Endoscopic removal of the Padlock-G clip

In recent years various new endoscopic closure techniques and devices have been developed [1]. Research has mainly been driven by the need for a secure and reliable closure for natural orifice transluminal endoscopic surgery (NOTES) [2]. At present, the clinical applicability of NOTES remains unclear, but research in this area has already immeasurably enriched our endoscopic armamentarium with regards to endoscopic closure of perforations [1] [3] [4].

Recently, two novel clipping devices have been developed, which are conceptually similar to endoscopic band ligation [3] [4] [5]. One of these devices is the Padlock-G clip ([Fig. 1]; Aponos Medical, Kingston, New Hampshire, USA), the feasibility of which has been demonstrated recently [5].

Fig. 1 Padlock-G clip closure device. a The clip; b the loaded clip on the applicator cap.

The closure mechanism consists of a 16.5-mm nitinol clip delivered via an over-the-scope delivery pod. Herein we report a technique that we have developed for the safe removal of this clip after it has been deployed.

In a 34-kg female domestic pig under general anesthesia, an 18-mm gastric wall opening was created using a needle knife and a dilation balloon. The Padlock-G clip was deployed after approximating the gastrotomy borders with a specialized tissue approximation grasper (Ovesco Endoscopy AG, Tübingen, Germany), thus creating a full-thickness closure of the defect ([Fig. 2 a], [Video 1]). Time to achieve endoscopic closure was 3 minutes.

Fig. 2 Removal of the Padlock-G clip. a The Padlock-G clip closure of an 18-mm full-thickness gastric wall defect. b – d Padlock-G clip removal using a standard endoscopic snare. By grasping two of the side bars (b), each anchoring pin of the clip can be pulled out of the tissue (c) in a serial fashion and the clip is removed (d).

Video 1 Padlock closure of an 18-mm gastric wall defect.

For removal, a soft oval endoscopic snare (SD-210U-25, Olympus, Center Valley, Pennsylvania, USA) was used. By grasping two of the side bars, each anchoring pin of the clip can be pulled out of the tissue in a serial fashion and the clip can be removed with minimal tissue trauma ([Fig. 2 b – d], [Video 2]). Removal was facilitated within 1 minute and without complications.

Video 2 Technique of endoscopic Padlock removal.

In conclusion, the novel Padlock-G clip seems to be a promising new device for endoscopic organ wall closure with the additional benefit of easy and swift endoscopic removal in cases of unsatisfactory or incomplete closure attempts.

Competing interests: None

Endoscopy_UCTN_Code_TTT_1AO_2AI

References

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• 2 ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery . White Paper October 2005.  Gastrointest Endosc. 2006;  63 199-203
• 3 Renteln D von, Schmidt A, Vassiliou M C. et al . Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study.  Endoscopy. 2009;  41 481-486
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