Endoscopic submucosal dissection (ESD) of lesions involving the appendix remains challenging due to the complex anatomy and high risk of complications, and many patients are still referred for surgery. This study aimed to compare the efficacy and safety of ESD performed with conventional traction techniques versus the adaptive traction strategy with the ATRACT device for appendiceal lesions.

We conducted a retrospective analysis of consecutive patients who underwent ESD for appendiceal lesions between November 2019 and November 2024. Patients were divided into two groups: those treated with conventional traction techniques (T-ESD) and those treated with the ATRACT device according to an adaptive traction strategy (A-ESD). The primary endpoint was lateral R0 resection at the appendiceal margin, the most critical and technically demanding component of R0 achievement because it requires dissecting as deeply as possible into the appendiceal orifice. A multivariate analysis was performed on the primary outcome, adjusting for lesion surface area, operators’ mean dissection speed, lesion location, and degree of fibrosis. Secondary endpoints included overall R0 resection rate, perforation rate, and need for additional surgery.

A total of 137 patients were included (59 in the A-ESD group, 78 in the T-ESD group). The proportion of lesions in patients with prior appendectomy (Toyonaga 3A) was 22% in the A-ESD group (13/59) and 32.5% in the T-ESD group (25/77). Lateral appendiceal R0 resection was achieved more frequently in the A-ESD group (93% vs 84%, p = 0.26), although the difference did not reach statistical significance. In the multivariate analysis, the A-ESD group showed a marked increase in lateral appendiceal R0 resection (OR 2.168 [0.702–7.760], p = 0.183), although the study lacked sufficient power for this effect to reach statistical significance. Overall R0 resection was also slightly higher with A-ESD (82.5% vs 80.5%, p = 1.00). The rate of secondary surgery was 5.3% in the A-ESD group (3/57: 2 for perforation, 1 for invaded appendiceal margin) compared with 7.8% in the T-ESD group (6/76: 1 for perforation, 5 for invaded appendiceal margin). Perforation rates were similar (12% vs 10%, p = 0.95). These findings suggest that adaptive traction may improve exposure of the appendiceal margin, thereby reducing the need for rescue surgery, without increasing perforation risk.

The findings suggest that the ATRACT device may increase lateral appendiceal R0 resection rates and reduce the need for additional surgery for involved appendiceal margins, without increasing perforation risk. However, the study lacks statistical power due to its limited sample size. Adaptive traction may therefore be particularly advantageous for ESD in this technically challenging location.