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Plain water is inadequate for ESD: insufficient conductivity higher diathermy settings required Isotonic saline (0.9% NaCl): electrolyte-rich conductive medium facilitates cutting, coagulation and vessel precoagulation ESGE 2023 guidelines explicitly endorse saline over water in immersion-assisted ESD SITE-PCM: especially powerful combination the pocket stabilises the dissection plane, SITE optimises optics, buoyancy and diathermy performance Asclepius tube: continuous drainage of excess saline without repeated through-the-scope suctioning Western cohort data (181 lesions, Royal Free): R0 92.3%, curative resection 90.6%, 93.4% under conscious sedation, 0.5% surgery rate Conclusion: SITE is not a competitor to conventional ESD it is a flexible adjunct, most valuable in fibrotic lesions, anatomically challenging segments, and for broadening access to ESD without general anaesthesia

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