Visual endoscopic retrograde appendicitis therapy (V-ERAT) has emerged as a promising minimally invasive alternative for acute appendicitis. While its safety and efficacy have been extensively validated, comprehensive understanding of risk factors associated with V-ERAT failure remains limited. This study aimed to compare clinical and laboratory characteristics between V-ERAT success and failure groups to identify potential associations.

A retrospective analysis was conducted on patients aged 18-65 years who underwent V-ERAT between January 1, 2024, and July 1, 2025. All patients had confirmed or suspected acute appendicitis by computed tomography (CT) and declined surgical intervention. The cohort was stratified into a success group (n=140) and a failure group (n=12). Demographic characteristics, clinical features, and laboratory parameters were collected for analysis. Continuous variables were analyzed using the Mann-Whitney U test, while categorical variables were compared using the Chi-square test or Fisher's exact test, as appropriate. P <0.05 was considered statistically significant.

The overall success rate of V-ERAT was 92.1%, with a failure rate of 7.9%. Patients in the failure group were significantly older (48 years, 95% CI: 34.5-58.5 vs. 36 years, 95% CI: 34-38; P=0.026). The failure group also demonstrated substantially longer procedure duration (78 min, 95% CI: 51-100 vs. 29 min, 95% CI: 26-33; P<0.001) and extended hospitalization (6 days, 95% CI: 4.5-7.5 vs. 3 days, 95% CI: 3-3; P<0.001). Laboratory findings revealed significantly elevated white blood cell counts in the failure group (11.38×10⁹/L, 95% CI: 9.63-12.70) compared to the success group (6.93×10⁹/L, 95% CI: 6.43-8.39) (P=0.0182). Similarly, neutrophil percentage was markedly higher in failure cases (81.30%, 95% CI: 75.15-83.40) than in the successful cases (65.90%, 95% CI: 62.60-68.32) (P=0.0034). Furthermore, the presence of complicated acute appendicitis (P<0.001) and peritonitis (P<0.001) were significantly associated with the failure of V-ERAT. Notably, subcecal appendix was identified in 91.6% cases of the failure group, representing a critical anatomical predictor of unsuccessful outcomes.

Subcecal appendix shows a strong association with V-ERAT failure, along with advanced age, elevated inflammatory markers, and peritonitis. Pre-procedural identification of appendix position through CT three-dimensional reconstruction combined with clinical and laboratory parameters may help identify patients at higher risk of V-ERAT failure.