A novel closure technique for a mucosal defect after endoscopic submucosal dissection: “closure on traction using a rotatable clip with a line loop”

Abstract

Figures

Schematic of the closure on traction using a rotatable clip with a line loop (CONTROLL) technique. a A post-endoscopic submucosal dissection ulcer defect. b First rotatable clip with a line loop placed at one side of the ulcer edge. c Second rotatable clip placed on the other side of the ulcer, including the line. d The third clip passed through the loop and moved to the first clip side for traction. e The opened third clip rotated to wrap the line around the clip. f By rotating the third clip, the line was shortened, resulting in a mucosa–mucosa traction, and the third clip was placed easily near the first and second clips.

First clip with a line loop. Making a 5–10-mm loop and setting the length of the line as approximately 5-10 mm longer than the ulcer size. We used SureClip; (Micro-Tech Co., Ltd, Nanjing, China) and polyester suture (Shirakawa Co.,Ltd, Tokyo, Japan) in this case.

Endoscopic images of closure on traction using a rotatable clip with a line loop (CONTROLL) technique for endoscopic submucosal dissection ulcer defect.

Endoscopic images 3 days after closure on traction using a rotatable clip with a line loop (CONTROLL) technique.

Full text

Endoscopic submucosal dissection (ESD) is widely performed for early gastrointestinal tumors; however, delayed bleeding is a major complication, reported in 5–10% of cases 1 . Various closure methods after ESD may reduce delayed bleeding 2 3 .

We have developed and used a novel closure technique named “closure on traction using a rotatable clip with a line loop (CONTROLL)” to treat a mucosal defect after ESD ( Fig. 1 ), using only rotatable clips and a line loop completed in the lumen, without scope reinsertion.

Schematic of the closure on traction using a rotatable clip with a line loop (CONTROLL) technique. a A post-endoscopic submucosal dissection ulcer defect. b First rotatable clip with a line loop placed at one side of the ulcer edge. c Second rotatable clip placed on the other side of the ulcer, including the line. d The third clip passed through the loop and moved to the first clip side for traction. e The opened third clip rotated to wrap the line around the clip. f By rotating the third clip, the line was shortened, resulting in a mucosa–mucosa traction, and the third clip was placed easily near the first and second clips.

A 71-year-old man underwent ESD for an early gastric cancer on the posterior side of the greater curvature of the antrum. Mucosal defect closure for an approximately 25-mm post-ESD ulcer was performed using CONTROLL. Before the procedure, a clip with a line with a 5–10-mm loop was set to a length approximately of 5-10 mm longer than the ulcer size ( Fig. 2 ). The first clip (SureClip; Micro-Tech Co., Ltd, Nanjing, China) with a line loop (polyester suture; Shirakawa Co., Ltd, Tokyo, Japan) was placed on one edge of the ulcer, including the muscular layer. A second clip (SureClip) grasping a line was deployed on the other side, including the muscular layer. A closed third clip (MANTIS Clip; Boston Scientific Corporation, Marlborough, MA, USA) was passed through the loop and moved to the side of the first clip. The third clip was opened and rotated to wrap a line around it. The edges of the ulcer simultaneously came close to the traction by shortening the line, and the third clip was placed near the first and second clips ( Fig. 3 and Video 1 ). Additional clips reinforced the defects. A follow-up endoscopy performed 3 days after the procedure showed no ulcer dehiscence ( Fig. 4 ).

First clip with a line loop. Making a 5–10-mm loop and setting the length of the line as approximately 5-10 mm longer than the ulcer size. We used SureClip; (Micro-Tech Co., Ltd, Nanjing, China) and polyester suture (Shirakawa Co.,Ltd, Tokyo, Japan) in this case.

Endoscopic images of closure on traction using a rotatable clip with a line loop (CONTROLL) technique for endoscopic submucosal dissection ulcer defect.

A case of closure on traction using a rotatable clip with a line loop (CONTROLL) technique for a post-endoscopic submucosal dissection ulcer defect.Video 1

Endoscopic images 3 days after closure on traction using a rotatable clip with a line loop (CONTROLL) technique.

CONTROLL enabled firm closure. The clip–line and clip–clip connections become stronger by rotating the clip and shortening the line.

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