# Evaluation of Delayed Bleeding Prevention and Sustained Closure Using the Reopenable Clip‐Over‐the‐Line Method for Gastric Endoscopic Submucosal Dissection

## TL;DR

A new method called ROLM prevents delayed bleeding after gastric ESD in high-risk patients and ensures complete closure of wounds.

## Contribution

The ROLM technique is introduced as a novel closure method with potential for preventing delayed bleeding and ensuring sustained wound closure.

## Key findings

- ROLM achieved 0% delayed bleeding in high-risk gastric ESD patients compared to 23.6% in non-ROLM patients.
- All ROLM cases showed complete mucosal closure on postoperative day 1.
- 80.9% of ROLM cases retained clips at 2 months, indicating durable performance.

## Abstract

Delayed bleeding is a major complication of gastric endoscopic submucosal dissection (ESD), particularly in high‐risk patients. The reopenable clip‐over‐the‐line method (ROLM) is a novel closure technique, but its durability and preventive effects remain unclear. We evaluated the impact of ROLM on delayed bleeding and sustained closure after gastric ESD in high‐risk patients.

We retrospectively reviewed gastric ESD cases from April 2021 to December 2024, including only patients with a BEST‐J score ≥3, and compared ROLM and non‐ROLM groups. In the ROLM group, mucosal closure was confirmed endoscopically on postoperative day 1 (POD1), and clip retention was assessed at 2 months. The primary outcome was delayed bleeding within 28 days. Secondary outcomes included sustained closure on POD1 and clip retention at 2 months.

The ROLM group included 21 lesions in 15 patients, and the non‐ROLM group included 93 lesions in 72 patients. Delayed bleeding occurred in 0/15 ROLM patients (0%) versus 17/72 non‐ROLM patients (23.6%) (p = 0.036). Multivariable models using Firth logistic regression consistently showed a reduced odds ratio (≈ 0.10), although not statistically significant. All ROLM lesions achieved sustained closure on POD1 (100%). At 2 months, 80.9% retained clips.

In high‐risk gastric ESD patients, ROLM was associated with no delayed bleeding and achieved complete POD1 closure with frequent 2‐month clip retention, suggesting a potential for a promising prophylactic strategy.

ROLM achieves complete closure of post‐ESD mucosal defects and is associated with no delayed bleeding in high‐risk patients. Complete closure is confirmed in 100% of lesions on postoperative day 1, and clip retention at 2 months remains high, suggesting the potential for durable performance of ROLM.