Unique closure of large colonic endoscopic submucosal dissection defect using zigzag clip with line pulley securing technique

Introduction

CLiPS (Clip with Line Pulley Securing) technique was reported as a suture method for post–endoscopic submucosal dissection (post-ESD) mucosal defect.1, 2, 3

Compared to previous reports,4, 5, 6 CLiPS has several unconventional advantages. CLiPS technique does not require the use of special endoscope (eg, 2-channel endoscope), special equipment attached to the endoscope, and endoscope replacement. It can be easily performed with inexpensive tools that are already commercially available: reopenable clip, nylon thread, plastic detachable snare, and loop cutter. Because of the simplicity of the procedure, the CLiPS method is considered one of the simplest techniques of defect closure.

With a single CLiPS system and additional hemostatic clips, the mucosal defect can be closed completely in most cases (Fig. 1). However, in a case of a large mucosal defect, a single CLiPS system was not sufficient to suture the whole defect, requiring the use of multiple CLiPS systems and additional hemostatic clips for complete closure (Fig. 2). When multiple CLiPS systems were applied, the procedure took more time and effort than when only 1 CLiPS was used for closure. In addition, cut plastic threads sometimes interfered with the field of view, making it difficult to perform subsequent procedures.

Figure 1.

CLiPS technique. A, The clip with thread is placed on the edge of defect. B, A second clip is placed opposite the first clip. C, By pulling the thread, the 2 clips are brought together in the center. Next, the plastic detachable snare is brought to the root of the clips to secure the thread. D, Once the snare is locked in place, the 2 ends are firmly attached. E, The free end of the thread and loop are cut with a loop cutter. F, Additional hemostatic clips are placed on both sides for complete closure.

Figure 2.

Multiple CLiPS for large mucosal defect. A, The clip with thread is placed on the edge of defect. B, A second clip is placed opposite the first clip. C, A plastic detachable snare is delivered through the thread. D, A single CLiPS system is applied. The proximal side of the defect remains open. E, The second and third CLiPS systems are added to the proximal part of the defect. F, Additional hemostatic clips are placed to close the defect.

In this report, we have developed a method of suturing large defects more simply by applying the CLiPS technique in a zigzag stitching pattern to the defect.

Zigzag-CLiPS

First, the clip (SureClip; Micro-tech Co Ltd, Nanjing, China) is prepared with the nylon thread (Bear nylon monofilament suture; BEAR Medic Co, Ibaraki, Japan) fixed to the clip's arm as in CLiPS and attached to the normal mucosa on the distal edge of the defect (Fig. 3A). The second clip is inserted into the accessory channel and it holds the thread between the clip arms, which is then attached to the opposite edge across the mucosal defect (Fig. 3B). In the same manner, the third clip is placed adjacent and proximal to the first clip (Fig. 3C). The fourth clip is placed at the opposite side of the third clip. Until the clips are placed around the entire defect, this procedure is repeated and the thread is pulled to form a zigzag stitching shape across the defect (Fig. 3D to E). As in the CLiPS technique, the mucosal defect is sutured by pulling the thread and securing it with a plastic detachable snare (Polyloop; Olympus, Tokyo, Japan) inserted through the thread (Fig. 3F and G). Finally, the free end of the thread and loop is cut with a loop cutter (Fig. 3H).

Figure 3.

Zig-zag CLiPS for large mucosal defect. A, The first clip with thread is placed on the edge of the distal side. B, A second clip is placed opposite the first clip. C, The third clip is placed adjacent and proximal to the first clip. D, Additional clips are arrayed in a zigzag pattern to cover the entire mucosal defect. E and F, By pulling the thread, the defect is pulled toward the scope and contracted. G, A plastic detachable snare is delivered through the thread and the thread is secured. H, The large defect is closed completely in 1 session.

Case

ESD was performed on a 50-mm lesion in the ascending colon. The lesion was resected en bloc and large mucosal defect was excised. First, a clip with line was placed on the oral side of the mucosal defect, and then additional clips were placed around the defect in an alternating zigzag fashion while securing the line with the clip. Finally, by tightening the snare while pulling the thread, most of the defect was secured in one sequence (Video 1, available online at www.videogie.org).

Compared with the conventional method in which multiple CLiPS are deployed in parallel, this method requires only 1 ligation, making the procedure quicker and easier to complete. Zigzag-CLiPS appears to be more simple and efficacious than conventional CLiPS when closing large mucosal defects.

In summary, the Zigzag-CLiPS technique is one of the good options for closing large mucosal defects. It appears to be a versatile closure method for other situations.

Disclosures

All authors disclosed no financial relationships.

Supplementary data

Video.1

Zigzag CLiPS technique for large mucosal defect after colonic endoscopic submucosal dissection (ESD).

So far we have reported the usefulness of CLiPS technique as a closure method for mucosal defects after ESD.

Compared to other methods, the CLiPS method is simpler as it does not require a scope replacement, or fitting of special instruments. And the procedure can be completed using only commercially available products.

This is an instructional video for CLiPS.

First, prepare a clip with a nylon thread attached to the arm.

A clip with thread is placed on the distal side of the defect.

Next, another clip is placed on the opposite side of the defect.

Next, a plastic detachable snare is inserted through the thread and through the instrumental channel. By pulling on the thread, the defect is pulled tight and the snare serves to secure the thread. Finally, the free ends of the thread and the snare are removed with a loop cutter.

Although CLiPS is useful, the problem is that as the defect size increased, multiple CLiPS systems are required for closure, which makes the procedure more complicated and time-consuming.

Therefore, we developed the zigzag CLiPS method, a method of closing the entire defect at once in a series of sequences by arranging the clips in a zigzag shape.

After colonic ESD, the size of defect was about 70 mm.

First, a clip with line is placed on the oral side of the mucosal defect. The second clip is then attached to the opposite edge across the mucosal defect. In the same manner, a third clip is placed adjacent and proximal to the first clip. A fourth clip is next placed at the opposite side of the third clip. Until the clips are placed around the entire defect, this procedure is repeated, and the thread is pulled to form a zigzag stitching shape across the defect.

Finally, by tightening the snare while pulling the thread, suturing most of the defect can be completed in one sequence.

Conclusions: Zigzag CLiPS requires only 1 ligation, making the procedure quicker and easier to complete. Zigzag CLiPS appears to be more simple and efficacious than conventional methods when closing large mucosal defects.