Treatment of a sessile serrated adenoma/polyp deeply invading the appendiceal orifice enabled by combined adaptive traction and underwater endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) of lesions that invade the appendix is technically challenging because of the difficulty of accessing the submucosa. A previous retrospective multicenter study reported a suboptimal R0 resection rate of around 80% [1]. Several tools, such as traction devices, have been developed to facilitate the procedure [2], including multipolar adaptive traction [3]. We herein report the case of a 73-year-old patient with a large dysplastic sessile serrated adenoma/polyp deeply invading the appendiceal orifice (type 3 of Toyonaga's classification) [4], which was successfully resected using an adaptative traction device (A-TRACT 2+2) combined with underwater ESD ([Video 1]).