ENDOSCOPIC LINE-ASSISTED COMPLETE CLOSURE OF LARGE COLONIC PERFORATION DURING ENDOSCOPIC SUBMUCOSAL DISSECTION

Complete closure of extra-large mucosal defects after endoscopic submucosal dissection (ESD) of wide colorectal lesions is a challenging procedure due to limited width-opening of the regular through-the-scope clips (TTSC). We report a case of successful management of a large perforation using the line-assisted complete closure (LACC) technique.

LACC technique, described by Kato et al, is performed introducing a TTSC with a long nylon line tied to one of its anchor blades and fixing it to about 5 mm from the distal edge of the perforation area. Subsequently another TTSC is inserted through the working channel and it grasps the line inside the lumen, close to the first clip, to be anchored to the proximal side of the perforation. Both sides of the wound are gathered by gently pulling the line from outside the patient. This allows applying complementary TTSC for the complete closure of the defect. The line is finally cut using scissor forceps.

A 78-year-old patient was found to have a 70 × 40 mm LST-NG (0-IIa + IIb) in transverse colon, pit pattern Kudo type IV. Along the final phase of ESD a spontaneous 5 – 6 cm disruption of the muscular layer within the mucosal defect was noted. Due to its large size, a LACC technique was executed to facilitate the approaching and further clipping of the mucosal edges with additional 31 regular TTSC. Abdominal-CT with rectal contrast administration after the procedure showed no sign of leaking at the perforation site. The patient remained asymptomatic and was discharged uneventfully six days later.

Compared with other endoscopic devices such as over-the-scope clip (OTSC), LACC only requires the use of regular TTSC, a nylon line and endoscopic scissors. It can be an effective alternative in the management of large iatrogenic perforations, even in proximal colon, avoiding surgical treatment.