The saline-immersion/irrigation technique (SITE) for endoscopic submucosal dissection (ESD) for the management of right colon lesions

Aims Endoscopic submucosal dissection (ESD) is increasingly used for selective en-bloc resection of colorectal lesions that preclude resection by snare-based techniques. The saline-immersion/irrigation technique (SITE) facilitated ESD may serve as an efficient and safe organ-preserving technique for en-bloc resection of lesions in the right colon, by providing enhanced visibility, effective diathermic pre-sealing of vessels, natural-traction through buoyancy and enhanced patient comfort. Therefore, the aim of our study was to present our centre’s experience regarding the efficacy and safety of SITE-ESD in the management of right-sided colonic lesions [1] [2] [3].

Methods Using our centre’s prospectively compiled database, we retrospectively reviewed our ESD procedures from 2018 up to October 2024. All patients who underwent SITE-facilitated ESD were included in our analysis. In all our cases SITE was used with the pocket-creation method (SITE-PCM-ESD) or its variant, the bridge formation method (SITE-BFM-ESD). Baseline characteristics, histological, as well as endoscopic parameters were recorded. Procedures abandoned due to suspected deep-invasion identified intra-procedurally, were not included in our analysis.

Results Forty-nine patients were included in our analysis. Median age was 70 years (IQR 62-75, range 45-84), 19 patients were women (38.8%). Nine lesions (18.4%) had a previous failed attempt of resection with endoscopic mucosal resection (EMR) or were recurrent lesions. Twenty-eight lesions (57.1%) were classified as Paris 0-IIa and 8 (16.3%) as 0-IIa+c. The median lesion diameter was 35mm (IQR 28-47, range 14-110) x 30mm (IQR: 18-40, range 10-75). Six cases (12.2%) were finalised with hybrid ESD, and one case (2.0%) was completed with piece-meal EMR due to intense fibrosis. The median procedure time was 120 minutes (IQR 90-180, range 30-420). En-bloc resection was achieved in 48 cases (98.0%). R0 resection was achieved in 43 cases (87.8%), Rx resection was present in 2 cases (4.1%) and R1 in 4 cases (8.2%). Regarding R1 resection cases, the first case was a deeply invasive cancer; this was treated surgically and remains disease-free at 12 months follow-up; the second was an invasive cancer which was managed conservatively due to patient comorbidities with the patient remaining disease free at two years of close follow-up; the other two cases were adenomas successfully managed with EMR at follow-up endoscopy. Adverse events, (although not deemed to be clinically relevant) consisted of 3 (6.1%) intraprocedural deep injuries (Sydney classification type 4); these were successfully managed endoscopically without any further consequence. There were no cases of delayed bleeding or perforation.

Conclusions Our data shows that SITE-facilitated ESD is a useful and effective organ-preserving technique for en-bloc resection of right colonic lesions, with a high R0 and an excellent safety profile.

 

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Conflicts of Interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Hayashi Y, Sunada K, Takahashi H. et al. Pocket-creation method of endoscopic submucosal dissection to achieve en bloc resection of giant colorectal subpedunculated neoplastic lesions. Endoscopy 2014; 46 (Suppl. 01) UCTN E421-E422
• 2 Despott EJ, Murino A.. Saline-immersion therapeutic endoscopy (SITE): An evolution of underwater endoscopic lesion resection. Dig Liver Dis 2017; 49 (12): 1376
• 3 Pimentel-Nunes P, Libânio D, Bastiaansen BAJ, Bhandari P, Bisschops R, Bourke MJ, Esposito G, Lemmers A, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, van Hooft JE, Deprez PH, Dinis-Ribeiro M.. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2022; 54 (06): 591-622 Epub 2022 May 6. PMID: 35523224.

Publication History

Article published online:
27 March 2025