Dual Action Tissue Clip: A New Kid on the Block for Large Defect Closure – Report of Two Cases

Introduction

Endoscopic submucosal dissection (ESD) often results in large mucosal defects, increasing bleeding and perforation risk. Effective defect closure may reduce delayed adverse events, particularly bleeding, which occurs in up to 4.7% after gastric ESDs [1]. Proper closure may also be pivotal in cases of perforation. Conventional through-the-scope (TTS) clips are commonly used in this context, but their effectiveness may be limited when closing large mucosal defects due to restricted opening width and inadequate tissue traction. We report two gastric ESD cases with large mucosal defects (online suppl. Video 1; for all online suppl. material, see https://doi.org/10.1159/000553067) successfully closed using the new Dual Action Tissue (DAT) clip (Micro-Tech Endoscopy, Hamburg, Germany) (Fig. 1).

Fig. 1.

a Dual Action Tissue (DAT) clip delivery system with dual color-coded control handles, allowing independent operation of each arm. b One arm of the DAT clip opens using the handle. c The second arm opens using the other handle. d Closure of both arms using both handles.

Case 1

A 68-year-old male with no relevant medical history underwent gastric ESD for a 15-mm Paris 0-IIa antral lesion using a therapeutic gastroscope (GIF-EZ1500, Olympus). En bloc resection yielded a 32 × 31 mm specimen. The mucosal defect was closed to prevent delayed bleeding using one DAT clip, sequentially grasping each defect edge to achieve approximation in 3 min 30 s. Residual small gaps were closed during 3 min 20 s with three 16-mm conventional TTS clips (Micro-Tech Endoscopy, Hamburg, Germany) (Fig. 2).

Fig. 2.

a Large mucosal defect post-endoscopic submucosal dissection. b DAT clip was deployed after sequentially approximating mucosal edges with both arms. c Successful defect size reduction after DAT clip deployment of the center of the mucosal defect. d Complete closure using conventional through-the-scope clips for the remaining smaller gaps.

Case 2

A 72-year-old male with no relevant medical history underwent gastric ESD for a 22-mm Paris 0-IIa lesion at the incisura, using a therapeutic gastroscope (GIF-EZ1500, Olympus). En bloc resection yielded a 31 × 30 mm specimen, followed by complete closure of the mucosal defect using one DAT clip in 5 min 40 s and four 16-mm conventional TTS clips (Micro-Tech Endoscopy, Hamburg, Germany) in 6 min 30 s (Fig. 3). In both cases, patients were discharged on the same day of the procedure, and no adverse events occurred during clip deployment or during the 1-month follow-up.

Fig. 3.

a Large mucosal defect post-endoscopic submucosal dissection. b Dual Action Tissue clip was deployed by sequentially grasping one edge of the defect with the first arm, followed by approximation and grasping of the opposing edge with the second arm. c Successful partial closure of the center of the mucosal defect. d Complete closure using conventional through-the-scope clips.

Discussion

The DAT clip proved effective in these 2 cases requiring high traction. This three-arm TTS clip features a 2-mm center-fixed column and two independently controlled arms, enabling secure grasping of one defect edge followed by controlled approximation of the opposing edge. The device (235 cm length) requires a 3.2-mm working channel and provides a 15-mm opening with a short stem (8.6 mm). Color-coded handles facilitate independent arm control [2].

This non-rotational device allows the closure of mucosal defects >20 mm, including the lesser curvature, which are often challenging with conventional TTS clips. It typically detaches within a few weeks. Its efficacy appears comparable to TTS tack-and-suture devices, with shorter procedure times and potential cost advantages [3]. In addition, Mohammed et al. [3] reported a 96.3% closure rate for large nonpedunculated colorectal lesions using the DAT clip, with a low delayed bleeding rate (0.9%) [4]. The DAT clip may also be useful for managing adverse events such as perforation and bleeding.

In selected low-risk patients, defect closure may support same-day outpatient ESD strategies [5], although evidence remains limited. Indeed, routine closure after gastric ESD is not recommended except in selected high-risk cases [1]. Given the low risk of delayed bleeding (∼5%) and lack of randomized evidence, the benefit of closure remains uncertain and should be balanced against additional time and costs. We highlight the DAT clip as a safe, user-friendly, and effective option for the closure of large mucosal defects.

Statement of Ethics

Ethical approval was not required in accordance with local/national guidelines. The patient has given written informed consent for publication (including the publication of images/video).

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This study was not supported by any sponsor or funder.

Author Contributions

Francisco Vara-Luiz and Filipe Craveiro wrote the manuscript. João Pedro-Pereira and Pedro Bernardes-Antunes performed the ESD on both patients. Francisco Baldaque-Silva performed the defect closure. João Pedro-Pereira, Pedro Bernardes-Antunes, Renato Medas, and Francisco Baldaque-Silva critically reviewed the manuscript. All authors approved the final version of this paper.

Funding Statement

This study was not supported by any sponsor or funder.

Data Availability Statement

The complete data of this study are not publicly available due to the patient’s privacy but are available from the corresponding author upon reasonable request.