Mucosal inverted closure of a post-gastric endoscopic submucosal dissection defect using grasping forceps with good rotatability and sharp claws

Although post-gastric endoscopic submucosal dissection (ESD) bleeding is reduced by defect closure ^{1 2 3} , there is no convenient and secure mucosal inverted closure method that enables early wound healing through sustained closure. We previously reported on post-ESD closure using jumbo grasping forceps (FG-47L-1; Olympus, Tokyo, Japan) ⁴ ; however, one problem was the poor maneuverability of the grasping forceps. Subsequently, we used EndoGrip grasping forceps (EndoGrip, AG-5039-2323; AGS MedTech, Tokyo, Japan) ( Fig. 1 ), which allows closure while inverting the mucosa. EndoGrip has two advantages: 1) small, sharp teeth at the tip and sharp claws in the arms that enable secure fold-and-drag maneuvers; and 2) good rotatability that provides easy maneuverability. We introduce a novel closure technique using EndoGrip forceps and endoclips.

Fig. 1.

Photographs of the EndoGrip grasping forceps (AG-5039-2323; AGS MedTech, Tokyo, Japan), which has small, sharp teeth at the tip and sharp claws in the arms that enable secure fold-and-drag maneuvers, as well as having good rotatability that provides easy maneuverability; the claw length is 1.5 mm, with an opening width of 8.3 mm.

A 68-year-old man who was taking aspirin presented with a large early gastric cancer located on the lesser curvature in the angle. After standard ESD had been performed, a 38-mm defect remained ( Fig. 2 a ). After written informed consent had been obtained, the defect was closed using the following steps ( Fig. 3 ; Video 1 ). The EndoGrip was inserted into an endoscope with dual working channels (GIF-2TQ260M, Olympus), and one edge of the mucosal defect was grasped ( Fig. 2 b ). The grasped edge was dragged to the opposite edge of the mucosal defect, the EndoGrip was reopened, and the other side of the mucosa was grasped ( Fig. 2 c ). An endoclip (EZ Clip, HX-610-090L; Olympus) was inserted into the second channel of the endoscope, and the clip was pressed against the mucosa and closed while pulling the EndoGrip ( Fig. 2 d,e ). This procedure was repeated until the defect was completely closed ( Fig. 2 f ). Further endoclips were added in any gaps. The closure time was 31 minutes, and sustained closure was confirmed on postoperative days 3 and 7 ( Fig. 4 ).

Fig. 2.

Endoscopic images of the closure procedure showing: a a 38-mm defect after standard endoscopic submucosal dissection; b the grasping forceps that had been inserted through one channel of a dual-channel endoscope being used to grasp one edge of the mucosal defect; c the grasped edge being dragged to the opposite edge of the mucosal defect, where the forceps is slowly reopened to grasp the other side of the mucosa; d an endoclip that had been inserted through the second channel of the endoscope being pressed against the mucosa and closed while pulling on the forceps; e the first two endoclips in place as the procedure is repeated along the entire defect length; f the completely closed defect.

Fig. 3.

Schema of the procedure. Source: Davinch Medical Illustration Office.

Fig. 4.

Endoscopic appearance on the 3rd and 7th postoperative days showing continued sustained closure, with all clips remaining in place.

Download video file ^{(48.6MB, mp4)}

Video showing the EndoGrip forceps being used to close an artificial gastric defect. Source for graphical illustrations: Davinch Medical Illustration Office.

Video 1

The ease of maneuverability and high grasping strength of the EndoGrip simplify the technique of mucosal inverted gastric closure.

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