Line-assisted complete closure of large gastric mucosal defects by use of multiple clip-and-line technique

Perforation is a serious adverse event of endoscopic resection. Although they are usually managed by endoscopic clip closure, 3% to 6% of perforations during gastric endoscopic resection cannot be completely closed and therefore require emergency surgery. We developed the line-assisted complete closure (LACC) technique to close large colorectal mucosal defects after endoscopic submucosal dissection (ESD) and have applied this technique to large mucosal defects after gastric ESD. A 40-mm mucosal defect resulting from gastric ESD was closed by LACC using a multiple clip-and-line technique (Figs. 1A and B; Video 1, available online at www.VideoGIE.org). Briefly, a nylon line was tied to a clip (HX-610-090; Olympus, Tokyo, Japan) mounted onto an applicator (HX-110LR; Olympus). The clip was retracted into the applicator and inserted into the accessory channel. The first clip-and-line was attached to the normal mucosa on the proximal side of the defect (Fig. 1C). A second clip without a line was inserted into the accessory channel and anchored to the distal side of the defect, and the clips were gathered by pulling the line. Additional clips were attached to keep the closure secure and tight (Fig. 1D). Because of its large size, however, the entire defect could not be completely closed by the first clip-and-line. After the line tied to the first clip was cut with scissor forceps (FS-3L-1; Olympus), a second clip-and-line was attached in the same way, resulting in complete closure of the large gastric mucosal defect (Fig. 1E). Most clips were attached to the area of the defect 1 month after ESD, and the mucosal defect was completely repaired (Fig. 1F).

Figure 1.

A, EGD view showing a slightly depressed 12-mm lesion at the fornix of the stomach. B, A 40-mm gastric mucosal defect after ESD. C, Attachment of the first clip-and-line to normal mucosa on the proximal side of the mucosal defect. D, After gathering of both sides of the defect, attachment of additional clips to close the defect. E, Complete closure of the large gastric mucosal defect, taking about 20 minutes in all. F, Attachment of most clips to the area of the defect 1 month after ESD. G, EGD view showing a 20-mm submucosal tumor at the fornix of the stomach. H, Large intraoperative perforation. I, Complete closure of the large perforation by line-assisted complete closure by use of multiple clip-and-line technique, taking about 18 minutes in all. ESD, endoscopic submucosal dissection.

We were able to close a large intraoperative perforation by using the same technique. A 20-mm GI stromal tumor located at the fornix of the stomach was treated by ESD (Fig. 1G). During ESD, a large perforation occurred (Fig. 1H). First, the muscular layer defect was closed by clips. After that, the mucosal layer was completely closed by LACC (Fig. 1I). Recently, simple closure techniques such as loop clip or slipknot closure have been reported; however, we consider LACC to be a simpler and more effective technique because it achieves a tight closure by pulling the line during the procedure.

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Line-assisted complete closure of a gastric mucosal defect after endoscopic submucosal dissection using the multiple clip-and-line technique. The first clip-and-line was attached to the normal mucosa, 5 mm from the proximal side of the mucosal defect. A second clip was inserted into the accessory channel and anchored to the opposite side of the normal mucosa. The 2 clips were gathered by gently pulling the line, and additional clips were attached to achieve closure. A second clip-and-line was applied in the same way, resulting in complete closure of the large gastric mucosal defect.