Clipping closure of large mucosal defects in the gastrointestinal tract can be difficult and time consuming, and sometimes requires many clips as the mucosa surrounding the defect stretches following endoscopic mucosal resection (EMR). Techniques utilizing the underwater method have been increasingly used in various endoscopic procedures 1 2 3 . Its application in clipping has been reported in large colonic and duodenal endoscopic submucosal dissection 4 . Here, we demonstrate the use of underwater clipping after EMR in the colon ( Video 1 ).
Video 1 Underwater clipping after colonic polypectomy in a 72-year-old man.
A 72-year-old man underwent a screening colonoscopy in which a 15-mm sessile elevated polyp (laterally spreading tumor, nongranular type) was discovered in the ascending colon ( Fig. 1 ). Narrow-band imaging revealed adenoma with no invasive findings ( Fig. 2 ). En bloc underwater EMR was performed using a bipolar snare (Dragonare; Zeon Medical Inc., Tokyo, Japan) ( Fig. 3 ). After the defect had been examined, and confirmation had been obtained with carbon dioxide that there was no perforation, the lumen was filled with saline. The tension of the mucosa around the defect decreased and the mucosa floated ( Fig. 4 ). The defect size decreased, making it easier to catch the mucosa with the clips (SureClip; Micro-Tech, Nanjing, China). The defect was completely closed with four clips ( Fig. 5 ). Underwater clipping was easier than the conventional under-gas method; it reduced both the procedure time and the number of clips.
Fig. 1.
A 15-mm sessile elevated polyp (laterally spreading tumor, nongranular type) in the ascending colon of a 72-year-old man.
Fig. 2.
Narrow-band imaging of the polyp.
Fig. 3.
Mucosal defect after endoscopic mucosal resection.
Fig. 4.
The size of the defect decreased in the water.
Fig. 5.
The defect was completely closed with four clips.
Endoscopy_UCTN_Code_TTT_1AQ_2AZ
Acknowledgments
We would like to thank Editage ( www.editage.com ) for English language editing.
Footnotes
Competing interests The authors declare that they have no conflict of interest.
Endoscopy E-Videos : https://eref.thieme.de/e-videos .
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
References
- 1.Binmoeller K F, Weilert F, Shah J et al. ‘Underwater’ EMR without submucosal injection for large sessile colorectal polyps (with video) Gastrointest Endosc. 2012;75:1086–1091. doi: 10.1016/j.gie.2011.12.022. [DOI] [PubMed] [Google Scholar]
- 2.Yamamoto S, Ishida H, Mita E. Acetic acid-assisted underwater endoscopic mucosal resection for successful resection of sessile serrated lesions. Endoscopy. 2022;54:E508–E509. doi: 10.1055/a-1647-2174. [DOI] [PubMed] [Google Scholar]
- 3.Yamamoto S, Parra-Blanco A. Underwater endoloop-assisted endoscopic resection for colorectal pedunculated polyps. Endoscopy. 2022;54:E835–E836. doi: 10.1055/a-1824-5056. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Yamasaki Y, Harada K, Oka S et al. Feasibility of underwater clip closure for large mucosal defects after colorectal endoscopic submucosal dissection. Digestion. 2019;99:327–332. doi: 10.1159/000492815. [DOI] [PubMed] [Google Scholar]