feasibility and outcomes in patients with PC-IPAA. METHODS: A retrospective evaluation was done on patients with PC-IPAA who had undergone SP TV-RARP from June 2020 to June 2023 at a high-volume center. Outcomes and clinicopathologic variables were analyzed. RESULTS: Eighteen patients underwent SP TV-RARP without experiencing any complications. The median hospital stay was 5.7 h, with 89% of cases discharged without opioids. Foley catheters were removed in an average of 5.5 days. Immediate urinary continence was seen in 39% of the patients, rising to 76 and 86% at 6- and 12-month follow-ups. Half of the cohort had non-organ confined disease on final pathology. Two patients with ISUP GG3 and GG4 exhibited detectable PSA post-surgery and required systemic therapy; both had SVI, multifocal ECE, and large cribriform pattern. Positive surgical margins were found in 44% of cases, mostly Gleason pattern 3, unifocal, and limited. After 11.1 months of follow-up, no pouch failure or additional BCR cases were found. CONCLUSION: Patients with PC-IPAA often exhibit aggressive prostate cancer features and may derive the greatest benefit from surgical interventions, particularly given that radiation therapy is contraindicated. SP TV-RARP is a safe option for this group, reducing the risk of bowel complications and promoting faster recovery.

Close margin of adverse histologic factors with a negative primary tumor margin is not associated with increased locoregional recurrence in colon cancer.

PURPOSE: Locoregional recurrence after resection of colon cancer is increased when primary tumor margin is positive (<1 â€‹mm). Data is limited regarding the risk of locoregional recurrence with close margin (<1 â€‹mm) of histologic factors, such as intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension. We hypothesized that close margin of these factors doesn't affect locoregional recurrence. METHODS: A retrospective review of all colon cancer surgical resections for adenocarcinoma from 2007 to 2020 was performed. Inclusion criteria were specimens with a negative primary tumor margin but a close margin of adverse histologic factors, defined as intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension within 1 â€‹mm of a mesenteric or circumferential margin. RESULTS: Among 4435 pathology reports reviewed, 45 (1 â€‹%) of cases met inclusion criteria. Average follow-up was 38 months. The adverse histologic factor was identified as intranodal tumor in 24 (53 â€‹%) cases, intravascular tumor in 8 (17.8 â€‹%), tumor deposits in 5 (11.1 â€‹%), and more than one pathologic feature in 6 (13.3 â€‹%). There were 9 (20 â€‹%) recurrences; 6 (13 â€‹%) had distant recurrences only, 2 (4 â€‹%) patients had locoregional recurrences only, and 1 (2 â€‹%) patient had both locoregional and distant recurrence. The adverse histologic factor in these three patients was intravascular in two and both intravascular and intranodal in one. CONCLUSION: Based on our results, we do not have evidence that the presence of intravascular tumor, intranodal tumor, tumor deposits, or extranodal extension within 1 â€‹mm of a mesenteric or circumferential margin is associated with increased risk of locoregional recurrence.

What is the Optimal Strategy for Pouch Salvage at the Time of Redo Ileal-Pouch Anal Anastomosis? Pouch Repair with Re-Anastomosis vs Pouch Excision with Neo-Pouch.

BACKGROUND: The long-term risk of pouch failure after restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) range from 5 and 15%. Salvage surgery for failing IPAA's may be achieved by disconnecting the IPAA and either repairing and re-using the existing pouch (REP) or constructing a neo-pouch (NEO). We aimed to evaluate whether there are differences in long-term functional pouch survival and functional outcomes between the REP group and the NEO group. We hypothesized patients undergoing REP have higher long-term pouch survival rates compared to patients who require NEO pouch construction. METHODS: Our prospectively maintained Pouch Registry was queried for patients who underwent a pouch salvage surgery with either pouch REP or NEO from 1988 - 2020. Patients who underwent pouch repair without disconnection from the anus were excluded. The primary endpoint was long-term pouch survival after redo pouch surgery. Secondary outcomes were patient reported quality of life and pouch function. RESULTS: Of 653 patients undergoing redo IPAA, 462 met inclusion criteria of transabdominal redo surgery with pouch reconnection: 243 (52.6%) had REP and 219 (47.4%) had NEO. Median age was 39 years and 59% were female. Median time between index and redo IPAA was 34 months for REP vs 54 months for NEO (p=0.002). The 5-year pouch survival after redo IPAA was similar between REP (79.5%) and NEO (76.8%) groups (p=0.4). Fewer patients in the REP group reported nighttime pad use (51.4% vs 68.2%, p=0.04). CONCLUSION: Pouch survival and functional outcomes after salvage surgery for failing ileoanal pouch was similar regardless of pouch salvage procedure. When performing redo pouch surgery, surgeons should not hesitate to construct a new pouch if indicated.

Early Experience with EndoRobotic Submucosal Dissection (ERSD): Pathologic and Short-term Outcomes in the First 28 Patients.

OBJECTIVE: To evaluate the safety and feasibility of single-port endorobotic submucosal dissection (ERSD) using the Da Vinci SP platform for the management of rectal neoplasms. SUMMARY BACKGROUND DATA: Endoscopic submucosal dissection (ESD) offers a potential organ-sparing treatment for advanced colorectal neoplasms but demands high technical skill and a steep learning curve. Advances in semiflexible robotic platforms, such as the Da Vinci SP, promise to simplify this procedure, potentially offering improved outcomes for patients with benign rectal neoplasms. METHODS: A retrospective analysis of 28 patients who underwent ERSD using the Da Vinci SP platform between 2020 and 2023 was performed. Patient demographics, lesion characteristics, procedure details, outcomes, and complications were reviewed. The primary endpoint was successful en-bloc resection. RESULTS: The cohort had a median age of 60.5 years and a median BMI of 28.2 kg/m², predominantly male(67.8%) with ASA categories 2 or 3(82%). Lesions had a median size of 38 mm and were located a median of 9 cm from the anal verge. The median procedure time was 87.5 minutes. En-bloc resection was achieved in all cases(100%), with no intraoperative complications or mortality. One patient experienced urinary retention, and one had late bleeding requiring blood transfusion. Pathology outcomes included 46.4% tubulovillous adenomas, 21.4% adenocarcinomas, and high-grade dysplasia in 53.6% of patients. CONCLUSION: Single-port ERSD using the Da Vinci SP platform is safe and feasible for the management of colorectal neoplasia, ensuring a high rate of en-bloc resection. It potentially offers advantages over conventional ESD, including shorter dissection times, although further studies are necessary for a definitive comparison.

Outcome of incidental versus preoperatively diagnosed colorectal cancer during total proctocolectomy with ileal pouch-anal anastomosis for inflammatory bowel disease.

AIM: Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for colorectal cancer (CRC) in inflammatory bowel disease. CRC may also be discovered incidentally at IPAA for other indications. We sought to determine whether incidentally found CRC at IPAA was associated with worse outcomes. METHODS: Our institutional pouch registry (1983-2021) was retrospectively reviewed. Patients with CRC at pathology after IPAA were divided into two groups: a preoperative diagnosis (PreD) group and an incidental diagnosis (InD) group. Their long-term outcomes (overall survival, disease-free survival and pouch survival) were compared. RESULTS: We included 164 patients: 53 (32%) InD and 111 (68%) PreD. There were no differences in cancer staging, differentiation and location. After a median follow-up of 11 (IQR 3-25) years for InD and 9 (IQR 3-20) years for the PreD group, deaths were 14 (26%) in the InD group and 18 (16%) in the PreD group. Pouch failures were five (9%) in the InD group and nine (8%) in the PreD group, of which two (5%) and four (4%) were cancer related. Ten-year overall survival was 94% for InD and 89% for PreD (P = 0.41), disease-free survival was 95% for InD and 90% for PreD (P = 0.685) and pouch survival was 89% for InD and 97% for PreD (P = 0.80). Pouch survival at 10 years was lower in rectal versus colon cancer (87% vs. 97%, P = 0.01). No difference was found in outcomes in handsewn versus stapled anastomoses. CONCLUSION: Inflammatory bowel disease patients with incidentally found CRC during IPAA appear to have similarly excellent oncological and pouch outcomes to patients with a preoperative cancer diagnosis.

Biocomposites of Poly(Lactic Acid) and Microcrystalline Cellulose: Influence of the Coupling Agent on Thermomechanical and Absorption Characteristics.

In this study, poly(lactic acid) (PLA) and microcrystalline cellulose (MCC)-based green biocomposites were developed using a solution casting technique. Essentially, the bonding between PLA and MCC is quite feeble; therefore, the current study is conducted to strengthen the bonding by incorporating a coupling agent, thereby enhancing the overall quality of the biocomposites. Thus, the present study aimed to examine the influence of combined coupling agents-maleic anhydride (MAH) and maleic acid (MA) (MAH-MA)-on the properties of polylactic acid (PLA)/microcrystalline cellulose (MCC) biocomposites. The investigation also encompassed an examination of the impact of MCC loading (2, 3, and 5% w/w) into a PLA matrix. The Fourier transform infrared spectroscopy (FTIR) and scanning electron microscopy (SEM) examination revealed the interfacial interaction and adhesion among MCC, PLA, and coupling agents and the formation of biocomposites. The incorporation of MAH-MA led to improved mechanical properties of the PLA/MCC biocomposites. Furthermore, the incorporation of MAH-MA into the PLA/3 wt % MCC composite exhibited enhancements in both the tensile strength and tensile modulus, accompanied by a reduced elongation at break. In addition, it is worth noting that the thermogravimetric analysis (TGA) curve of the PLA composite with 3% w/w of MCC and MAH-MA displayed a significant decrease in weight beyond a temperature threshold of 492.65 °C. The water absorption demonstrates that the incorporation of MAH-MA into the PLA/MCC composite led to advantageous water barrier characteristics. The observed improvements were attributed to the efficient dispersion of MCC at the most favorable amount of coupling agents, along with the chemical interactions involving grafting and esterification between MCC and the MAH-MA coupling agent. Furthermore, the incorporation of MAH-MA into the PLA/3% (w/w) MCC composite exhibited enhancements in both the tensile strength and tensile modulus, accompanied by a reduction in the elongation percentage at break. The experimental results about water absorption demonstrate that the incorporation of MAH-MA into the PLA/MCC composite led to advantageous water barrier characteristics. These improvements were attributed to good MCC dispersion and the chemical interactions involving grafting and esterification between the MCC and the MAH-MA coupling agent.

Rediversion of the Failing Ileoanal Pouch: First Step in Pouch Salvage?

BACKGROUND: Ileal pouch-anal anastomosis is a technically demanding procedure with many potential complications. Rediversion with an ileostomy is often the first step in pouch salvage; however, it may not be clear if an individual patient will undergo subsequent pouch salvage surgery. We aimed to describe the indications and short- and long-term outcomes of rediversion in our pouch registry. METHODS: We queried our institutional pouch registry for patients who underwent index 2- or 3-stage IPAA and subsequent rediversion at our institution between 1985 and 2022. Pouches constructed elsewhere, rediverted elsewhere, or those patients who underwent pouch salvage/excision without prior rediversion were excluded. Patients were selected for pouch salvage according to the surgeon's discretion. RESULTS: Overall, 177 patients (3.4% of 5207 index pouches) were rediverted. At index pouch, median patient age was 32 years and 50.8% were women. Diagnoses included ulcerative colitis (86.4%), indeterminate colitis (6.2%), familial adenomatous polyposis (4.0%), and others (3.4%). Median time from prior ileostomy closure to rediversion was 7.2 years. Indications for rediversion were inflammatory in 98 (55.4%) and noninflammatory in 79 (44.6%) patients. After rediversion, 52% underwent pouch salvage, 30% had no further surgery, and 18.1% underwent pouch excision. The 5-year pouch survival rates for inflammatory and noninflammatory indications were 71.5% and 94.5%, respectively (P = .02). CONCLUSION: Rediversion of ileoanal pouches is a safe initial strategy to manage failing pouches and is a useful first step in pouch salvage in many patients. Subsequent salvage surgery for noninflammatory indications had a significantly higher pouch salvage rate than those rediverted for inflammatory complications.

Rediversion with an ileostomy was a safe, useful first step in pouch salvage, and subsequent salvage surgery for noninflammatory indications had a significantly higher pouch salvage rate than those rediverted for inflammatory complications.

The role of advanced endoscopy in appendiceal polyp management and outcomes.

BACKGROUND: Appendiceal orifice lesions are often managed operatively with limited or oncologic resections. The aim is to report the management of appendiceal orifice mucosal neoplasms using advanced endoscopic interventions. METHODS: Patients with appendiceal orifice mucosal neoplasms who underwent advanced endoscopic resections between 2011 and 2021 with either endoscopic mucosal resection (EMR), endoscopic mucosal dissection (ESD), hybrid ESD, or combined endoscopic laparoscopic surgery (CELS) were included from a prospectively collected dataset. Patient and lesion details and procedure outcomes are reported. RESULTS: Out of 1005 lesions resected with advanced endoscopic techniques, 41 patients (4%) underwent appendiceal orifice mucosal neoplasm resection, including 39% by hybrid ESD, 34% by ESD, 15% by EMR, and 12% by CELS. The median age was 65, and 54% were male. The median lesion size was 20 mm. The dissection was completed piecemeal in 49% of patients. Post-procedure, one patient had a complication within 30 days and was admitted with post-polypectomy abdominal pain treated with observation for 2 days with no intervention. Pathology revealed 49% sessile-serrated lesions, 24% tubular adenomas, and 15% tubulovillous adenomas. Patients were followed up for a median of 8 (0-48) months. One patient with a sessile-serrated lesion experienced a recurrence after EMR which was re-resected with EMR. CONCLUSION: Advanced endoscopic interventions for appendiceal orifice mucosal neoplasms can be performed with a low rate of complications and early recurrence. While conventionally lesions at the appendiceal orifice are often treated with surgical resection, advanced endoscopic interventions are an alternative approach with promising results which allow for cecal preservation.