The saline-immersion/irrigation technique (SITE) to facilitate colorectal endoscopic submucosal dissection

Aims Endoscopic submucosal dissection (ESD) is increasingly recognised as the gold standard for en-bloc resection of superficial colorectal neoplasms [1]. Conventionally, ESD is performed using carbon dioxide (CO₂) insufflation. However, since our description of the saline-immersion/irrigation technique (SITE) [2] [3], this has proven to overcome the disadvantages that occur with the use of CO₂ or de-ionised water. In order to build on the emerging supporting evidence highlighting SITE-ESD and its associated benefits, we conducted a study to evaluate the efficacy and safety of SITE- facilitated ESD.

Methods This study retrospectively analyzed consecutive patients referred to our hospital for colorectal ESD of a suspected adenomatous lesions, retrieved from our prospective database from July 2017 to October 2024.

Results A total of 179 procedures were included in the analysis. Mean age was 67.53 (SD 11.84, range 27-88), 58.1% were men (n=104). Median ASA score was 2 (IQR 1-2, range 1-3). Lesions were resected from the caecum (n=23, 12.8%), ascending colon (n=32, 17.9%), transverse colon (n=9, 5.0%), descending colon (n=17, 9.5%), sigmoid colon (n=31, 17.3%) and rectum (n=67, 37.4%). Median maximum diameter size was 40mm (IQR 30-60, range 11-200). Out of 179, 10 procedures (5.6%) were abandoned due to suspected deep-invasion, only identified intra-procedurally; these cases required elective surgery. Seven procedures (3.9%) were converted to piecemeal resection. The remaining 162 procedures were completed with ESD. SITE with variants of the pocket-creation method (PCM) was used. Additionally, clip-band traction was applied to accelerate finalization of procedures in selected 41 cases (22.9%). R0 resection was achieved in 85.18% (138/162) of the cases, R1 resection in 12.34% (20/162) and Rx in 2.46% (4/162). Of the 71 cases that have already had surveillance endoscopy (58 patients in the R0 group, 10 in the R1 and 3 in the Rx), no recurrence was seen in the R0 resection group and 1 recurrence was seen in an Rx resection, which included the ICV; this was treated successfully with en-bloc EMR. In terms of adverse events, although not clinically relevant, 6 (3.7%) intraprocedural deep mural injuries (Sydney classification type 4) occurred and these were managed endoscopically without further consequence. There was 1 (0.61%) delayed perforation in the sigmoid colon; this followed the use of a coagulation forceps and required surgery (a Hartman´s procedure). Delayed bleeding occurred in 1 (0.61%) case; this settled conservatively.

Conclusions Our data shows that SITE-facilitated ESD is a safe and effective technique for resection of colorectal adenomatous lesions, with a very low adverse event rate and a high R0 resection rate. Further prospective studies are encouraged.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

• 1 Yamamoto H, Hayashi Y, Despott EJ.. The pocket-creation method for endoscopic submucosal dissection combined with saline-immersion: another potential option to overcome challenges in colorectal endoscopic submucosal dissection. Gastrointest Endosc [Internet]. 1. August 2019 [zitiert 6. August 2023];90(2):288–9. Verfügbar unter https://pubmed.ncbi.nlm.nih.gov/31327340/
• 2 Despott EJ, Murino A.. Saline-immersion therapeutic endoscopy (SITE): An evolution of underwater endoscopic lesion resection. Digestive and Liver Disease [Internet]. 1. Dezember 2017 [zitiert 25. August 2023];49(12):1376. Verfügbar unter http://www.dldjournalonline.com/article/S1590865817310538/fulltext
• 3 Libânio D, Pimentel-Nunes P, Bastiaansen B, Bisschops R, Bourke MJ, Deprez PH. u. a. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2023; 55 (04): 361-89