Double-wire-guided reopenable-clip closure of a mucosal defect after endoscopic papillectomy

Endoscopic papillectomy has been reported as a curative endoscopic treatment for laterally spreading tumors of the duodenal papilla and near the papilla [1] [2]. However, endoscopic papillectomy is associated with postoperative complications such as pancreatitis, cholangiopancreatic stricture, and bleeding. Insertion of a pancreatic ductal stent may prevent these problems and should be performed if possible [3] [4]. In addition, clip closure of mucosal defects may reduce delayed bleeding [5]. However, the presence of pancreatic and bile duct stents may interfere with clip closure and result in incomplete closure of the mucosal defects. We developed a new method, double-wire-guided closure with reopenable clips, which enables closure of mucosal defects before pancreatic and bile duct stents are inserted. With this method, guidewires are inserted into the pancreatic and bile ducts after complete resection of the lesion. The mucosal defect is then securely closed using a reopenable clip (SureClip; Micro-Tech Co., Ltd, Nanjing, China), with two guidewires in place to prevent respiratory movement. The clip can be opened and closed even with the elevator mechanism of conventional duodenoscopes.

Our patient was a 65-year-old man with a laterally spreading tumor in the descending duodenum extending to the papilla. We performed piecemeal resection of the tumor with a duodenoscope (TJF-290V; Olympus Medical Systems). We closed the mucosal defect using double-wire-guided closure with a reopenable clip. If the reopenable clip inadvertently gripped the ulcer base of the mucosal defect, it could be reopened and reclosed to completely close the defect on both sides. Since two wires were intubated into the pancreatic and bile ducts, respiratory movement was prevented, and the reopenable clip could be easily positioned. Subsequently, pancreatic and bile duct stents were inserted. The mucosal defect was completely closed ([Fig. 1], [Video 1]). The patient was discharged without any adverse events.

Fig. 1 a Laterally spreading tumor 20 mm in size in the descending duodenum extending to the papilla in a 65-year-old man. b Mucosal defect after piecemeal resection by endoscopic papillectomy using a duodenoscope. c Guidewires cannulated into the pancreatic duct and bile duct. d Normal mucosa at the edge of the mucosal defect completely grasped and held by a reopenable clip using the double-wire-guided reopenable-clip closure method. e Plastic stents inserted into the pancreatic duct and bile duct. f Complete closure of the mucosal defect after endoscopic papillectomy.

Video 1 Double-wire-guided reopenable-clip closure of a mucosal defect after endoscopic papillectomy.

Double-wire-guided closure with reopenable clips can reliably close the mucosal defect after endoscopic papillectomy before pancreatic and bile duct stents are inserted.

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Publication History

Article published online:
16 April 2021

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