Complete sealing of a duodenal perforation during endoscopic submucosal dissection using a novel through-the-scope twin clip

Intraprocedure and postprocedure perforation are serious complications that limit the clinical application of endoscopic submucosal dissection (ESD) for duodenal neoplasia; thus, how to seal a perforation of the duodenum during ESD efficiently and safely is an important topic. Current sealing instruments include conventional through-the-scope (TTS) clips with or without nylon purse-string sutures, over-the-scope (OTS) clips, and high-end suture devices; however, these are time-consuming, high-cost, and difficult to use for sealing large perforations [1] [2]. We report the successful application of a novel TTS twin clip (TTS-TC), which is expected to achieve efficient closure of large perforations in difficult locations, in sealing a duodenal perforation that occurred during ESD [1] [3] [4] [5].

A 54-year-old man who was diagnosed with a villous tubular adenoma in the duodenal bulb at a local hospital 5 months ago was referred to our hospital to undergo endoscopic resection. The esophagogastroduodenoscopy (EGD) showed the presence in the bulb of a sessile lesion with an uneven surface and an estimated size of 6 × 4 cm ([Fig. 1]). The nonlifting sign was positive after initial submucosal injection with sodium hyaluronate solution. ESD with clip-line traction was performed to remove the lesion, during which obvious submucosal fibrosis and Brunner’s gland hyperplasia were observed. The lesion was successfully removed but the removal was complicated by a 3-mm perforation ([Fig. 2]). The perforation was closed by inserting a TTS-TC ([Fig. 3]) through the biopsy channel of the endoscope, accurately clamping one side of the entire duodenal wall layer near the perforation, positioning the other side, and then releasing the TTS-TC ([Video 1]). The patient fasted for 3 days and was discharged after 7 days with no postoperative complications and no residue or recurrence observed by EGD performed 3 months later. The TTS-TC is an accurate, efficient, and safe instrument for sealing duodenal perforation occurring during ESD, with excellent clamping and closing force.

Fig. 1 Endoscopic view of a sessile lesion with uneven surface situated in the duodenal bulb, histologically confirmed as villous tubular adenoma.

Fig. 2 Perforation occurred during endoscopic submucosal dissection.

Fig. 3 Perforation sealed with a through-the-scope twin clip.

Video 1 The process of sealing the perforation was completed by accurately clamping the entire tissue on one side, positioning the other side, and then releasing the through-the-scope twin clip.

Endoscopy_UCTN_Code_CCL_1AD_2AG

Citation Format

Endoscopy 2023; 55: E505–E506. doi: 10.1055/a-2037-5002.

Competing interests

The authors declare that they have no conflict of interest.

^* X. Ma and L. Yang are co-first authors and contributed equally to this work.

• References

• 1 Zhang Q, Jin HY, Shen ZH. et al. Novel through-the-scope twin clip for the closure of GI wounds: the first experimental survival study in pigs (with videos). Gastrointest Endosc 2021; 94: 850-858.e2
• 2 Modi RM, Shami VM. Making endoscopic submucosal dissection in the duodenum safer: is it possible?. Gastrointest Endosc 2021; 93: 950-951
• 3 Zhang Q, Wang Z, Liu S. Gastric bypass was performed with a novel through-the-scope twin clip under endoscopy. Endoscopy 2022; 54: E962-E963
• 4 Zhang Q. A novel through-the-scope twin clip traction-assisted endoscopic submucosal dissection in an in vitro pig stomach model. Endoscopy 2021; 53: E259-E260
• 5 Zhang Q, Wang Z, Bai Y. A novel through-the-scope twin endoclip for a large mucosal closure in a live pig model. Endoscopy 2019; 51: E372-E373

Publication History

Article published online:
27 July 2023