Clip-fixed endoloop: an efficacious new method for mucosal defect closure

Endoloop suturing of a mucosal defect using a two-channel scope has been shown to be efficacious [1] [2]. Recently, methods of simple, useful endoloop suturing with a single-channel scope have also been reported [3] [4]. However, fixing the first clip to determine the position of the endoloop is cumbersome. We have developed a new and efficient suturing method, the clip-fixed endoloop, that fixes the endoloop to the clip in advance.

The clip-fixed endoloop consists of the clip (ZEOCLIP ZP-CH; Zeon Medical Inc.), a clip applicator (ZP-S-195S; Zeon Medical Inc.), an endoloop (MAJ254; Olympus), and a surgical thread ([Fig. 1 a]). [Video 1] shows how to perform mucosal closure using the clip-fixed endoloop. First, the tip of endoloop is fixed to the clip’s teeth with surgical thread ([Fig. 1 b]). The clip-fixed endoloop is housed in the outer sheath of the clip by moving the outer slider distally until the clip-fixed endoloop is completely hidden in the outer sheath ([Fig. 1 c]). It is opened by slowly moving the outer sheath until it is endoscopically confirmed that the endoloop is properly open.

Fig. 1 Photographs of the clip-fixed endoloop. a The device consists of a clip, clip applicator, endoloop, and surgical thread. b The tip of the endoloop is fixed to the clip’s teeth with surgical thread. c The clip-fixed endoloop is housed in the outer sheath of the clip by moving the outer slider distally.

Video 1 The clip-fixed endoloop is prepared and then used to suture a mucosal defect after colorectal endoscopic submucosal dissection.

[Video 1] shows how the mucosal defect is sutured after colorectal endoscopic submucosal dissection (ESD) using the clip-fixed endoloop. The patient had a 40-mm sessile serrated adenoma in the descending colon. ESD was performed; the area of the mucosal defect after ESD was slightly larger than 40 mm ([Fig. 2 a]). The clip-fixed endoloop was inserted through the working channel of the endoscope and was confirmed to be opening properly ([Fig. 2 b]). It was then fixed onto the normal mucosa near the mucosal defect ([Fig. 2 c]). Four metal clips were used to anchor the endoloop around the edge of the mucosal defect. The endoloop tail was then grasped by a hook device (HX-20Q-1; Olympus) and the endoloop was tightened to close the defect. Additional clips were added to the remaining mucosal defect to ensure it was completely sutured ([Fig. 2 d]).

Fig. 2 Endoscopic images showing: a a mucosal defect with an area > 40 mm post-endoscopic submucosal dissection; b the clip-fixed endoloop, which has been inserted into the working channel of the endoscope, and is confirmed to be opening properly; c the clip-fixed endoloop having been fixed to the normal mucosa near the mucosal defect; d complete closure of the mucosal defect following application of the clip-fixed endoloop and a number of additional clips.

By fixing the endoloop to the clip in advance and housing it in the outer sheath, we have made simple and efficient suturing of a mucosal defect possible.

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• References

• 1 Matsuda T, Fujii T, Emura F. et al. Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope. Gastrointest Endosc 2004; 60: 836-838
• 2 Shi Q, Chen T, Zhong YS. et al. Complete closure of large gastric defects after endoscopic full-thickness resection, using endoloop and metallic clip interrupted suture. Endoscopy 2013; 45: 329-334
• 3 Lua GW, Liu F. Closure of a large mucosal defect after endoscopic submucosal dissection using “pre-detached loop and clips” method with a single-channel gastroscope. Endoscopy 2015; 47: E464-E465
• 4 Wang J, Wang X, Liu L. et al. Endoscopic closure of a colonic defect using a novel endoloop system via a single-channel endoscope. Endoscopy 2016; 48: E142-E143