Suture-and-clip continuous suturing technique: a novel endoscopic closure method for large mucosal defects

Abstract

Figures

Endoscopic views of the closure of a large gastric mucosal defect after endoscopic submucosal dissection (ESD). a Early gastric cancer at greater curvature of lower gastric body. b A 40 × 35-mm mucosal defect post-ESD. c A reopenable clip with sutures was placed on the distal edge of the defect. d A second clip was hooked onto the suture and placed on the opposite side of the defect. e The suture was pulled to tighten and close the defect. f The last clip was hooked onto the suture, rotated 360 degrees, and placed at the end of the defect.

Gastroscopy performed one week later did not reveal a split defect or detachment of the clip.

Full text

We describe a case of a 56-year-old man in whom upper endoscopy revealed early gastric cancer at the greater curvature of the lower gastric body ( Fig. 1 a ). Endoscopic submucosal dissection (ESD) was performed to achieve complete resection of the lesion. Following resection, a 40 × 35-mm mucosal defect remained ( Fig. 1 b ). To prevent delayed perforation and bleeding, the defect required closure. As the gastric wall thickness and lesion tension precluded approximation using clips alone, we employed a novel suturing strategy utilizing surgical suture material.

Endoscopic views of the closure of a large gastric mucosal defect after endoscopic submucosal dissection (ESD). a Early gastric cancer at greater curvature of lower gastric body. b A 40 × 35-mm mucosal defect post-ESD. c A reopenable clip with sutures was placed on the distal edge of the defect. d A second clip was hooked onto the suture and placed on the opposite side of the defect. e The suture was pulled to tighten and close the defect. f The last clip was hooked onto the suture, rotated 360 degrees, and placed at the end of the defect.

The procedure for defect closure was as follows ( Video 1 ). An absorbable surgical suture was secured to one arm of a reopenable clip. The first clip (with attached suture) was deployed at the distal margin of the defect, engaging the full thickness of the gastric wall ( Fig. 1 c ). Thereafter, a second clip was hooked onto the suture and placed on the opposite side of the defect ( Fig. 1 d ). The suture was pulled to approximate the edges, with sequential repetition of this process until achieving complete tension-free closure ( Fig. 1 e ). Ultimately, reinforcement clips were placed to consolidate the closure. For the terminal clip, it was hooked onto the suture, rotated 360°, and anchored at the proximal defect margin ( Fig. 1 f ). Finally, the suture was transected using a hemostat. Gastroscopy performed one week later did not reveal a split defect or detachment of the clip ( Fig. 2 ).

Novel endoscopic closure method for large mucosal defects.Video 1

Gastroscopy performed one week later did not reveal a split defect or detachment of the clip.

Large post-ESD mucosal defects may lead to serious postoperative complications, including delayed bleeding and perforation 1 . Although novel endoscopic closure techniques have emerged, most require specialized devices with significant technical complexity 2 3 . Our technique utilizes universally available absorbable sutures combined with standard clips to achieve continuous endoscopic suturing. This method provides rapid, accessible closure with balanced tension distribution, representing a potentially valuable advancement in endoscopic defect management.

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