Muscle-Anchor-Assisted Coagulation, Clipping, and Closure to Prevent Delayed Bleeding After Gastric Endoscopic Submucosal Dissection Using Inexpensive Reopenable Clips

CASE REPORT

Several closure methods, including our previously reported coagulation, clipping, and closure (CCC) method,¹ have been proposed to prevent delayed bleeding after gastric endoscopic submucosal dissection (ESD).^2,3 To improve tissue approximation while maintaining low cost, we developed a muscle-anchor-assisted CCC method using inexpensive reopenable clips.

Gastric ESD was performed in a patient undergoing maintenance hemodialysis, resulting in a 30-mm post-ESD ulcer on the greater curvature of the lower gastric body (Figure 1). After coagulation of visible vessels (Figure 2), perforating vessels emerging between the muscle layers were clipped together with the surrounding muscle layer while sufficient air was suctioned (Figure 2). This maneuver created a muscle anchor by folding and elevating the muscle layer, thereby reducing the size of the mucosal defect. The mucosa was then draped over the elevated muscle layer and clipped together with it (Figure 2). The same procedure was repeated on the opposite side, and the approximated mucosal edges were completely closed with additional clips (Figure 1, Video 1).

Figure 1.

Endoscopic findings before and after closure. (A) A 30-mm postendoscopic submucosal dissection ulcer on the greater curvature of the lower gastric body. (B) Complete closure of the mucosal defect achieved using the muscle-anchor-assisted coagulation, clipping, and closure method.

Figure 2.

Muscle-anchor-assisted coagulation, clipping, and closure method. (A) Coagulation was performed targeting visible vessels at the margin of the ulcer base. (B) Perforating vessels emerging between the muscle layers were clipped together with the surrounding muscle layer using inexpensive reopenable clips (SureClip eco; Micro-Tech Co. Ltd.) while sufficient air was suctioned, resulting in folding and elevation of the muscle layer. (C) The mucosa was draped over the elevated muscle layer and clipped together with it, creating a muscle-anchor configuration.

The postoperative course was uneventful, with no delayed bleeding, perforation, or additional intervention. Follow-up endoscopy on postoperative day 4 confirmed that the closure remained intact without wound dehiscence (Figure 3). At 5 months, complete healing of the post-ESD ulcer was observed without delayed complications (Figure 3).

Figure 3.

Follow-up endoscopic findings. (A) Follow-up endoscopy on postoperative day 4 showing that the closure remained intact without wound dehiscence. (B) Follow-up endoscopy at 5 months showing complete healing of the postendoscopic submucosal dissection ulcer.

This technique incorporates muscle-anchor creation into the standard clipping step without requiring dedicated devices. By clipping the mucosa together with the elevated muscle layer, secure tissue approximation may be achieved even in the thick gastric wall. We primarily envision this technique for patients at high risk of delayed bleeding after gastric ESD. Further studies are needed to evaluate its reproducibility, clinical efficacy, and appropriate indications.

Because this technique uses inexpensive reopenable clips and extends the conventional CCC method, it may be readily adopted by endoscopists experienced in ESD.

DISCLOSURES

Author contributions: S. Abiko wrote the manuscript. E. Ishibe, X. Zhang, S. Hayasaka, S. Nakajima, H. Egami, T. Sone, M. Inoue, S. Miyamoto, M. Ono, S. Ono, and N. Sakamoto edited the manuscript. S. Abiko is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.