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01-12-2020 | Ileocolonoscopy | The Last Image
The cecal mucus sign underlying appendiceal sessile serrated polyp/adenoma without dysplasia
Published in: Techniques in Coloproctology | Issue 12/2020
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Neoplastic lesions of the appendix are on the rise, with mucinous appendix neoplasia the most critical in terms of preoperative diagnosis and up-front surgical treatment. A mucus-filled appendix opening, designated “the cecal mucus sign”, warrants detailed assessment for neoplastic tissue [1, 2]. With the exception of device-assisted full thickness resection, endoscopic resection techniques are highly demanding and, unless deeper appendiceal expansion and/or full-blown mucinous neoplasia can be firmly excluded, may impact patient outcomes deleteriously, particularly in relation to potential peritoneal spread [3] (Fig. 1).
Fig. 1
Ileocolonoscopy of a 27-year-old male patient presenting for a second opinion for a lesion in the appendix base with abdominal magnetic resonance imaging indicating minor appendiceal dilation suspicious for inflammatory changes. a A partly protruding appendix with a thick, adherent mucus cap was seen b with proper flattening during air insufflation. c After cleansing using a water jet system, d faint flat-elevated neoplastic tissue (Paris 0-IIa) became visible over the left lateral circumference from 6 to 2 o’clock and the appendiceal base itself. e Blue laser imaging with magnification revealed tiny branching vessels, f in combination with dark spots in the crypts most clearly visible on linked colour imaging highly suggestive of a serrated lesion, as confirmed on separate endoscopic biopsies from the periphery and center of the lesion. Due to persistent concerns about malignant appendiceal neoplasia not visible from the luminal side, the patient finally had an uncomplicated laparoscopic ileocecal resection with frozen section. Final surgical pathology indicated a sessile serrated adenoma/polyp without dysplasia with limited expansion into the appendiceal lumen and evidence of recurrent bouts of obstructive appendicits
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