To the Editor,

We thank Yang and colleagues for their correspondence highlighting the results of ACIE Appy II study [1] and proposing the endoscopic retrograde appendicitis therapy (ERAT) as a new tool to improve the management of acute appendicitis (AA) even during pandemic times.

We did not include any questions about ERAT in the ACIE Appy studies [1, 2] because no guideline or scientific society recommended it for AA at the time of the study [3, 4].

Although we agree that both non-operative management and surgery may present potential risks, we think that the current evidence is still not sufficient to consider ERAT as a mitigation strategy during times when resources and workforce are limited, as it was during the pandemic.

A metanalysis on the topic [5] revealed high heterogeneity among the included studies, with funnel plot analysis rising serious concerns of publication bias. Most of the studies included few patients and were mainly from China, making worldwide generalization questionable. The most recent randomized trial published by Shen et al. [6] including 33 patients undergoing ERAT is a “pilot study”, implicitly assuming that a larger study is necessary to confirm its findings in favor of the technique.

The diagnosis of uncomplicated AA, a preliminary step to indicate ERAT, may require an abdominal CT, questionable in childhood and in pregnancy, claimed as potential targets of ERAT by the authors. Furthermore, an endoscopy service is not universally available, and the need for dedicated expertise may represent a further challenge and burden for a healthcare system already stretched by a pandemic. During the worst phases of the COVID-19 outbreak, endoscopic services were centralized and their activities limited to urgent cases [7].

As of today, ERAT cannot be recommended as an alternative strategy during pandemic, as the preliminary results need to be corroborated by stronger evidence.