Clip with line-pulley securing technique with plastic detachable snare for endoscopic submucosal dissection defect closure

Video

Video 1

Clip with line-pulley securing technique with plastic detachable snare for endoscopic submucosal dissection defect closure.

Endoscopic closure of post–endoscopic submucosal dissection (ESD) defects has been shown to prevent delayed bleeding and delayed perforation.¹ Various closure methods have been reported, including the use of through-the-scope (TTS) hemostatic clips, plastic detachable snares, over-the-scope clips (OTSCs), and, more recently, closure with suturing devices,2, 3, 4, 5 Closure with TTS hemostatic clips is simple, but it may not be feasible for large defects. Closure with clips placed over a plastic detachable snare enables the closure of large defects, but it requires scope exchange and the use of a double-channel endoscope and is a complicated and time-consuming procedure.² The procedure is also technically challenging, owing to the need to align the axes of the instrument and the endoscope. Closure using suturing devices is effective but expensive. We had previously reported the clip with line-pulley securing (CLiPS) technique using a modified anchoring clip that serves the purpose of a knot.⁶ Because modifying clips manually is cumbersome, we devised a modification of the CLiPS technique using a plastic detachable snare that does not require special equipment, endoscopes, or scope exchange. Accessories required include reopenable TTS clips (Sure Clip; Micro-Tech Co, Ltd, Nanjing, China), a line (BEAR nylon monofilament suture; BEAR Medic Co, Ibaraki, Japan), a plastic detachable snare (Polyloop; Olympus, Tokyo, Japan), and a loop cutter (FS-5L-1; Olympus).

An 86-year-old woman on anticoagulants required an ESD for a 25-mm early gastric cancer at the upper body along the lesser curvature. The resulting post-ESD defect was about 4 cm in diameter (Fig. 1A). The defect showed features of thermal injury. To prevent delayed perforation and bleeding, we attempted closure of the defect with the CLiPS technique using a plastic detachable snare (Video 1, available online at www.videogie.org). First, a reopenable clip with a line was attached to the normal mucosa on one lateral edge of the defect. The second clip with another line was inserted in the instrument channel and then attached to the normal mucosa on the other lateral edge of the defect. Subsequently, the 2 lines were passed through a plastic detachable snare, and the loop was tightened, just enough to allow the lines to move smoothly (Fig. 1B). The edges, with the clips, were then approximated by pulling both lines simultaneously while pushing the plastic detachable snare over the lines. The plastic detachable snare was then tightened fully and released, enabling it to serve the purpose of a knot (Fig. 1C). Finally, the free ends of the lines as well as the detachable snare were cut with a loop cutter (Fig. 1D). Further closure of the approximated edges of the defect could then be completed with TTS hemostatic clips (Fig. 1E).

Figure 1.

A, A gastric mucosal defect after endoscopic submucosal dissection. B, Two clips with lines were attached to the edge of the defect. Pass the 2 lines through the plastic detachable snare and push the plastic detachable snare along the lines. C, After tightening the plastic detachable snare and releasing it, the size of the defect became reduced. D, Cut the plastic detachable snare and 2 lines with a loop cutter. E, The defect was closed completely.

Suturing devices and OTSCs have the potential to limit the maneuverability of the endoscope, especially at difficult locations. Compared with the previously reported CLiPS technique that uses a modified clip, this method using a commercially available plastic detachable snare, which serves the purpose of a knot, is easier. While we used a therapeutic gastroscope with a 3.2-mm channel in this case, we could perform this using scopes with 2.8-mm accessory channels in subsequent cases.

When this technique is used, edges of large defects can be approximated well enough to facilitate full closure by adding TTS hemostatic clips after approximating. Very large defects can also be possibly closed by applying multiple iterations of the CLiPS technique, along the defect. This is a simple, easy, and effective method that does not require special devices, scopes, or scope exchange.

Disclosure

The authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Clip with line-pulley securing technique with plastic detachable snare for endoscopic submucosal dissection defect closure.