{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,26]],"date-time":"2026-07-26T03:48:05Z","timestamp":1785037685591,"version":"3.55.0"},"reference-count":95,"publisher":"MDPI AG","issue":"20","license":[{"start":{"date-parts":[[2024,10,19]],"date-time":"2024-10-19T00:00:00Z","timestamp":1729296000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>The endoscopic resection of gastrointestinal tract lesions embraces different types of techniques, ranging from conventional polypectomy\/endoscopic mucosal resection (EMR) to the field of third-space endoscopy, including endoscopic submucosal dissection (ESD), full-thickness resection and peroral endoscopic myotomy (POEM). Parallelly, the advent of underwater techniques has served as an add-on for both basic and advanced procedures, since its first report in 2012. We aimed to provide a comprehensive update on the state of the art about the feasibility of underwater basic and advanced techniques for GI endoscopy. Underwater EMR (U-EMR) has proved effective and safe in treating &gt; 10 mm sessile or flat or all-size recurrent colonic lesions. Conversely, although data show good effectiveness and safety for &lt;10 mm lesions, it is preferred when high-grade dysplasia is suspected, favouring cold snare polypectomy for all other cases. Moreover, promising data are emerging regarding the feasibility of U-ESD for difficult-to-resect colonic lesions. U-EMR represents a standard of care for treating &lt; 25 mm superficial non-ampullary duodenal epithelial tumours. Data regarding oesophageal, gastric and ampullary lesions remains limited to small cohorts. Finally, using water immersion for POEM has shown a reduction in procedure time compared to the CO2 insufflation technique for vessel coagulation, albeit in a single-centre experience. Based on these results, U-EMR has become a standard for treating intermediate-size colonic and non-ampullary duodenal lesions, as highlighted also in the European Society of Gastrointestinal Endoscopy guidelines. Promising results have been shown in third-space endoscopy studies, even though further prospective studies are awaited to standardise the technique for both ESD and POEM.<\/jats:p>","DOI":"10.3390\/cancers16203535","type":"journal-article","created":{"date-parts":[[2024,10,21]],"date-time":"2024-10-21T08:53:11Z","timestamp":1729500791000},"page":"3535","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["Underwater Techniques in Gastrointestinal Endoscopy: Diving into the Depths"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7595-0129","authenticated-orcid":false,"given":"Sandro","family":"Sferrazza","sequence":"first","affiliation":[{"name":"Gastroenterology and Endoscopy Unit, ARNAS Civico Di Cristina Benfratelli Hospital, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0802-3173","authenticated-orcid":false,"given":"Giulio","family":"Calabrese","sequence":"additional","affiliation":[{"name":"Gastroenterology and Endoscopy Unit, ARNAS Civico Di Cristina Benfratelli Hospital, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberta","family":"Maselli","sequence":"additional","affiliation":[{"name":"IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy"},{"name":"Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rui","family":"Morais","sequence":"additional","affiliation":[{"name":"Gastroenterology Unit, Unidade Local de Sa\u00fade S\u00e3o Jo\u00e3o, 4200-319 Porto, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2107-2156","authenticated-orcid":false,"given":"Antonio","family":"Facciorusso","sequence":"additional","affiliation":[{"name":"Section of Gastroenterology, Department of Surgical and Medical Sciences, University of Foggia, 71122 Foggia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georgios","family":"Mavrogenis","sequence":"additional","affiliation":[{"name":"Unit of Hybrid Interventional Endoscopy, Department of Gastroenterology, Mediterraneo Hospital, 16675 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberto","family":"Di Mitri","sequence":"additional","affiliation":[{"name":"Gastroenterology and Endoscopy Unit, ARNAS Civico Di Cristina Benfratelli Hospital, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandro","family":"Repici","sequence":"additional","affiliation":[{"name":"IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy"},{"name":"Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4992-9289","authenticated-orcid":false,"given":"Marcello","family":"Maida","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, University of Enna \u201cKore\u201d, 94100 Enna, Italy"},{"name":"Gastroenterology Unit, Umberto I Hospital, 94100 Enna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,10,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1055\/a-2304-3219","article-title":"Colorectal Polypectomy and Endoscopic Mucosal Resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline\u2014Update 2024","volume":"56","author":"Ferlitsch","year":"2024","journal-title":"Endoscopy"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1159\/000524138","article-title":"Incidence and Mortality of Post-Polypectomy Colorectal Cancer in Patients with Low-Risk Adenomas: A Systematic Review and Meta-Analysis of Observational Studies","volume":"41","author":"Yang","year":"2023","journal-title":"Dig. 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