Bleeding is the most common adverse event associated with gastric endoscopic resection.1
A 63-year-old woman with multiple comorbidities, who was taking clopidogrel, underwent hot snare polypectomy after submucosal lifting of a 40-mm short pedicle polyp in the cardia (Figs. 1 and 2). Immediate postpolypectomy bleeding occurred (Fig. 3), and endoclip application was not possible because of insufficient retroflexion of the endoscope with the endoclip placed in the working channel, impeding access to the bleeding spot (Fig. 4) (Video 1, available online at www.VideoGIE.org). The clip-with-line method was used by withdrawing the endoscope, introducing an endoclip into the working channel, externalizing it, and tying a suture to 1 of its prongs (Fig. 5). Afterward, the endoscope was reinserted into the gastric cavity, the endoclip was externalized in the retroflexioned position, and traction to the suture thread through the oral cavity allowed it to be guided to the bleeding area. Two endoclips were correctly applied by use of this method (Figure 6, Figure 7, Figure 8).
Figure 1.
Polyp in the cardia.
Figure 2.
Submucosal lifting.
Figure 3.
Immediate postpolypectomy bleeding.
Figure 4.
Insufficient retroflexion with the endoclip in the working channel.
Figure 5.
Suture thread tied to 1 of the endoclip’s prongs.
Figure 6.
Traction to the suture thread directing the endoclip to the area of interest.
Figure 7.
Traction to the suture thread, allowing the endoclip to be guided to the bleeding area.
Figure 8.
Final aspect.
There was no bleeding at the end of the procedure or on the following days. Histologic examination revealed a hyperplastic polyp with ulceration.
The clip-with-line method is used to facilitate endoscopic submucosal dissection under circumstances in which exposure of the submucosal layer is difficult. In this case it was impossible to access the cardia with the endoclip in the working channel, which rendered the endoscope to be stiffer, causing insufficient retroflexion.2, 3, 4 This technique was used to create traction on the endoclips, directing them to the bleeding spot and allowing their correct placement.
We describe the successful application of this technique in this particular setting, with potentially severe bleeding. This procedure can be used to apply endoclips in locations that require extreme retroflexion of the endoscope.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
Supplementary data
Endoclip line-assisted traction to control cardial postpolypectomy bleeding.
References
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Associated Data
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Supplementary Materials
Endoclip line-assisted traction to control cardial postpolypectomy bleeding.