{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T20:17:56Z","timestamp":1791231476939,"version":"4.1.0"},"reference-count":51,"publisher":"Ovid Technologies (Wolters Kluwer Health)","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Endoscopic submucosal dissection (ESD) allows precise en-bloc resection of early gastrointestinal neoplasia, reducing recurrence, and increasing cure rates compared with conventional endoscopic mucosal resection. However, its use in the colon remains limited due to the technical complexity, restricted scope maneuverability, and the thin colonic wall. To address these challenges, procedural modifications such as the pocket-creation method (PCM) and traction-assisted techniques have been developed. Since its introduction in 2017, the saline immersion\/irrigation technique (SITE) has emerged as an alternative platform to facilitate ESD. SITE differs from approaches referred to as \u201cunderwater-ESD\u201d as it specifically uses isotonic saline, whose electrolyte content enhances electrical conductivity, enabling effective coagulation, reduced thermal injury, and improved procedural precision. Advantages of SITE include improved visualization through optical magnification and avoidance of smoke-clouding, natural buoyancy providing intrinsic traction, heat-dissipation limiting collateral tissue damage, and reduced luminal distension, contributing to improved patient comfort. When combined with PCM, SITE has been associated with increased dissection speed and reduced procedure time. Current evidence demonstrates that SITE-ESD achieves en-bloc and R0 resection rates comparable to conventional ESD, with similar rates of adverse events, including perforation, bleeding, and post-ESD coagulation syndrome (PECS). The heat-sink effect of saline may further contribute to reduced thermal injury and potentially lower PECS incidence. SITE may also facilitate ESD performance for less experienced endoscopists, expanding accessibility to colorectal ESD. Further large-scale prospective studies are needed to define its optimal role in clinical practice. The term \u201csaline-immersion\/irrigation technique\u201d should be used to emphasize the importance of the ionic medium.<\/jats:p>","DOI":"10.4103\/sjg.sjg_422_25","type":"journal-article","created":{"date-parts":[[2025,12,3]],"date-time":"2025-12-03T15:00:38Z","timestamp":1764774038000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":7,"title":["The saline-immersion\/irrigation technique (SITE) for colonic endoscopic submucosal dissection (ESD): A comprehensive evaluation of outcomes, efficacy, and safety"],"prefix":"10.4103","author":[{"given":"Elisabetta","family":"Dell\u2019Unto","sequence":"first","affiliation":[{"name":"Royal Free Unit for Endoscopy, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, London, UK"},{"name":"Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Digestive Disease Unit, ENETS Center of Excellence, Sant\u2019Andrea University Hospital, Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandro","family":"Rimondi","sequence":"additional","affiliation":[{"name":"Royal Free Unit for Endoscopy, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georgios","family":"Kalopitas","sequence":"additional","affiliation":[{"name":"Royal Free Unit for Endoscopy, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elisabet Maristany","family":"Bosch","sequence":"additional","affiliation":[{"name":"Royal Free Unit for Endoscopy, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gianluca","family":"Esposito","sequence":"additional","affiliation":[{"name":"Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Digestive Disease Unit, ENETS Center of Excellence, Sant\u2019Andrea University Hospital, Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hironori","family":"Yamamoto","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edward John","family":"Despott","sequence":"additional","affiliation":[{"name":"Royal Free Unit for Endoscopy, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alberto","family":"Murino","sequence":"additional","affiliation":[{"name":"Royal Free Unit for Endoscopy, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, London, UK"},{"name":"Digestive Diseases and Surgical Institute, Cleveland Clinic London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2025,12,3]]},"reference":[{"key":"R1-20251203","doi-asserted-by":"crossref","first-page":"690","DOI":"10.1055\/s-2003-41516","article-title":"Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood","volume":"35","author":"Yamamoto","year":"2003","journal-title":"Endoscopy"},{"key":"R2-20251203","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1016\/j.gie.2014.07.034","article-title":"Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: A meta-analysis of studies comparing EMR and endoscopic submucosal dissection","volume":"81","author":"Fujiya","year":"2015","journal-title":"Gastrointest Endosc"},{"key":"R3-20251203","doi-asserted-by":"crossref","first-page":"591","DOI":"10.1055\/a-1811-7025","article-title":"Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) guideline\u2014update 2022","volume":"54","author":"Pimentel-Nunes","year":"2022","journal-title":"Endoscopy"},{"key":"R4-20251203","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1055\/a-2031-0874","article-title":"Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) technical review","volume":"55","author":"Lib\u00e2nio","year":"2023","journal-title":"Endoscopy"},{"key":"R5-20251203","doi-asserted-by":"crossref","first-page":"E421","DOI":"10.1055\/s-0034-1377438","article-title":"Pocket-creation method of endoscopic submucosal dissection to achieve en bloc resection of giant colorectal subpedunculated neoplastic lesions","volume":"46","author":"Hayashi","year":"2014","journal-title":"Endoscopy"},{"key":"R6-20251203","doi-asserted-by":"crossref","first-page":"1775","DOI":"10.1007\/s00464-021-08452-8","article-title":"Traction-assisted endoscopic submucosal dissection reduces procedure time and risk of serious adverse events: A systematic review and meta-analysis","volume":"36","author":"Lopimpisuth","year":"2022","journal-title":"Surg Endosc"},{"key":"R7-20251203","doi-asserted-by":"crossref","first-page":"1137","DOI":"10.1016\/j.gie.2011.07.037","article-title":"Gastric endoscopic submucosal dissection assisted by a new traction method: The clip-band technique. A feasibility study in a porcine model (with video)","volume":"74","author":"Parra-Blanco","year":"2011","journal-title":"Gastrointest Endosc"},{"key":"R8-20251203","doi-asserted-by":"crossref","first-page":"1376","DOI":"10.1016\/j.dld.2017.08.035","article-title":"Saline-immersion therapeutic endoscopy (SITE): An evolution of underwater endoscopic lesion resection","volume":"49","author":"Despott","year":"2017","journal-title":"Dig Liver Dis"},{"key":"R9-20251203","doi-asserted-by":"crossref","first-page":"E227","DOI":"10.1055\/s-0043-113556","article-title":"Water pressure method for duodenal endoscopic submucosal dissection","volume":"49","author":"Yahagi","year":"2017","journal-title":"Endoscopy"},{"key":"R10-20251203","doi-asserted-by":"crossref","first-page":"E67","DOI":"10.1055\/s-0042-101855","article-title":"\u201cUnderwater\u201d endoscopic submucosal dissection: A novel technique for complete resection of a rectal neuroendocrine tumor","volume":"48","author":"Yoshii","year":"2016","journal-title":"Endoscopy"},{"key":"R11-20251203","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1016\/j.gie.2016.07.018","article-title":"\u201cUnderwater\u201d endoscopic submucosal dissection for superficial esophageal neoplasms","volume":"85","author":"Akasaka","year":"2017","journal-title":"Gastrointest Endosc"},{"key":"R12-20251203","doi-asserted-by":"crossref","first-page":"1345","DOI":"10.1016\/j.gie.2017.11.032","article-title":"Usefulness of underwater endoscopic submucosal dissection in saline solution with a monopolar knife for colorectal tumors (with videos)","volume":"87","author":"Nagata","year":"2018","journal-title":"Gastrointest Endosc"},{"key":"R13-20251203","doi-asserted-by":"crossref","first-page":"1566","DOI":"10.1111\/jgh.16259","article-title":"Underwater endoscopic submucosal dissection for colorectal tumors decreases the incidence of post-electrocoagulation syndrome","volume":"38","author":"Koyama","year":"2023","journal-title":"J Gastroenterol Hepatol"},{"key":"R14-20251203","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1055\/a-2445-4970","article-title":"Prospective randomized trial comparing conventional and underwater endoscopic submucosal dissection for superficial colorectal neoplasms","volume":"57","author":"Nagata","year":"2025","journal-title":"Endoscopy"},{"key":"R15-20251203","doi-asserted-by":"crossref","first-page":"1079","DOI":"10.1016\/j.gie.2024.06.039","article-title":"Comparing underwater endoscopic submucosal dissection and conventional endoscopic submucosal dissection for large laterally spreading tumor: A randomized controlled trial","volume":"100","author":"Oh","year":"2024","journal-title":"Gastrointest Endosc"},{"key":"R16-20251203","doi-asserted-by":"crossref","first-page":"607","DOI":"10.1016\/j.gie.2021.03.026","article-title":"Safety and efficacy of water pressure endoscopic submucosal dissection for colorectal tumors with submucosal fibrosis (with video)","volume":"94","author":"Ozeki","year":"2021","journal-title":"Gastrointest Endosc"},{"key":"R17-20251203","doi-asserted-by":"crossref","first-page":"551","DOI":"10.1016\/j.gie.2024.10.029","article-title":"Underwater versus conventional endoscopic submucosal dissection for colorectal lesions: Systematic review and meta-analysis","volume":"101","author":"Singh","year":"2025","journal-title":"Gastrointest Endosc"},{"key":"R18-20251203","doi-asserted-by":"crossref","first-page":"1945","DOI":"10.1136\/gutjnl-2025-334995","article-title":"Underwater endoscopic submucosal dissection for large non-pedunculated colorectal polyps","volume":"74","author":"de Sire","year":"2025","journal-title":"Gut"},{"key":"R19-20251203","doi-asserted-by":"crossref","first-page":"944","DOI":"10.1055\/a-2619-1271","article-title":"Underwater compression hemostasis method for active bleeding in underwater endoscopic submucosal dissection","volume":"57","author":"Nagata","year":"2025","journal-title":"Endoscopy"},{"issue":"(Suppl 1)","key":"R20-20251203","first-page":"E854","article-title":"Successful underwater endoscopic submucosal dissection for ulcerative colitis-associated neoplasia using a synchronized irrigation fluid management system","volume":"57","author":"Tanabe","year":"2025","journal-title":"Endoscopy"},{"key":"R21-20251203","doi-asserted-by":"crossref","first-page":"844","DOI":"10.1055\/a-2633-6238","article-title":"Underwater vs. conventional endoscopic submucosal dissection: Retrospective analysis from a German high-volume center","volume":"63","author":"Ayoub","year":"2025","journal-title":"Z Gastroenterol"},{"key":"R22-20251203","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1016\/j.gie.2019.03.023","article-title":"Saline-pocket endoscopic submucosal dissection for superficial colorectal neoplasms: A randomized controlled trial (with video)","volume":"90","author":"Harada","year":"2019","journal-title":"Gastrointest Endosc"},{"key":"R23-20251203","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1016\/j.gie.2019.04.244","article-title":"The pocket-creation method for endoscopic submucosal dissection combined with saline-immersion: Another potential option to overcome challenges in colorectal endoscopic submucosal dissection","volume":"90","author":"Yamamoto","year":"2019","journal-title":"Gastrointest Endosc"},{"key":"R24-20251203","doi-asserted-by":"crossref","first-page":"652","DOI":"10.1016\/j.gie.2018.10.005","article-title":"Saline immersion therapeutic endoscopy\u2013facilitated pocket-creation method for endoscopic submucosal dissection (with video)","volume":"89","author":"Despott","year":"2019","journal-title":"Gastrointest Endosc"},{"key":"R25-20251203","doi-asserted-by":"crossref","first-page":"E699","DOI":"10.1055\/a-2368-9612","article-title":"Continuous low water pressure dissection technique minimizing air bubbles during underwater endoscopic submucosal dissection","volume":"56","author":"Nagata","year":"2024","journal-title":"Endoscopy"},{"key":"R26-20251203","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.vgie.2024.10.002","article-title":"The \u201cAsclepius tube\u201d: A slim drainage tube wrapped around the distal part of the endoscope for cecal endoscopic submucosal dissection","volume":"10","author":"Morikawa","year":"2024","journal-title":"VideoGIE"},{"issue":"(Suppl 1)","key":"R27-20251203","first-page":"A49.3","article-title":"Saline-immersion therapeutic endoscopy (SITE) for endoscopic submucosal dissection (ESD) of a large rectal lesion","volume":"67","author":"Murino","year":"2018","journal-title":"Gut"},{"key":"R28-20251203","doi-asserted-by":"crossref","first-page":"4388","DOI":"10.1038\/s41598-024-83503-3","article-title":"Different behavior of electrosurgical currents between air and saline immersion therapeutic endoscopy","volume":"15","author":"Capogreco","year":"2025","journal-title":"Sci Rep"},{"key":"R29-20251203","doi-asserted-by":"crossref","first-page":"e155","DOI":"10.1111\/den.14680","article-title":"Trans-anal Foley catheter facilitates endoscopic submucosal dissection of a distal rectal tumor","volume":"35","author":"Kagaya","year":"2023","journal-title":"Dig Endosc"},{"key":"R30-20251203","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/j.vgie.2023.09.008","article-title":"Saline-immersion endoscopic submucosal dissection using pocket-creation method","volume":"9","author":"Javia","year":"2023","journal-title":"VideoGIE"},{"key":"R31-20251203","doi-asserted-by":"crossref","first-page":"e107","DOI":"10.1111\/den.14603","article-title":"Trans-anal tube facilitates endoscopic submucosal dissection of a >10 cm rectal laterally spreading tumor","volume":"35","author":"Morikawa","year":"2023","journal-title":"Dig Endosc"},{"key":"R32-20251203","doi-asserted-by":"crossref","first-page":"755","DOI":"10.1080\/00365521.2025.2531040","article-title":"Underwater versus standard endoscopic submucosal dissection for superficial colorectal neoplasms: A propensity score\u2013matched analysis","volume":"60","author":"Andrisani","year":"2025","journal-title":"Scand J Gastroenterol"},{"key":"R33-20251203","doi-asserted-by":"crossref","first-page":"1217","DOI":"10.1016\/j.gie.2010.08.004","article-title":"A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video)","volume":"72","author":"Saito","year":"2010","journal-title":"Gastrointest Endosc"},{"key":"R34-20251203","doi-asserted-by":"crossref","first-page":"1042","DOI":"10.1111\/den.14223","article-title":"Outcomes of endoscopic submucosal dissection for colorectal neoplasms: Prospective, multicenter, cohort trial","volume":"34","author":"Kobayashi","year":"2022","journal-title":"Dig Endosc"},{"key":"R35-20251203","doi-asserted-by":"crossref","first-page":"E1082","DOI":"10.1055\/a-2181-5929","article-title":"Colorectal endoscopic submucosal dissection in the West: A systematic review and meta-analysis","volume":"11","author":"Singh","year":"2023","journal-title":"Endosc Int Open"},{"key":"R36-20251203","doi-asserted-by":"crossref","first-page":"E1166","DOI":"10.1055\/a-0965-8531","article-title":"High proficiency of colonic endoscopic submucosal dissection in Europe thanks to countertraction strategy using a double clip and rubber band","volume":"7","author":"Jacques","year":"2019","journal-title":"Endosc Int Open"},{"key":"R37-20251203","first-page":"578","article-title":"Outcomes of 601 colorectal endoscopic submucosal dissections in a single Western center: Is right colon location still a major concern?Surg Laparosc Endosc Percutan Tech","volume":"31","author":"Spychalski","year":"2021"},{"key":"R38-20251203","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/j.gie.2017.02.024","article-title":"Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: A systematic review and meta-analysis","volume":"86","author":"Fuccio","year":"2017","journal-title":"Gastrointest Endosc"},{"key":"R39-20251203","doi-asserted-by":"crossref","first-page":"1413","DOI":"10.21037\/tcr-21-2074","article-title":"Endoscopic resection for colorectal laterally spreading tumors in East Asian countries: A systematic review","volume":"11","author":"Liu","year":"2022","journal-title":"Transl Cancer Res"},{"key":"R40-20251203","doi-asserted-by":"crossref","first-page":"E694","DOI":"10.1055\/a-1789-0548","article-title":"Effectiveness and safety of endoscopic submucosal dissection using the pocket creation method in the Japanese population: A systematic review and meta-analysis","volume":"10","author":"Shinozaki","year":"2022","journal-title":"Endosc Int Open"},{"key":"R41-20251203","article-title":"Underwater vs Traction-assisted ESD in Colorectal Lesions Underwater versus Traction-assisted Endoscopic Submucosal Dissection for Colorectal Lesions: A Network Meta-Analysis of Randomized Controlled Trials","author":"de Sire","journal-title":"Gastrointest Endosc"},{"key":"R42-20251203","doi-asserted-by":"crossref","first-page":"E641","DOI":"10.1055\/a-2102-7578","article-title":"Effectiveness of water pressure method in colorectal endoscopic submucosal dissection by novice endoscopists","volume":"11","author":"Masunaga","year":"2023","journal-title":"Endosc Int Open"},{"issue":"(Suppl 1)","key":"R43-20251203","doi-asserted-by":"crossref","first-page":"S10","DOI":"10.1080\/0284186X.2019.1568547","article-title":"European experience of colorectal endoscopic submucosal dissection: A systematic review of clinical efficacy and safety","volume":"58","author":"Thorlacius","year":"2019","journal-title":"Acta Oncol"},{"key":"R44-20251203","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1136\/flgastro-2018-101145","article-title":"Deep sedation and anaesthesia in complex gastrointestinal endoscopy: A joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA)","volume":"10","author":"Sidhu","year":"2019","journal-title":"Frontline Gastroenterol"},{"key":"R46-20251203","doi-asserted-by":"crossref","first-page":"919","DOI":"10.1016\/j.dld.2012.06.021","article-title":"SCoPE consortium. The Global Rating Scale in clinical practice: A comprehensive quality assurance programme for endoscopy departments","volume":"44","author":"Sint Nicolaas","year":"2012","journal-title":"Dig Liver Dis"},{"key":"R47-20251203","doi-asserted-by":"crossref","first-page":"102029","DOI":"10.1016\/j.bpg.2025.102029","article-title":"Patient experience as a quality marker in gastrointestinal endoscopy","volume":"76","author":"Neilson","year":"2025","journal-title":"Best Pract Res Clin Gastroenterol"},{"key":"R48-20251203","doi-asserted-by":"crossref","first-page":"472","DOI":"10.1097\/MCG.0000000000001737","article-title":"Development and validation of a patient-reported experience measure for gastrointestinal endoscopy: The Comprehensive Endoscopy Satisfaction Tool (CEST)","volume":"57","author":"Kutyla","year":"2023","journal-title":"J Clin Gastroenterol"},{"key":"R49-20251203","doi-asserted-by":"crossref","first-page":"29","DOI":"10.7326\/M23-1812","article-title":"Endoscopic en bloc versus piecemeal resection of large nonpedunculated colonic adenomas: A randomized comparative trial","volume":"177","author":"Jacques","year":"2024","journal-title":"Ann Intern Med"},{"key":"R50-20251203","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1111\/den.14826","article-title":"International consensus on the management of large (\u226520 mm) colorectal laterally spreading tumors: World Endoscopy Organization Delphi study","volume":"36","author":"Djinbachian","year":"2024","journal-title":"Dig Endosc"},{"key":"R51-20251203","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1016\/j.mayocpiqo.2017.10.002","article-title":"Overall cost comparison of gastrointestinal endoscopic procedures with endoscopist- or anesthesia-supported sedation by activity-based costing techniques","volume":"1","author":"Helmers","year":"2017","journal-title":"Mayo Clin Proc Innov Qual Outcomes"},{"key":"R52-20251203","doi-asserted-by":"crossref","first-page":"932","DOI":"10.1080\/00365521.2025.2531436","article-title":"Low rate of general anaesthesia and hospital admission following colonic saline-immersion\/irrigation technique (SITE) endoscopic submucosal dissection (ESD)","volume":"60","author":"Rimondi","year":"2025","journal-title":"Scand J Gastroenterol"}],"container-title":["Saudi Journal of Gastroenterology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.4103\/sjg.sjg_422_25","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T15:49:55Z","timestamp":1787068195000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.4103\/sjg.sjg_422_25"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,3]]},"references-count":51,"URL":"https:\/\/doi.org\/10.4103\/sjg.sjg_422_25","relation":{},"ISSN":["1319-3767","1998-4049"],"issn-type":[{"value":"1319-3767","type":"print"},{"value":"1998-4049","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,3]]},"assertion":[{"value":"2025-11-03","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-11-15","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}