Two-layer closure method using anchor pronged clips for endoscopic full-thickness resection

Abstract

Figures

Esophagogastroduodenoscopy a and EUS b revealed a 25-mm submucosal tumor in the lower gastric body. EUS, endoscopic ultrasound.

Computed tomography revealed a 25-mm gastric submucosal tumor and no evidence of metastasis.

a The submucosa to minimize any resulting full-thickness defects prior to specimen removal. b Extraction of specimens with minimal muscle dissection.

a Use anchor-pronged clips (MANTIS clips; Boston Scientific) to close the wound between the muscle layers. b Use MANTIS clips and conventional clips to close the mucosal defects.

Postoperative day 3: complete closure of the treatment site was maintained.

Full text

A 54-year-old man underwent esophagogastroduodenoscopy, which revealed a 25 mm submucosal tumor in the lower gastric body ( Fig. 1 a ). Endoscopic ultrasound-guided fine-needle biopsy led to a diagnosis of gastric gastrointestinal stromal tumors (GISTs; Fig. 1 b ). Computed tomography revealed no evidence of metastasis ( Fig. 2 ). We therefore proceeded with endoscopic full-thickness resection (EFTR) to treat this submucosal tumor ( Video 1 ).

Esophagogastroduodenoscopy a and EUS b revealed a 25-mm submucosal tumor in the lower gastric body. EUS, endoscopic ultrasound.

Computed tomography revealed a 25-mm gastric submucosal tumor and no evidence of metastasis.

The defect after EFTR was closed with four MANTIS clips for the muscle layer and additional clips for the mucosa following successful specimen extraction. EFTR, endoscopic full-thickness resection.Video 1

Under general anesthesia, we carefully dissected the submucosa to minimize any resulting full-thickness defects prior to specimen removal ( Fig. 3 a ). The specimen was successfully extracted via a minimal muscle layer incision without capsule injury ( Fig. 3 b ).

a The submucosa to minimize any resulting full-thickness defects prior to specimen removal. b Extraction of specimens with minimal muscle dissection.

Four anchor-pronged clips (MANTIS clips; Boston Scientific) were used to close the defect between the muscle layers of the stomach wall ( Fig. 4 a ). Subsequently, we used three additional MANTIS and five conventional clips to close the mucosal defects, achieving complete closure ( Fig. 4 b ).

a Use anchor-pronged clips (MANTIS clips; Boston Scientific) to close the wound between the muscle layers. b Use MANTIS clips and conventional clips to close the mucosal defects.

Esophagogastroduodenoscopy on postoperative day 3 confirmed complete closure of the resection site ( Fig. 5 ). No postoperative complications such as bleeding or delayed perforation were observed, and the patient was discharged on postoperative day 6.

Postoperative day 3: complete closure of the treatment site was maintained.

Postoperative histopathological evaluation confirmed negative horizontal and vertical margins, with a final diagnosis of very low risk GIST (Modified Fletcher Classification).

EFTR represents an effective treatment option for small GISTs 1 . However, delayed perforation at full-thickness closure sites after resection remains a major concern 2 .

While earlier methods focused on mucosal layer closure 1 , various techniques have since been proposed to improve closure security, averting perforation 3 4 . Our recommended approach employs MANTIS clips for the independent closure of the muscle and mucosal layers, similar to the standard two-layer surgical suturing technique 5 . This method offers more robust closure than mucosal-only suturing, and is therefore expected to reduce postoperative complications.

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