ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD): EXPERIENCE FROM A TERTIARY REFERRAL CENTRE IN LONDON REGARDING SALINE-IMMERSION THERAPEUTIC ENDOSCOPY (SITE) COMBINED WITH THE POCKET-CREATION METHOD (PCM)

Aims Endoscopic submucosal dissection (ESD) is a potentially curative, minimally-invasive alternative to major surgery for the endoscopic management of superficial gastric and colorectal neoplasms. Due to its several advantages pocket-creation method (PCM) appears to simplify ESD. Since 2017, we have combined PCM with saline-immersion therapeutic endoscopy (SITE), as this could improve view quality (through refractive magnification, and minimal lense fogging) and lesion lifting (through buoyancy).

Methods The aim of our study is to review our experience of SITE-PCM-ESD cases from July 2017 to November 2019. Demographic, endoscopic, histopathological data were analysed.

Results ESDs were performed in 39 patients, mean age: 65-years. Six lesions were removed from the stomach, 1 from the caecum, 6 from the ascending colon, 14 from the sigmoid and 12 from the rectum. En-bloc pure-SITE-PCM-ESD resection was achieved in 28 patients (71.797%); in 3 patients (7.69%) the procedure was not completed due to the suspicion of invasive malignancy and these patients were referred for surgery.

Details of the cases managed by pure SITE-PCM-ESD are described as follows. Median specimen size was of 38mm. Histopathological examination showed: 2 villous-adenomas with low-grade dysplasia, 7 tubular-adenomas with low-grade dysplasia, 3 tubular-adenomas with high-grade dysplasia, 2 tubulovillous-adenomas with high-grade dysplasia, 11 tubulovillous-adenomas with low-grade dysplasia, 1 adenocarcinoma, 7 neuroendocrine tumors, 1 serrated-adenoma with low-grade dysplasia, 1 hyperplastic gastric polyp and 1 sessile-serrated lesion without dysplasia. R0-resection rate was 94.44%. Lymphovascular infiltration was suspected in the one case of malignancy (2.56%). Two patients suffered from early post-procedural rectal bleeding, warranting further endotherapy; no further complications were identified. To date, 28 patients (77.77%) have completed endoscopic follow-up; none of these patients have presented any evidence of disease recurrence.

Conclusions Our series of SITE-PCM-ESD showed favorable results in term of efficacy and safety. Further comparative randomised control studies are required to further evaluate potential advantages of this technique.